Digital health: implications for heart failure management.

Digital health encompasses the use of information and communications technology and the use of advanced computing sciences in healthcare. This review covers the application of digital health in heart failure patients, focusing on teleconsultation, remote monitoring and apps and wearables, looking at how these technologies can be used to support care and improve outcomes. Interest in and use of these technologies, particularly teleconsultation, have been accelerated by the coronavirus disease 2019 pandemic. Remote monitoring of heart failure patients, to identify those patients at high risk of hospitalisation and to support clinical stability, has been studied with mixed results. Remote monitoring of pulmonary artery pressure has a consistent effect on reducing hospitalisation rates for patients with moderately severe symptoms and multiparameter monitoring shows promise for the future. Wearable devices and apps are increasingly used by patients for health and lifestyle support. Some wearable technologies have shown promise in AF detection, and others may be useful in supporting self-care and guiding prognosis, but more evidence is required to guide their optimal use. Support for patients and clinicians wishing to use these technologies is important, along with consideration of data validity and privacy and appropriate recording of decision-making

The role of wearables in heart failure.

PURPOSE OF REVIEW: This review discusses how wearable devices-sensors externally applied to the body to measure a physiological signal-can be used in heart failure (HF) care. RECENT FINDINGS: Most wearables are marketed to consumers and can measure movement, heart rate, and blood pressure; detect and monitor arrhythmia; and support exercise training and rehabilitation. Wearable devices targeted at healthcare professionals include ECG patch recorders and vests, patches, and textiles with in-built sensors for improved prognostication and the early detection of acute decompensation. Integrating data from wearables into clinical decision-making has been slow due to clinical inertia and concerns regarding data security and validity, lack of evidence of meaningful impact, interoperability, regulatory and reimbursement issues, and legal liability. Although few studies have assessed how best to integrate wearable technologies into clinical practice, their use is rapidly expanding and may support improved decision-making by patients and healthcare professionals along the whole patient pathway

Telemonitoring after discharge from hospital with heart failure: cost-effectiveness modelling of alternative service designs.

Objectives To estimate the cost-effectiveness of remote monitoring strategies versus usual care for adults recently discharged after a heart failure (HF) exacerbation. Design Decision analysis modelling of cost-effectiveness using secondary data sources. Setting Acute hospitals in the UK. Patients Patients recently discharged (within 28 days) after a HF exacerbation. Interventions Structured telephone support (STS) via human to machine (STS HM) interface, (2) STS via human to human (STS HH) contact and (3) home telemonitoring (TM), compared with (4) usual care. Main outcome measures The incremental cost per quality-adjusted life year (QALY) gained by each strategy compared to the next most effective alternative and the probability of each strategy being cost-effective at varying willingness to pay per QALY gained. Results TM was the most cost-effective strategy in the scenario using these base case costs. Compared with usual care, TM had an estimated incremental cost effectiveness ratio (ICER) of £11 873/QALY, whereas STS HH had an ICER of £228 035/QALY against TM. STS HM was dominated by usual care. Threshold analysis suggested that the monthly cost of TM has to be higher than £390 to have an ICER greater than £20 000/QALY against STS HH. Scenario analyses performed using higher costs of usual care, higher costs of STS HH and lower costs of TM do not substantially change the conclusions. Conclusions Cost-effectiveness analyses suggest that TM was an optimal strategy in most scenarios, but there is considerable uncertainty in relation to clear descriptions of the interventions and robust estimation of costs

Five-year survival and use of hospital services following ICD and CRT implantation: comparing real-world data with RCTs

Aims Guidelines recommend the use of an implantable cardioverter-defibrillator (ICD) and/or cardiac resynchronization therapy (CRT) device based on the results of randomized controlled trials (RCTs), typically with selected patients and short follow-up. Methods and results We describe the 5 year survival rate and use of hospital services following ICD and CRT implantation in England from April 2011 to March 2013 using the national hospital administrative database covering emergency department visits, inpatient admissions, and clinic appointments, linked to the national death register. Five-year survival was 64% after ICD implantation and 58% after CRT implantation, with median survival times of 6.8 and 6.2 years, respectively. Hospital use was high in both device groups, for the 5 years prior and after implantation, peaking around the implantation date. Most hospital activity was not primarily related to heart failure. Healthcare costs were dominated by admissions, but emergency department and clinic activity were both high. Only the CRT group saw total per-patient costs fall after the index month (implantation), driven by a slight fall in the heart failure admission rate. Patients were typically older than in the trials, but with similar co-morbidity except for substantially more atrial fibrillation and less dementia. Survival and device complications were similar to the RCTs. Conclusions Clinical and cost-effectiveness assessments of ICD and CRT implantation are supported by real-world data, although the prevalence of atrial fibrillation remains substantially higher than in the RCTs

Practical approach on frail older patients attended for acute heart failure

Acute heart failure (AHF) is a multi-organ dysfunction syndrome. In addition to known cardiac dysfunction, non-cardiac comorbidity, frailty and disability are independent risk factors of mortality, morbidity, cognitive and functional decline, and risk of institutionalization. Frailty, a treatable and potential reversible syndrome very common in older patients with AHF, increases the risk of disability and other adverse health outcomes. This position paper highlights the need to identify frailty in order to improve prognosis, the risk-benefits of invasive diagnostic and therapeutic procedures, and the definition of older-person-centered and integrated care plans