Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients With Heart Failure: The Better Effectiveness After Transition — Heart Failure (BEAT-HF) Randomized Clinical Trial
Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients With Heart Failure: The Better Effectiveness After Transition — Heart Failure (BEAT-HF) Randomized Clinical Trial
Importance: It remains unclear whether telemonitoring approaches provide benefits for patients with heart failure (HF) after hospitalization.
Objective: To evaluate the effectiveness of a care transition intervention using remote patient monitoring in reducing 180-day all-cause readmissions among a broad population of older adults hospitalized with HF.
Design, setting, and participants: We randomized 1437 patients hospitalized for HF between October 12, 2011, and September 30, 2013, to the intervention arm (715 patients) or to the usual care arm (722 patients) of the Better Effectiveness After Transition-Heart Failure (BEAT-HF) study and observed them for 180 days. The dates of our study analysis were March 30, 2014, to October 1, 2015. The setting was 6 academic medical centers in California. Participants were hospitalized individuals 50 years or older who received active treatment for decompensated HF.
Interventions: The intervention combined health coaching telephone calls and telemonitoring. Telemonitoring used electronic equipment that collected daily information about blood pressure, heart rate, symptoms, and weight. Centralized registered nurses conducted telemonitoring reviews, protocolized actions, and telephone calls.
Main outcomes and measures: The primary outcome was readmission for any cause within 180 days after discharge. Secondary outcomes were all-cause readmission within 30 days, all-cause mortality at 30 and 180 days, and quality of life at 30 and 180 days.
Results: Among 1437 participants, the median age was 73 years. Overall, 46.2% (664 of 1437) were female, and 22.0% (316 of 1437) were African American. The intervention and usual care groups did not differ significantly in readmissions for any cause 180 days after discharge, which occurred in 50.8% (363 of 715) and 49.2% (355 of 722) of patients, respectively (adjusted hazard ratio, 1.03; 95% CI, 0.88-1.20; P = .74). In secondary analyses, there were no significant differences in 30-day readmission or 180-day mortality, but there was a significant difference in 180-day quality of life between the intervention and usual care groups. No adverse events were reported.
Conclusions and relevance: Among patients hospitalized for HF, combined health coaching telephone calls and telemonitoring did not reduce 180-day readmissions.
Finally, a Real Chance for Change in Medicare Related to Telehealth & Remote Monitoring
February 3, 2016 | Krista Drobac, Executive Director of the Alliance for Connected Care
Today represents the first real chance we have had to change Medicare payment policy for telehealth and remote patient monitoring. While the commercial market adopts these tools at a rapid rate, there is virtually no access for seniors in Medicare. This issue got a powerful boost this morning with the introduction of the CONNECT for Health Act in both the U.S. Senate and the U.S. House of Representatives.
Six bipartisan U.S. Senators, including three Committee chairman, and four U.S. Representatives on committees of jurisdiction, came together to introduce a bill that has been endorsed by more than 50 groups, including AARP, the American Medical Association, America’s Health Insurance Plans, the American Heart Association and more.
The CONNECT for Health Act, which is led in the Senate by Senators Brian Schatz (D-HI) and Roger Wicker (R-MS), and in the House by Representatives Diane Black (R-TN) and Peter Welch (D-VT), is a measured approach that lifts Medicare’s outdated restrictions on the use of telehealth, provides resources for remote patient monitoring technology for patients with chronic conditions, ensures new payment models will include these tools, makes these technologies part of Medicare Advantage, and addresses specific challenges related to stroke and dialysis.
Telehealth and remote monitoring are important for achieving the goals of value-based care, providing more access to primary care and behavioral health, improving chronic care management and advancing patient engagement. Patients with commercial coverage have access to these tools through their employers, health plans or health system. The evidence from their usage proves that telehealth and remote monitoring can move our health care system toward better care at lower costs.
According to an independent analysis from Avalere Health, the CONNECT for Health Act will decrease federal spending by $1.8 billion over the next ten-year period. In addition, the study estimates an immediate impact improving patient access with nearly 8.2 million Medicare beneficiaries receiving telemedicine and remote patient monitoring services through a demonstration waiver program by 2017.
