Rise of the machines: will heart failure become the first cyber-specialty?

Br J Cardiol 2020;27:27–30doi:10.5837/bjc.2020.006 Leave a comment
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Digital healthcare is being introduced to the management of heart failure as a consequence of innovations in information technology. Advancement in technology enables remote symptom and device monitoring, and facilitates early detection and treatment of heart failure exacerbation, potentially improving patient outcomes and quality of life. It also provides the potential to redesign our heart failure healthcare system to one with greater efficacy through resource-sparing, computer-aided decision-making systems. Although promising, there is, as yet, insufficient evidence to support the widespread implementation of digital healthcare. Patient-related barriers include user characteristics and health status; privacy and security concerns; financial costs and lack of accessibility of digital resources. Physician-related barriers include the lack of infrastructure, incentive, knowledge and training. There are also a multitude of technical challenges in maintaining system efficiency and data quality. Furthermore, the lack of regulation and legislation regarding digital healthcare also prevents its large-scale deployment. Further education and support and a comprehensive workable evaluation framework are needed to facilitate confident and widespread use of digital healthcare in managing patients with heart failure.

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Dr Sze, BJCA essay prize winner
Dr Sze, BJCA essay prize winner

Introduction

According to the European Society of Cardiology Atlas project, >83 million people suffered from cardiovascular diseases in Europe in 2015.1 Heart failure (HF) is a common chronic disease in the ageing population. It is associated with poor prognosis, recurrent admissions and limited quality of life.2 Despite development of effective guideline-based treatment, the prognosis of HF patients remains poor. With the advancement of cyber technologies, digital healthcare has become more popular and may develop as a promising way to tackle challenges in HF management.

The objectives of this article are:

  1. Provide an overview of digital healthcare and its impact on patient outcome and healthcare delivery.
  2. Highlight the important challenges/barriers for large-scale digital health implementation.
  3. Predict the future of digital healthcare, in the field of HF.

Digital healthcare in HF

Digital healthcare involves the use of information and communication technologies to treat and monitor patients, convey healthy lifestyle information and advice (primary prevention), conduct research, educate healthcare professionals and monitor public health. Digital healthcare encompasses e-learning, mobile applications, remote monitoring, telerehabilitation and teleconsultation. Table 1 shows an overview of utilisation of digital healthcare in HF.3-15

