Heart failure is a chronic disease with a high prevalence. In Belgium, 10-20% of the population between the ages of 70 and 80 suffers from the condition.1 The disease process is intrinsically fluctuating with multiple episodes of acute exacerbation, often requiring hospitalisation. These frequent hospitalisations are a major factor in the overall cost of heart failure patients, which is estimated to be one to two percent of the Belgian national healthcare budget.1 Internationally, an ageing population will drive up the prevalence of heart failure, making it increasingly difficult to maintain the quality of care.2 It has been shown that hospitalisation due to an acute exacerbation is preventable through high quality self-management by the patient, including symptom monitoring and taking prompt action when deterioration begins.2-5 The barriers to achieve qualitative self-management are lack of knowledge, symptom recognition, motivation, and medication- and diet compliance. Thus, education about diagnosis, treatment, follow-up, and alarm symptoms is essential.6-8 For example, the patient would be advised to regularly measure their body weight and would be given instructions in case of a significant increase.7 This requires a holistic approach and proximity to the patient. GPs are therefore key figures in the care of patients with heart failure, with close follow-up by the GP leading to better compliance and fewer hospital admissions.7 However, this leads us to some other barriers to performing prevention in primary care, which is hindered by a lack of time, lack of skills and a lack of patient motivation.8 The lack of time is caused by a steadily increasing number of consultations and a declining clinical capacity.9-11 Again, as discussed in the case of the global prevalence of heart failure, the ageing of the population with the accompanying increase in multi-morbidity puts pressure on the ability to provide quality care.12, 13 To cope with this increasing pressure, information and communication technologies are being explored as a means of providing support for healthcare providers.14 This is generally known as eHealth. Moreover, national and international organisations are encouraging primary care workers to embrace these innovative ways of working.15-17 In this article we explore how eHealth can support the management of heart failure patients in primary care basing our assumptions on existing research.
To maintain and improve the quality of care for heart failure, a switch from crisismanagement (by hospitalisation) to health maintenance (prevention of exacerbations with the use home monitoring) may be an affordable method.2 In 2015, the Cochrane institute concluded in a systematic review that the risk of all-cause mortality and heart failure related hospitalizations is reduced by non-invasive home tele-monitoring of patients. Furthermore, the interventions demonstrated improvements in health-related quality of life, heart failure knowledge, and self-care behaviours. Additionally, patient satisfaction with these interventions was high.2 In 2018, the British National Institute for Health and Care Excellence (NICE) dedicated a section discussing the literature on tele- and self-monitoring in its latest guideline for the diagnosis and management of chronic heart failure in adults. From their literature review they concluded that there was a clinically significant reduction in mortality and hospital admissions for those who had recently been hospitalised and were tele-monitored on an outpatient basis. However, they did not state an official recommendation for clinical practice as the evidence could not demonstrate a clear clinical benefit. This was because the studies provided little information about the standard of provided care in the usual care arm and a lack of homogeneity in the tele-monitoring tools used (with variability in frequency and type of technology).18 It can be concluded that the evidence shows a clear trend towards a benefit from tele-monitoring. However, more uniform research is needed to confirm a clear clinical benefit.
A uniformity in tele-monitoring can be achieved with patient reported outcomes (PROs). PROs can be defined as any report of the status of a patient’s health condition or health behaviour that comes directly from the patient. The key domains of PROs are health-related quality of life, symptoms, and symptom burden (e.g., pain, fatigue), and health behaviours (e.g., smoking, exercise).19 Disease-specific PROs are often more sensitive to clinical changes, interpretable, useful in clinical practice, and fairer reflections of the quality of care for a specific disease.20 In the case of heart failure, the patient would periodically report their experience of symptoms and signs such as dyspnoea, exercise tolerance and formation of peripheral oedema, and parameters such as blood pressure and heart rate. In practice, PROs have been shown to aid in providing patient-centred care to patients with heart failure, tailoring treatments to a patient’s specific goal. Comparing these tracked measures with a target increased goal motivation, symptom awareness, and understanding of the relationship between lifestyle or behavioural choices and health status, encouraging patients to better self-manage their condition.21 A recent systematic review on the use of mobile apps for heart failure self-management saw that only 20% of the applications used PROs based on a validated questionnaire.21 It is not known how responsive these non-validated questionnaires are to clinical change. Moreover, it is difficult to use the resulting aggregated data for quality research. Validated questionnaires suitable for tele-monitoring would be the Kansas City Cardiomyopathy questionnaire (KCCQ-12) and Minnesota Living with Heart Failure Questionnaire (MLHFQ) which are the most extensively evaluated and validated PRO measures in heart failure.20 However, compared to the MLHFQ, the KCCQ not only independently quantifies more domains of heart failure-specific health status, it has also been shown to be more responsive to clinical change than the MLHFQ. It may be used with younger and older patients and across gradations of socio-economic status.20 For the implementation of the KCCQ-12 in clinical practice, it has been suggested that a first step would be for the clinician to focus on the overall summary score. If the score is low, then a deeper exploration of the individual KCCQ domains can be useful to best determine which domains—symptoms, function, or quality of life—are most limiting the patients’ health status.20 Further exploration of these domains could then be achieved with questionnaires developed specifically for primary care.
There is potential for eHealth to help general practitioners to better manage chronic heart failure patients. Using PROs, digital tools can be developed to specifically educate and empower patients to monitor their symptoms and medication compliance. Future research on the role of tele-monitoring in the management of chronic heart failure could make use of a validated questionnaire such as the KCCQ-12 to ensure uniformity.
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