It is long overdue for Congress to modernize care and access for all Medicare beneficiaries.
Diverse Group of Patients, Providers, Industry Applaud Consensus Approach to Telemedicine in Medicare
February 3, 2016 – Today, a diverse group of patient, provider and industry groups applauded the introduction of the CONNECT for Health Act, a bipartisan piece of legislation introduced by Senators Brian Schatz (D-HI) and Roger Wicker (R-MS) that lifts Medicare’s outdated restrictions on the use of telehealth and provides a benefit for remote patient monitoring. Organizations as diverse as AARP, the American Medical Association, America’s Health Insurance Plans and the American Heart Association came to support the CONNECT for Health Act as it represents the first time in more than a decade that consensus has been reached on how to modernize Medicare’s approach to remote patient care. [more…]
Sustained efficacy of pulmonary artery pressure to guide adjustment of chronic heart failure therapy: complete follow-up results from the CHAMPION randomised trial
Sustained efficacy of pulmonary artery pressure to guide adjustment of chronic heart failure therapy: complete follow-up results from the CHAMPION randomised trial
Background: In the CHAMPION trial, significant reductions in admissions to hospital for heart failure were seen after 6 months of pulmonary artery pressure guided management compared with usual care. We examine the extended efficacy of this strategy over 18 months of randomised follow-up and the clinical effect of open access to pressure information for an additional 13 months in patients formerly in the control group.
Methods: The CHAMPION trial was a prospective, parallel, single-blinded, multicentre study that enrolled participants with New York Heart Association (NYHA) Class III heart failure symptoms and a previous admission to hospital. Patients were randomly assigned (1:1) by centre in block sizes of four by a secure validated computerised randomisation system to either the treatment group, in which daily uploaded pulmonary artery pressures were used to guide medical therapy, or to the control group, in which daily uploaded pressures were not made available to investigators. Patients in the control group received all standard medical, device, and disease management strategies available. Patients then remained masked in their randomised study group until the last patient enrolled completed at least 6 months of study follow-up (randomised access period) for an average of 18 months. During the randomised access period, patients in the treatment group were managed with pulmonary artery pressure and patients in the control group had usual care only. At the conclusion of randomised access, investigators had access to pulmonary artery pressure for all patients (open access period) averaging 13 months of follow-up. The primary outcome was the rate of hospital admissions between the treatment group and control group in both the randomised access and open access periods. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00531661.
Findings: Between Sept 6, 2007, and Oct 7, 2009, 550 patients were randomly assigned to either the treatment group (n=270) or to the control group (n=280). 347 patients (177 in the former treatment group and 170 in the former control group) completed the randomised access period in August, 2010, and transitioned to the open access period which ended April 30, 2012. Over the randomised access period, rates of admissions to hospital for heart failure were reduced in the treatment group by 33% (hazard ratio [HR] 0·67 [95% CI 0·55-0·80]; p<0·0001) compared with the control group. After pulmonary artery pressure information became available to guide therapy during open access (mean 13 months), rates of admissions to hospital for heart failure in the former control group were reduced by 48% (HR 0·52 [95% CI 0·40-0·69]; p<0·0001) compared with rates of admissions in the control group during randomised access. Eight (1%) device-related or system related complications and seven (1%) procedure-related adverse events were reported.
Interpretation: Management of NYHA Class III heart failure based on home transmission of pulmonary artery pressure with an implanted pressure sensor has significant long-term benefit in lowering hospital admission rates for heart failure.
Telemedicine fans point to CBO’s history of cost overestimates
Politico | December 21, 2015
Excerpt:
The Alliance for Connected Care, a two-year-old telemedicine lobbying group that’s been driving congressional interest in the industry, has produced multiple studies that it says show the technology can save Medicare money.
Five National Policy Developments that Advance Telemedicine
This year was a busy year for telemedicine at the state level. State legislatures and medical boards across the country considered dozens of measures, most of them aimed at improving the policy environment for telemedicine. In the flurry of activity, you may have missed some major developments at the national level that are going to continue to propel telemedicine into the mainstream of health care tools. I will elaborate on these developments in future blog posts, but here is a summary.