Table 1. Overview of digital healthcare in heart failure

Study Population Intervention Outcome
Remote device monitoring
EVOLVO 20123 200 CHF patients with ICD/CRTD Remote implant-based, multi-parameter monitoring 35% less frequent emergency visits for HF, arrhythmia or ICD-related events between intervention vs. control group
IN-TIME
20144
716 CHF patients with ICD/CRTD Remote implant-based, multi-parameter monitoring 8% less deterioration in a clinical composite score (all-cause mortality, HF hospitalisation, NYHA class and change in patient global self-assessment) in the intervention vs. control group
OptiLink HF 20165 1,002 CHF patients with ICD ± CRT Fluid status alerts via text message to responsible physician No difference in composite all-cause mortality and cardiovascular hospitalisation between intervention vs. control group
Telemonitoring
WHARF 20036 280 CHF patients AlereNet monitoring system with symptom and weight monitoring 56% reduction in mortality but no difference in hospitalisation between intervention vs. control group
TEN-HMS 20057 426 CHF patients with recent HF hospitalisation Home telemonitoring vs. nurse telephone support vs. usual care Similar hospitalisation and mortality among patients assigned to home telemonitoring or nurse telephone support. 1-year mortality was higher in control (45%) vs. intervention groups (27–29%)
DIAL
20088
23 CHF patients 6-week in-home telemedicine education and monitoring programme No difference in healthcare utilisation rates between intervention vs. control groups. Intervention group facilitated self-care
Tele-HF 20109 1,653 CHF patients with recent HF hospitalisation Telephone-based interactive voice response system No difference in all-cause hospitalisation/mortality within 180-days between intervention vs. control group
TIM-HF 201110 710 CHF patients Remote telemonitoring using portable devices for ECG, weight and BP No difference in all-cause/cardiovascular mortality or HF hospitalisation between intervention vs. control group
Cochrane
Inglis et al. 201511
41 studies (5,472 CHF patients) Structured telephone support/non-invasive home telemonitoring Reduction in all-cause mortality (RR 0.87, 95%CI 0.77–0.98) and HF-related hospitalisation (RR 0.85, 95%CI 0.77–0.93) in intervention vs. control group
BEAT-HF 201612 1,457 CHF patients discharged after hospitalisation for decompensated HF Telemonitoring and health coaching telephone calls No difference in 30-day and 180-day all-cause hospitalisation or 180-day mortality between intervention vs. control group
REM-HF
201713
1,650 CHF patients with cardiac implanted electronic devices Remote monitoring of devices No difference in all-cause mortality and unplanned cardiovascular hospitalisation between intervention and control group
Telerehabilitation
Piotrowicz et al. 201014 152 CHF patients 8-week home-based telerehabilitation programme based on walking training Telerehabilitation is equally as effective as standard care with similar improvement in quality of life
Piotrowicz et al. 201515 111 CHF patients with cardiac implantable electronic devices 8-week home-based telerehabilitation programme based on walking training Improvement in exercise capacity and quality of life in the intervention vs. control group
Key: BP = blood pressure; CHF = chronic heart failure; CI = confidence interval; CRT = cardiac resynchronisation therapy;
CRTD = cardiac resynchronisation therapy with a defibrillator; ECG = electrocardiogram; HF = heart failure;
ICD = implantable cardiac defibrillator; NYHA = New York Heart Association; RR = relative risk

Impact of digital healthcare on patients’ healthcare experience

The ageing population and frailty have become major themes for patients with HF. Physical deconditioning and cognitive decline contribute to medication non-adherence, which predisposes to recurrent hospitalisation and death. HF management is complex and is guided by subtle changes in symptoms and signs of congestion and volume overload. Failure to make ongoing small, but clinically significant, titrations in HF medications contribute to increased hospitalisation and mortality. In patients with cardiac resynchronisation therapy, optimal management requires yet another layer of oversight – device management. With the advent of Bluetooth-connected cardiac resynchronisation therapy, a smartphone could provide remote device status and diagnostics.16 Digital healthcare enables remote symptom and implanted device monitoring and facilitates early detection and treatment of HF exacerbations, leading to better outcomes and quality of life.17 Provision of remote patient support also enhances patient-doctor communication. Furthermore, as online educational resources become more available, patients are also empowered to take a more active role in managing their conditions. Mobile applications that promote healthy lifestyle induce behavioural change, particularly against poor diet, smoking and physical inactivity;18 directly improving patient outcome.

Impact of digital healthcare on healthcare delivery

Our National Health Service (NHS) has limited resources to meet the increasing healthcare demand of the ageing population. Shortage of medical staff means that most healthcare resources are allocated to managing acutely unwell patients in hospital. This has a great impact on the management of patients with HF – a chronic condition that needs regular medical input. Digital healthcare provides the potential to redesign our HF healthcare system to one with greater efficacy through resource-sparing, computer-aided decision-making systems, remote monitoring and consultation.19 Artificial intelligence has been applied in various contexts, from the construction of automated clinical decision support systems to imaging interpretation. The Seattle HF model is a machine-learning risk-prediction model that was trained with clinical data routinely obtained from electronic health records to predict HF prognosis, which could potentially be useful in the management of high-risk HF patients.20

Challenges for implementing digital healthcare

Patient-related barriers

Health applications and online resources, although positively perceived, were not widely used in HF populations. An observational study reported a telemonitoring intervention adherence rate of only 50% in HF patients.9

