Congestive Heart Failure

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Contents

Introduction

Congestive Heart Failure (CHF), or heart failure, is a condition in which the heart can't pump enough blood to the body's other organs. Congestive Heart Failure is the most frequent cause of disability and death in persons aged 65 years and older. CHF is the most common cause of re-admission to hospitals, each costing up to $10 000 and is expected to double over the next 40 years [1]. Patient adherence to medication is a key factor in successful treatment of CHF, often requiring long-term use of multiple medications to treat the problem as well as further medication to ameliorate signs and symptoms. A major factor in re-admissions is failure to detect early indicators of episodes and patient non-adherence to medication or treatment regimes. Changing the current focus on treatment following acute episodes or attacks through preventative intervention systems and home based monitoring will reduce the need for expensive hospital admissions.

Remote physiological monitoring of CHF allows physiological indicators and symptoms to be observed and recorded by a carer or healthcare professional without the need to be in the same physical location as the patient. This reduces some of the burden on the healthcare system and allows for monitoring in the home. Home monitoring in this case could indicate the need for medical attention prior to the development of an acute exacerbation.

Remote CHF monitoring systems examine one or more of the following indicators:

  • Weight (Device: Weight Scales)
  • Blood Pressure (Device: BP Monitor)
  • Peak Expiratory Flow Rate (Device: Peak Flow Meter)
  • Blood oxygen saturation (Device: Pulse Oximeter)

These indicators are recorded by an aggregator which records the data and forwards it on to the relevant carer or GP. This device may also act as an actuator which feeds information back to the patient, such as medication reminders or advice from medical staff.

International Aspects

US

The National Institute of Health (NIH) is the umbrella organisation responsible for health funding in the United States. It has a number of sub-organisations or Institutes with specific areas of responsibility, such as the Institute of Medicine (IOM) or the National Institute on Aging.

The American Heart Association is a non-profit organisation that promotes cardiac care and has programs funding research into heart health.

EU

In the UK the National Health Service (NHS) runs one of the largest health information systems in the world.

  • SHAPE The Study Group on Heart Failure Perception and Awareness in Europe was founded in 2002 by a group of independent medical specialists with the aim of improving heart failure care across Europe through increasing public awareness.

Japan

  • Japan Public Health Association - An incorporated foundation dedicated to promoting healthy living for Japanese citizens. Funds research into public health, co-ordinates activities of public health organizations, dissemination of information, hosting academic conferences.
  • Japanese Heart-Faliure Society - An academic society that works to furthing research on heart failure by co-ordinating research and hosting annual academic conferences.

Interventions and Challenges

It is estimated that in the U.S. telehealth services could reduce physician visits by 20% at a saving of up to $9 billion [2], with institutional care representing the largest and most expensive component of CHF treatment[3]. Research has shown that 53% of CHF related hospital readmissions are due to preventable issues such as noncompliance with medication, diet or non-detection of problematic indicators[4]. Poor adherence to medication is a contributing factor in 20-64% of hospital readmissions for CHF related problems [5]. According to [2] “The ability to collect sound clinical data, combined with improved communication between patients and nurses, increased patient compliance.”

Plant and Moran P.L.L.C. health care consulting preliminary studies have indicated that telemedicine does reduce hospital and ER visits and results in better patient outcomes. Studies carried out by Pearson et al. in the University of South Australia, University of Queensland and the Chinese University of Hong Kong have showed that home based intervention methods in patients with Chronic Illness have reduced hospital admission rates by 14% within two years and by 21% in all surviving patients within 3 to 8 years. Research completed by Pat A. Heffernan, President Genesee Region Home Care & Hospice showed that hospital admission was reduced by 28% using a daily home monitoring systems and resulting hospital re-admission reduced by 8% as a result. The department of Veteran Affairs has shown a 35% drop in hospital readmissions and a 60% drop in emergency visits for diabetic and lung disease patients by deploying a remote monitoring tool for physically impaired patients at home. Strategic Healthcare Programs (SHP) have shown that an average improvement rate in the stabilization in ADL’s of patients with CHF increased by 4.9% when monitored by a home monitoring device and improvements of 10.9% in stabilisation of independent activities of daily living (IADL) They also showed that hospitalisation decreased by 3.9% in monitored CHF patients.

Some studies indicate that patients who utilize in-home telehealth monitoring systems have a higher self-perceived quality of life [6]. This may be due to comfort/familiarity factors combined with not perceiving themselves as ‘sick’ due to less frequent physical contact with doctors and the health services.