1. Network Adequacy
The National Association of Insurance Commissioners (NAIC) establishes model guidelines for network adequacy, which defines the sufficient number of medical providers and hospitals a health plan must have to adequately treat patients. On September 1st, the NAIC released a draft Network Adequacy Plan for legislators across the country to consider in 2016. The plan adds telemedicine to the list of criteria an insurance commissioner can take into consideration in determining the sufficiency of networks. This development, if finalized in its current form, means that health plans will be able to use telemedicine as a factor in determining whether plan members have adequate access to providers. In areas with provider shortages, this means that telemedicine will officially be able to fill gaps in access to care.
2. The Medicare Access and CHIP Reauthorization Act (MACRA)
Signed into law in April, the legislation fundamentally changes the way physicians, nurses and other practitioners will be paid by Medicare. Starting in 2019, providers will no longer receive automatic annual payment updates. For the first time, pay increases will depend on performance. Providers can achieve reimbursement growth through one of two paths – participation in an alternative payment model, or positive results as part of the Merit-based Incentive Performance System (MIPS). MIPS will measure performance in four areas: 1) quality; 2) resource utilization; 3) investment in clinical improvement activities; 4) electronic health records usage. Telemedicine will be helpful in either route because providers will be required to reach outside the four walls of their office to ensure holistic, quality care that avoids costly and unnecessary services.
If providers choose MIPS, part of their performance score will be related to improving clinical practice or care delivery. Categories include: (1) expanded practice access; (2) population health management; (3) care coordination, “including use of remote monitoring or telehealth”; (4) beneficiary engagement; (5) patient safety and practice assessment; and, (6) participation in an alternative payment model. Telemedicine was specifically mentioned in the statute, and the other categories of MIPS, such as expanded practice access, population health management, care coordination and beneficiary engagement are significantly advanced by telemedicine tools.
3. Medicare Physician Fee Schedule (MPFS)
In the 2016 MPFS proposed rule published by Centers for Medicare and Medicaid Services (CMS) in July, the agency, for the first time proposed reimbursement for telemedicine services provided in the home setting. They propose adding payment for telemedicine services related to End-Stage Renal Disease (ESRD) counseling in a patient’s home. While the codes are narrow and the patient still has to be connected to an “originating site,” the proposal is a positive step toward telemedicine access in the home for Medicare patients.
4. Comprehensive Care for Joint Replacement Payment Model (CCJR)
In July, CMS and the Centers for Medicare and Medicaid Innovation (CMMI) released a new payment demonstration model aimed at reducing Medicare costs for lower extremity joint replacement. The CCJR creates a mandatory bundled payment for the most common surgeries in Medicare, hip and knee replacements. According to the agency, in 2013, there were more than 400,000 inpatient primary procedures in Medicare, costing more than $7 billion for hospitalization alone. The new payment model will “hold hospitals financially accountable for the quality and cost of a model episode of care and incentivize increased coordination of care among hospitals, physicians, and post-acute care providers.” In order to facilitate improved coordinated care delivery, CMS is lifting Medicare restrictions on telemedicine for CCJR participants. The agency says “the use of remote access technologies may improve the accessibility and timeliness of needed care, increase communication between providers and patients, enhance care coordination and improve the efficiency of care.”
5. U.S. Senate Chronic Care Working Group
In May, a powerful group of bipartisan U.S. Senators, including Finance Committee Chairman Orrin Hatch, Ranking Member Ron Wyden, Senator Johnny Isakson and Senator Mark Warner released a request for information from stakeholders on how to improve chronic care for Medicare beneficiaries. The letter stated, “developing and implementing policies designed to improve disease management, streamline care coordination, improve quality and reduce Medicare costs is a daunting challenge. But we are committed to tackling this urgent matter head on and finding ways to provide high quality care at greater value and lower cost…” The letter went on to specifically ask about “ideas to effectively use or improve the use of telehealth and remote patient monitoring technology.” An implicit recognition that telemedicine and remote monitoring are part of the value equation for chronically ill Medicare patients.