Patient-related barriers to digital healthcare include user characteristics and health status, privacy and security concerns; financial costs and lack of accessibility of digital resources; mistrust of online information; and lack of motivation.21 Old age, frailty, poor socioeconomic and health status, and low e-health literacy in the HF population predispose to suboptimal uptake of digital healthcare. Other contributors include lack of understanding of the concept of ‘patient empowerment’ or worries about receiving a poorer level of care due to the impersonal nature of a digital service.22 Most patients still regard their physicians as their predominant and most reliable source of health information. Others were overwhelmed by technology and were unable to keep up with technological advancements.22 There were also patient concerns regarding low self-efficacy and user-friendliness of telemonitoring technology.22 These problems might be partially attributable to the fact that development of digital healthcare is largely technically-driven and patients are rarely involved in its creation and design.23

Physician-related barriers

Physician-related barriers to digital healthcare include lack of infrastructure, incentives, knowledge and training, regulations and standardisation.24 While digital healthcare enables easier patient monitoring, a heavy time investment is needed from clinicians to review incoming data and provide feedback to patients. Furthermore, most digital healthcare is added on top of existing healthcare rather than replacing it. For example, nurse-led telemonitoring for HF patients are set up without adapting the frequency of conventional hospital-based care by cardiologists, leading to increased healthcare costs.

Technical/clinical efficacy

Digital healthcare has a multitude of technical challenges. For example, telemonitoring involves transfer of physiological data to a centralised platform using wireless networks, software, algorithms for data capture and processing support. This process involves many challenges including technological capabilities, system efficiency and data integrity and quality. Despite a plethora of mobile applications available, only a very limited number have been tested for technical and clinical efficacy and quality. Of 11 chronic diseases studied (including HF), consistent evidence of benefit was only seen for diabetes applications. The benefits detected were of marginal clinical importance and there were no reports of hard clinical end points.25 Randomised-controlled trials provided conflicting evidence of efficacy of telemonitoring and telerehabilitation on outcomes such as hospitalisation and mortality (table 1). The lack of an evidence base behind digital healthcare limits the physicians’ confidence in adopting digital healthcare in daily practice.

Regulatory issues

Lack of regulation and legislation regarding digital healthcare prevents its widespread implementation. A World Health Organization (WHO) survey revealed huge variations among European countries in terms of e-health regulation or guidance on data validity, security and value assessment.26 To tackle this problem, national authorities are developing regional certification programmes for technological interventions.

The future of digital healthcare

Many think digital healthcare will improve the cost-effectiveness of our healthcare system and improve patients’ healthcare experience. Although promising, there is, as yet, insufficient evidence to support its widespread implementation, at least in the field of HF. Further education and support, and a comprehensive workable evaluation framework are needed to facilitate confident and widespread use of these technologies in managing HF patients. In particular, according to the ARCHIE framework, digital healthcare should be “anchored in what matters to users; realistic about natural history of illness, continuously co-created with users, embedded in social networks and integrated to mobilise knowledge across network” before implementation.27 Interestingly, a study pointed out that HF self-management may be associated with reduced hospital admissions in only a subgroup of patients who are under 65 years of age, whereas in other subgroups, such as patients with depression, self-management may be associated with reduced survival rate.28 This emphasises the importance of careful selection of patients before implementing digital healthcare.

Conclusion

Digital healthcare is being introduced to the management of HF as a consequence of innovations in information technology. Initial evaluation is that it might improve healthcare delivery but there are multiple barriers impeding its large-scale deployment. These challenges have to be tackled before HF becomes a cyber-specialty.

Key messages

  • Advancement in technology enables remote symptom and device monitoring, potentially improving patient outcomes and quality of life. It also provides the potential to redesign our heart failure healthcare system to one with greater efficacy through computer-aided decision-making systems
  • Barriers to widespread implementation of digital healthcare in heart failure include patient-related barriers such as user characteristics; privacy and security concerns; physician-related barriers such as lack of infrastructure, knowledge and training; technical barriers, such as challenges in maintaining system efficiency and data quality; and the lack of regulation and legislation regarding digital healthcare
  • Further education and support, and a comprehensive workable evaluation framework, are needed to facilitate confident and widespread use of digital healthcare in managing patients with heart failure

Conflicts of interest

None declared.

Funding

None.

References

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