Issues

Patient Compliance - patients must remember and/or want to take regular physiological measurements themselves and forward them to the relevant person. This may create feelings of 'illness' or be inconvenient. Other therapy related barriers to adherence include: adverse effects, polypharmacy, frequent dosing and cost. Other reasons for nonadherence are: poor communication/education regarding the medication, complexity of drug regimens and failure to initiate therapy in hospital when the patient is most likely to relate the drug to health[7].


  • Ease of use - the monitoring device must be usable by an elderly person, who may have some form of functional or cognitive impairment.
  • Interoperability of monitoring systems with healthcare IT systems - the monitoring device must provide data in the right format to be accessible to the relevant healthcare professional
  • Data security - the data from the monitoring system must be inaccessible to unauthorised users.
  • Sensor Reliability - the healthcare professional must be able to make accurate and reliable diagnosis from the data provided and able to detect system failure.
  • Genetic screening may be of use in determining susceptibility to CHF[8], however there are ethical and social issues to be considered, such as who has access to the data (employers, insurers, family, government).
  • Cost - the initial outlay makes current telehealth systems still relatively expensive, however it is believed that they will ultimately have cost savings by avoiding costly emergency treatment. More research is needed into the efficacy of such systems in order to prove their worth to insurers and healthcare providers.

Enabling Technologies

Challenges

While home or telehealth monitoring has been shown to have health and economic benefits, it is dependent on the patient adhering to the monitoring regime. At present monitoring is done through explicit devices which the patient must be trained to use. This equipment is not yet cheap or universal and may not integrate with other health information systems. There are also open questions about who has/should have access to different levels of patient health information and where responsibility for responding to telehealth data lies.


Research Projects

The HHM is a hand held device with an integrated modem which automatically transmits the following physiologic indices directly to a computer server: Blood pressure levels and pulse-rate (automatic, non-invasive), Weight, Blood oxygen saturation levels, Glucose levels. In a pilot study, the hospital readmission rate for 35 congestive heart failure patients using the Home Health Monitor was 14% over a six-month period, compared to the national readmission average of 42% over a three-month period.

The Home Link System provides for communication and data recording of patient information, such as information for monitoring and managing congestive heart failure (CHF).

  • PulmoTrace@Home - Tel-Aviv University. CardioInspect employs the bio-impedance and electrical impedance tomography (EIT) principles in order to monitor and diagnose pulmonary edema and cardiac functionality indices in CHF patients. The Tele-Medicine home system is designed for CHF patients for an on-going monitoring of lung congestion at home environment, allowing the detection of potential CHF condition degradation. The measured data, including right and left lungs resistivities and a 10-seconds ECG, is transmitted via modem-connection into a medical-center, which gathers all incoming data, and compares it to previous measurements to help determine further treatment.


Commercial Products

  • Honeywell HomMed System - A suite of hardware and software home monitoring solutions, that can measure heart rate, blood pressure, oxygen saturation, temperature and weight. Also prompts users as to when it's time to measure their vital signs. Includes the Genesis, Sentry and Lifestream systems.
  • Medtronic Inc. Reveal Insertable Cardiac Monitor An insertable cardiac monitor is a small implantable device that continuously monitors heart rhythms and records them automatically or by using a hand-held patient activator. The device is implanted just beneath the skin in the upper chest area, during a simple procedure.
  • Telcomed - Wristclinic/Miniclinic - Portable and mobile multi-parameter telehealth monitoring system measuring: Heart rate, ECG, Blood pressure, Heart rhythm regularity, Respiratory rate, Oxygen saturation (SpO2), Body temperature. Also manufacture and sell: Blood Pressure Monitor, Wireless Weight Scale and the MedicGate/MiniGate vital signs collecting gateways for use in conjunction with their systems.
  • Cardiocom Telescale - Interactive networked weighing scales for monitoring of CHF. AlsoCompact Telescale
  • Cardiocom Commander
  • Cardionetics have ambulatory ECG halter monitors that can also preform analysis and abnormality detection and alerts. Modular telehealth monitoring system that takes a variety of sensors and so can be configured for specific patient needs.
  • Docobo HealthHub - PDA style interactive system capable of monitoring a variety of chronic diseases.

