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'.
Telemonitoring 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.
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.
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.
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
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.
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.