There is no reduction in the risk of readmission or death from any cause with telemonitoring as compared with usual care. There were no step-downs in the risk of hospitalization for heart failure, the number of days in the hospital, or the time to readmission or death.
Science may be defined as 'an enterprise that builds and organizes knowledge in the form of testable explanations and predictions about the natural world'. Not a single concept in science escapes scrutiny. Every new disease-management system goes through serious evaluations before getting a nod of approval. Telemonitoring happens to be the latest victim. Purely contradictory results have pushed the concept into a cloud of suspicion. It has barely been months since the Cochrane Reviews praised telemonitoring for its positive impact. The latest report by the New England Journal of Medicine crucifies the concept. The clash of the titans has left the scientific world wondering 'whether telemonitoring needs to be implemented in heart failure patients'.
AdvertisementTelemonitoring makes it possible to monitor patients remotely so that clinicians can intervene early if there is evidence of clinical deterioration. It involves remotely monitoring patients who are not at the same location as the health care provider. A patient will have a number of monitoring devices at home. The results of these devices will be communicated via telephone to the health care provider. Most telemonitoring programs also include subjective questioning regarding the patient's health and comfort. Questioning occurs either through phone or the telemonitoring software lets the patient to be in touch with the health provider.
Telemonitoring is particularly effective for patients with diabetes or hypertension since regular vital sign monitoring is easier. Telemonitoring is a promising strategy for improving heart-failure outcome. A recent Cochrane review concluded that telemonitoring of patients with heart failure reduced the rate of death from any cause by 44% and the rate of heart-failure-related hospitalizations by 21%.
However studies included in the review had lots of limitations and hence a larger scale randomized controlled trial was performed. The result that was published in the New England Journal of Medicine was shocking. There is no reduction in the risk of readmission or death from any cause with telemonitoring as compared with usual care. There were no step-downs in the risk of hospitalization for heart failure, the number of days in the hospital, or the time to readmission or death. The efficaciousness of complex interventions such as telemonitoring depends on the context in which they are applied.
14% of the patients who were randomly assigned to undergo telemonitoring never used the system. By the final week of the study period, only 55% of the patients were still using the system at least three times per week.
The question that arises is whether an automated monitoring system with transmission of information to the clinicians responsible for the patients' care scores better than one-to-one telephone calls with a clinician. There is thus a need for rigorous, independent evaluation of disease-management systems before their adoption. The health sector has already taken a business oriented track with vendors trying all means to promote their products. Success of any system will require a great organizational capacity to implement it.
Thus it is high time to take discussions to a serious note about the utility of a strategy like telemedicine in a developing economy like ours. Cost effectiveness has to be thoroughly reviewed. The contrasting result of the new study also reveals the necessity of assuring the quality of health related studies.
In short, the latest revelation is that 'telemonitoring strategy has failed to provide a benefit over usual care in a setting optimized for its use'. This is contradictory to the previous claims of success of similar strategies. The provider of the latest results claims that their study is of a 'higher methodologic quality' unlike the previous one. All that is clear is that there remains a need for strategies to improve heart-failure outcomes. We better hope that a clear consensus about the application of telemedicine will soon be out.
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