Players


Business Models

Home monitoring systems with the ability to track weight, temperature, peak flow, and blood pressure allows for the ability to respond quickly if vital signs return abnormal results. This allows physicians to give priority to patients that have been ‘flagged’ and helps avoid hospital stays and strains on resources. Strategic Healthcare Programs (SHP) have shown that an average improvement rate in the stabilisation in ADL’s of patients with CHF increased by 4.9% when monitored by a home monitoring device and improvements of 10.9% in stabilisation of independent activities of daily living (IADL) They also showed that hospitalisation decreased by 3.9% in monitored CHF patients.

Business models for CHF measurement have a long history starting with the provision of holter monitors and cardiac event monitors for recording and transmitting ECG outside the hospital environment. Generally these were reimbursed by the insurance or government health body, possibly after approval by a primary care physician More recently the business models are driven by the telehealth.

Current business models are built around provision of home monitoring services to healthcare providers, provision of equipment and software, communications networks and response to alerts.

Business models need to be developed which allow for cost effective integration of telehealth services into existing systems and services. Such services may piggyback on existing services, exploiting synergies with them or develop new methods for recruiting clients. An excellent example of leveraging existing technologies is the ‘Heart Monitor’ application [9] for Apples’ iPhone. This is a simple software download, which lets the user monitor their heart rate using their iPhone hardware. As yet this is not connected to any telehealth service but is a good example of cross-purposing consumer technology.

Opportunities exist for companies specialised in data security for healthcare systems and should be promoted and exploited. Provision of services to telehealth users: patient/disease tracking and care, treatment appointment reminders. An example of this type of service is the Canadian Ministry of Healths ‘Chronic Disease Management Toolkit’[10]. Such service providers must work to gain patient/customer confidence and provide tangible benefits to the end-user, particularly when they are to work in conjunction with state healthcare systems.

Companies such as Nike have capitalised on customers competitive spirit by offering exercise tracking in some of their new products, allowing users to graph their performance and compare it to that of their peers. We see this as an important approach to promote adherence to exercise and prevention regimes.


Standards

Interoperability standards are key to the future success of telehealth and home care information systems. HL7 is a commonly adopted standard supported by the American National Standards Institute (ANSI) and the International Organization for Standardization (ISO). HL7 develops Conceptual standards, Document standards, Application standards and Messaging standards (particularly important for interoperability of systems and devices).See CAPSIL section on Standards for a full treatment of this topic.

Gaps in the Basic Science

Most studies carried out into CHF have not looked at patients with multiple morbitities or symptoms, generally in order to simplify results. Little is known about interactions between treatment regimes or adverse side effects on susceptible patients e.g. the controversy over Rosiglitazone

More research is needed into pattern recognition algorhythms for detection of CHF indicators via remote sensors or telehealth systems. Also work into effective triaging from data supplied by telehealth or AAL systems is needed.

Gaps in Operation

Many of the patient-worn CHF monitoring devices are too complex in use and operation. Also displays and buttons tend to be too small for easy use by those with visual or physical impairments.

Gaps in Implementation

Current systems are difficult to use for non-medically trained (home) users. Human Computer Interaction (HCI) design for older users in general has a long way to go. Some standards for interoperability exist but there is not yet a common agreement among manufacturers and customers as to 'definitive' or universal standards. Standards for reporting of health information (both critical and non-critical) to telehealth users, carers and healthcare workers are needed. Also clearly defined systems and procedures for responding to medical alerts delivered as part of a telehealth system.

Future Vision

Multiple 'invisible' sensors deployed throughout an 'ambient assisted living' environment, able to monitor CHF relevant physiological factors, potentially as part of a larger integrated system for home health, not requiring a regular measurement routine. System feedback when necessary (e.g. medication reminders) or carer/clinician notification. Integration into non-physiological monitoring systems for diet, exercise, social connectedness.

