Does 'Telemonitoring' of Patients Improve Care?

An aging population means more and more frail patients who can't make it to the clinic for appointments. One way for doctors to keep tabs on them is by telephone. But, a study published in the New England Journal of Medicine casts doubt on that strategy.

Heart disease is one of the leading causes of death in Canada.  For a growing number of people with heart disease, heart failure is an unfortunate outcome.  Heart failure means the heart isn't pumping blood properly.  Symptoms include severe shortness of breath and fatigue.  Patients with heart failure are admitted frequently to hospital.  Without close follow up, they end up having to rush back to the ER and frequently require readmission to hospital.  A number of pilot studies have shown that keeping tabs on patients by telephone - so called telemonitoring - could keep them out of hospital. 

Researchers at Yale University School of Medicine recruited heart specialists at 33 hospitals involving more than 1600 patients.  They used a telephone-based voice-response system to track the patients' symptoms.  Unfortunately, the system had absolutely no impact on hospital readmission rates or on the death rate from heart failure.

Click here to read more about the study.

To me, the failure of telemonting in this study had nothing to do with technology or with the way things were set up.  The system required heart failure patients to dial into an automated, interactive voice response system daily to enter their weight and answer questions about heart failure symptoms. Sudden weight gain and shortness of breath meant that the patient's heart failure was getting worse.  Doctors reviewed the information and called patients back to discuss worrisome reports. Based on pilot studies, the system should have worked.  It's possible there was something about the doctor's advice to the patient during the follow up call that undid the benefits of the phone tracking system. Or it may be that the earlier studies overrated the benefits of keeping track of patients by phone. 

That said, there are numerous examples of medical conditions for which doctors are using phones and other communication devices to improve patient care.  The list includes patients with high blood pressure, diabetes, cholesterol, asthma, and chronic obstructive lung disease or emphysema. 

Researchers are now exploring the potential of a mobile phone monitoring system that automatically picks up patients' home blood pressure readings, which is then sent out wirelessly via radio signals from monitoring equipment outfitted with Blue-tooth technology.  Dr. Sandy Logan from Mount Sinai Hospital and the University of Toronto talked about it at the American Heart Association meeting held recenlty in Chicago.  The cell phones are pre-programmed to transmit the blood pressure readings and receive appropriate feedback (which appear instantly on the cell phone screen). 

Good readings prompt a message of "Congratulations," while bad results may trigger a message advising the patients to make a check-up appointment with their doctor. The interactive system may also instruct patients to take more readings over a specified period of time to get a more reliable overall reading. Preliminary results showed that 37% of patients with poorly-controlled blood pressure got it under control.

The study of patients with heart failure is a setback for sure.  But in my opinion, there's no way this one study will put a stop to telemonitoring.  The stakes are too high.  Doctors can't be everywhere all the time. On every shift I work as an emergency doctor, I see all kinds of patients who were recently admitted and discharged from hospital who end up having to be readmitted.  That tells me we're failing to keep tabs on them.  To me, that is simply too costly to patients and to the system.

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