The mortality risk of deferring optimal medical therapy in heart failure: a systematic comparison against norms for surgical consent and patient information leaflets

Aims: The prescription of optimal medical therapy for heart failure is often delayed despite compelling evidence of a reduction in mortality. We calculated the absolute risk resulting from delayed prescription of therapy. For comparison, we established the threshold applied by clinicians when discussing the risk for death associated with an intervention, and the threshold used in official patient information leaflets.

Methods and results: We undertook a meta-analysis of randomized controlled trials to calculate the excess mortality caused by deferral of medical therapy for 1 year. Risk ratios for angiotensin-converting enzyme inhibitors, beta-blockers and aldosterone antagonists were 0.80, 0.73 and 0.77, respectively. In patients who might achieve a 1-year survival rate of 90% if treated, a 1-year deferral of treatment reduced survival to 78% (i.e. an annual absolute increase in mortality of 12 in 100 patients). This corresponds to an additional absolute mortality risk per month of 1%. A survey of clinicians carried out to establish the risk threshold at which they would obtain written consent showed the majority (85%) sought written consent for interventions associated with a 12-fold lower mortality risk: one in 100 patients. A systematic review of UK patient information leaflets to establish the magnitude of risk considered sufficient to be stated explicitly showed that leaflets begin to mention death at a ∼18 000-fold lower mortality risk of just 0.0007 in 100 patients.

Conclusions: Deferring heart failure treatment for 1 year carries far greater risk than the level at which most doctors seek written consent, and 18 000 times more risk than the level at which patient information leaflets begin to mention death.

Remote management of heart failure using implantable electronic devices

Aims: Remote management of heart failure using implantable electronic devices (REM-HF) aimed to assess the clinical and cost-effectiveness of remote monitoring (RM) of heart failure in patients with cardiac implanted electronic devices (CIEDs).

Methods and results: Between 29 September 2011 and 31 March 2014, we randomly assigned 1650 patients with heart failure and a CIED to active RM or usual care (UC). The active RM pathway included formalized remote follow-up protocols, and UC was standard practice in nine recruiting centres in England. The primary endpoint in the time to event analysis was the 1st event of death from any cause or unplanned hospitalization for cardiovascular reasons. Secondary endpoints included death from any cause, death from cardiovascular reasons, death from cardiovascular reasons and unplanned cardiovascular hospitalization, unplanned cardiovascular hospitalization, and unplanned hospitalization. REM-HF is registered with ISRCTN (96536028). The mean age of the population was 70 years (range 23-98); 86% were male. Patients were followed for a median of 2.8 years (range 0-4.3 years) completing on 31 January 2016. Patient adherence was high with a drop out of 4.3% over the course of the study. The incidence of the primary endpoint did not differ significantly between active RM and UC groups, which occurred in 42.4 and 40.8% of patients, respectively [hazard ratio 1.01; 95% confidence interval (CI) 0.87-1.18; P = 0.87]. There were no significant differences between the two groups with respect to any of the secondary endpoints or the time to the primary endpoint components.

Conclusion: Among patients with heart failure and a CIED, RM using weekly downloads and a formalized follow up approach does not improve outcomes.

Remote Monitoring of Patients With Heart Failure: An Overview of Systematic Reviews

Background

Many systematic reviews exist on the use of remote patient monitoring (RPM) interventions to improve clinical outcomes and psychological well-being of patients with heart failure. However, research is broadly distributed from simple telephone-based to complex technology-based interventions. The scope and focus of such evidence also vary widely, creating challenges for clinicians who seek information on the effect of RPM interventions

Objective

The aim of this study was to investigate the effects of RPM interventions on the health outcomes of patients with heart failure by synthesizing review-level evidence.

Telemonitoring Reduced Costs and Inpatient Visitation Rates for Patients with Advanced Cardiovascular Disease: A Matched Cohort Study Telemonitoring Reduced Costs and in-Patient Visitation Rates for Patients with Advanced Cardiovascularddisease

Introduction: Reducing the cost of care of patients with cardiovascular disease is an important target for integrated health systems. Managing these patients is difficult and costly, with commensurately high rates of inpatient (IP) visitation.

Hypothesis: Medical costs and IP visitation rates of patients receiving remote telemonitoring (TM) will decrease, relative to what they would have otherwise been.

Methods: We performed a concurrent matched cohort study, comparing patients receiving TM to those who did not. Our treatment cohort includes all members of Priority Health, Grand Rapids, MI (PH) that received TM between January 2012 and September 2013. Members of the treatment cohort were matched 1:1 against non-TM members of PH, indexed on the month of TM enrollment. Matching criteria includes age and sex; chronic morbidity status (heart failure, COPD, HTN, diabetes); observed medical costs 12 and 6 months prior to initiation of TM; and IP utilization within 12 months prior to initiation of TM. Members were excluded from treatment and putative control cohorts if they did not have continuous enrollment for 12 months prior and 24 months post initiation of TM. Endpoints include 24 month cumulative medical cost and IP visitations.

Results: We provide population-level metrics (Table) with 80% confidence intervals for endpoint differences and average cumulative cost and inpatient visitation curves (Figure) for our treatment and matched control cohorts.

Conclusions: Remote telemonitoring of patients with advanced cardiovascular disease can reduce inpatientvisitation rates, driving a reduction in medical costs. In this study, we estimate a visitation rate reduction of 4.9%, and a medical cost reduction of $13,608 over 24 months.