Information Links

  • Erik B Friedrich MD & Michael Bˆhm MD (2006). Treatment of Chronic Heart Failure.
  • Krum H, National Heart Foundation of Australia and Cardiac Society of Australia & New Zealand Chronic Heart Failure Clinical Practice Guidelines Writing Panel. (2001). "Guidelines for management of patients with chronic heart failure in Australia." Med J Aust 174 (9): 459-66. PMID 11386592.
  • Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. (2005). "ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult". Circulation 112 (12): e154-235. PMID 16160202.
  • Granger CB, McMurray JJ, Yusuf S, Held P, Michelson EL, Olofsson B, Ostergren J, Pfeffer MA, Swedberg K; CHARM Investigators and Committees. (2003). "Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial." Lancet 362 (9386): 772-6. PMID 13678870.
  • Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL, Olofsson B, Ostergren J, Yusuf S, Pocock S; CHARM Investigators and Committees. (2003). "Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme." Lancet 362 (9386): 759-66. PMID 13678868.
  • Exner DV, Dries DL, Domanski MJ, Cohn JN (2001). "Lesser response to angiotensin-converting-enzyme inhibitor therapy in black as compared with white patients with left ventricular dysfunction.". N Engl J Med. 344 (18): 1351-7. PMID 11333991.
  • Taylor AL, Ziesche S, Yancy C, Carson P, D'Agostino R Jr, Ferdinand K, Taylor M, Adams K, Sabolinski M, Worcel M, Cohn JN; African-American Heart Failure Trial Investigators. (2004). "Combination of isosorbide dinitrate and hydralazine in blacks with heart failure." N Engl J Med 351 (20): 2049-57. PMID 15533851.
  • Erik B Friedrich MD & Michael Bˆhm MD (2006). Treatment of Chronic Heart Failire.
  • Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T, Carson P, DiCarlo L, DeMets D, White BG, DeVries DW, Feldman AM; Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Investigators. (2004). "Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure". N Engl J Med 350 (21): 2140-50. PMID 15152059.
  • Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, Tavazzi L; Cardiac Resynchronization-Heart Failure (CARE-HF) Study Investigators. (2005). "The effect of cardiac resynchronization on morbidity and mortality in heart failure". N Engl J Med 352 (15): 1539-49. PMID 15753115.
  • Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Boineau R, Domanski M, Troutman C, Anderson J, Johnson G, McNulty SE, Clapp-Channing N, Davidson-Ray LD, Fraulo ES, Fishbein DP, Luceri RM, Ip JH; Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) Investigators. (2005). "Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure." N Engl J Med 352 (3): 225-37. PMID 15659722.
  • Mandeep R. Mehra, Patricia A. Uber, Don B. Chomsky, Ron Oren ; Emergence of Electronic Home Monitoring in Chronic Heart Failure: Rationale, Feasibility, and Early Results With the HomMed Sentry™-Observer™ System; Congestive Heart Failure, Volume†6,†Issue†3 , Pages137†-†139, 2000 by CHF, Inc
  • Fiona M Blyth, Ross Lazarus, David Ross, Michael Price, Gary Cheuk and Stephen R Leeder; "Burden and outcomes of hospitalisation for congestive heart failure"; http://www.mja.com.au/public/issues/jul21/blyth/blyth.html ; article published on the Internet by The Medical Journal of Australia
  • www.health.gov.bc.ca/cpa/publications/practicalguide.pdf



References

  1. ↑ ScienceDaily. Retrieved October 17, 2008, from: http://www.sciencedaily.com/releases/1997/02/970218173035.htm
  2. ↑ 2.0 2.1 Craig Lehmann PhD CC (NRCC) FACB and Jean Marie Giacini BS; "Pilot Study: The Impact of Technology on Home Bound Congestive Heart Failure Patients"; Home Health Care Technology Report, v1(4):50,59-60, 2004, Civic Research Institute.
  3. ↑ RydÈn-Bergsten, T., Andersson, F., The health care costs of heart failure in Sweden. Journal of Internal Medicine, Volume 246, Number 3, September 1999 , pp. 275-284(10)
  4. ↑ Vinson JM, Rich MW, Sperry JC, Shah AS, McNamara T. Early readmission of elderly patients with congestive heart failure. J Am Geriatric Soc. 1990;38:1290-1295.
  5. ↑ Leventhal MJ, Riegel B, Carlson B, De GS. Negotiating compliance in heart failure: remaining issues and questions. Eur J Cardiovasc Nurs. 2005;4:298–307.
  6. ↑ Sue Myers, Richard W. Grant, Nancy E. Lugn, Beth Holbert and Joseph C. Kvedar, Impact of Home-Based Monitoring on the Care of Patients with Congestive Heart Failure, 2006; 18; 444 Home Health Care Management Practice
  7. ↑ Albert NM., Improving medication adherence in chronic cardiovascular disease, Crit Care Nurse. 2008 Oct;28(5):54-64
  8. ↑ Small KM, Wagoner LE, Levin AM, Kardia SLR, Liggett SB. 2002. Synergistic polymorphisms of _1- and 2C-adrenergic receptors and the risk of congestive heart failure. N Engl J Med 347(15):1135-1142
  9. ↑ http://www.tuaw.com/2008/09/29/first-look-heart-monitor/
  10. ↑ Chronic Disease Management Toolkit; http://www.health.gov.bc.ca/cdm/practitioners/toolkit_facts.pdf

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