Last month a study published in JAMA Internal Medicine made headlines and caused a few waves in digital health after concluding telemonitoring supported by a nurse call center intervention after discharge did not have an effect on outcomes for congestive heart failure patients. This week Dr. Joseph Kvedar, Vice President of Connected Health at Partners HealthCare, which was not involved in the study, helped shed some light on why the intervention showed little effect.
"This trial included a large sample size and was published in a well-respected and well-read journal," Kvedar wrote in a blog post. "On initial reading, it was less clear to me why they did not see an effect. I had to read thoroughly – way beyond the headline — to get an idea. The authors, in the discussion section, provide several thoughtful possibilities. One that jumps out to me is that the intervention was not integrated into the physician practices caring for the patients. In our experience with CHF telemonitoring, it is crucial that the telemonitoring nurses have both access to the physician practices and the trust of the patients’ MDs. Sometimes a simple medication change can prevent a readmission if administered in a timely manner. This requires speedy communication between the telemonitoring nurse and the prescribing physician. If that connection can’t be made, the patient may wind up in the emergency room and the telemonitoring is for naught."
Kvedar also pointed out an important data point that is worth paying attention to in just about any digital health intervention study: adherence.
"It is also fascinating that the authors point out that adherence to the intervention was only about 60 percent," Kvedar wrote. "This reminds me of another high profile paper from 2010 that came to the conclusion that telemonitoring for CHF ‘doesn’t work.’ I blogged on that at the time, pointing out that their adherence rate was 50 percent. In both cases, with such low adherence, it is not surprising that the effect was not noted."
Kvedar said that in Partners' own connected health CHF program adherence was nearly 100 percent, which helped keep readmission rate to about 50 percent. Partners also found their intervention correlated to a 40 percent improvement in mortality over six months.
"The telemonitoring nurses from Partners HealthCare at Home cajole the patients in the most caring way and patients are therefore quite good at sending in their daily vitals. If they don’t, the nurses call to find out why," Kvedar wrote. "Our program is also tightly aligned with the patients’ referring practitioners. I suspect these two features are important in explaining our outcomes."
Kvedar continued: "I think we’ve collectively fallen into a trap of treating ‘mobile health’ and ‘telemonitoring’ as monolithic things when, as you can see, these interventions are designed quite differently." He went on to conclude: "I’m not sure intention to treat analysis is the right way to evaluate connected health interventions. If patients are non-adherent to the intervention, is it any surprise that they don’t respond? I’m having trouble wrapping my head around that one."