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Evidence Based Clinical Question: Search Assignment


I have previously studied the health outcomes related to the application of modern telehealth technologies in wound care management. As a result of the conducted research, I arrived at the conclusion that the development of information and telecommunication technologies was associated with significant changes in health care practice. After doing a quick research, I found that the application of telehealth care is still largely understudied in regard to the treatment of chronic illnesses, in particular chronic heart failure (CHF). Studying the patients with CHF is also linked to my interests related to the nursing practice.

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CHF is a complex condition that requires the application of the appropriate and timely means of treatment. In the structure of mortality, a sudden cardiac death ranks first. More than 50% of the total number of deaths is associated with the cardiovascular causes. The overall cardiovascular diseases accounted for 30% of all deaths in 2010 (Estes, 2011; Frederix, Vanhees, Dendale, & Goetschalckx, 2014). The heart failure alone affects over five million Americans. In the developed countries, nearly 2% of all adults have CHF. It is a leading cause of hospitalization in patients aged over 65 (Fairbrother et al., 2014).

In this paper, I decided to continue the study of the application of telehealth technologies in the clinical practice. To this end, I wanted to focus more on the capacity of the remote technologies, including homecare for the treatment of the patients with CHF. The paper will argue that the clinical practice including homecare nursing requires the application of the reliable diagnostic algorithms to monitor the conditions of the CHF. It will also analyze the possibility of the improvement of the remote systems monitoring the patients’ heart activity. The existing data on the use of such systems for monitoring heart failure patients will be included.

Literature Search

I have formulated a clinical question “In patients with chronic heart failure, does telehealth, compared to usual care, help to improve the treatment outcomes?” using a patient, intervention, comparison, outcome (PICOT) criteria. P is patients with advanced/chronic heart failure; I is telehealth/telemedicine; C is usual care; O is improvement of clinical outcomes; and T does not apply. I have searched Cochrane Library and Pub Med databases to collect the evidence using different Boolean operators and keywords chronic heart failure, clinical outcomes, comparative effectiveness, cardiology, and telehealth/telemedicine. A total of 134 reviews were identified. Four articles that best suited the topic were chosen for the review. The inclusion criteria were based on the following factors. The articles had to focus on setting telehealth as a core component of the CHF-related intervention with interaction or input from health professionals or facilitators and include details on telehealth in terms of acceptance, abandonment, or perceptions. They also had to contain a sufficient data on population, intervention, and outcomes.

Literature Review

Telehealth/Telemedicine/Telehomecare Technology Assessment and Treatment of HF Patients

Telehealth is a system of the home-based management of the patients with chronic illnesses of long-term conditions, including heart failure. It is likely to have emerged as a result of the modern patient-centered and cost-efficient healthcare doctrine. To certain extent, the latter is associated with the application of the achievements of telecommunication technologies in providing health services. Today, one has a technical opportunity to design the devices that are both convenient in everyday use and capable of continuous operation and dynamic monitoring of vital body functions in the remote mode. Such projects are implemented in the world under the concept of telemedicine (Kvedar, Coye, & Everett, 2014).

Telemedicine was introduced as a “potential means for reducing the likelihood of worsening cardiac illnesses or the prospect of repeated or lengthy hospital readmissions” (Kotb, Cameron, Hsieh, & Wells, 2015). The problem of patients suffering from the heart failure is that they cannot rate, in a timely manner, the deterioration of their heart without somebody’s assistance. This obstacle often occurs in the course of the disease. As a result, the patients visit the doctor when the necessary time has already been lost. Early diagnosis of deterioration of the heart in patients with CHF is one of the goals of telemedicine. It monitors the changes of heart activity.

In addition, the application of telecommunication transmission technologies helps one to identify the malfunctions of the heart in the homecare setting in a timely manner. Special measuring devices transmit daily relevant patient-related data wirelessly to the telemedicine center. The system responds to the out-of-ordinary data, and the healthcare experts take the appropriate actions. It can be an emergency visit or a phone call.

This way, patients with CHF continue to live their ordinary lives remaining under the constant supervision of the health care professionals. It should be noted that telehealth is not some kind of a unique unified system, but a set of different technology-based systems. They can also be rated against one another. These systems are telemonitoring, video monitoring, structured telephone support, electrocardiographic data transmission, and structured telephone support with telemonitoring (Kotb et al., 2015).

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A Target Population Approach to Telemetric Intervention in Patients with CHF

Anker, Koehler, and Abraham (2011) mentioned that certain experts expressed their reasonable doubts on whether the stable patients should be telemonitored. The authors asserted that telemonitoring must be selective. It should be applied in the treatment of certain types of patients with respect to their age, medication, and decease severity. The overall profile of such patients is, however, unknown. The issue was addressed wider by the Heart Failure Society of America (2010). The latter has found that the heart failure is a prevalent condition in women, African Americans, and the elderly of both sexes and any race. According to this research, the medical practice lacks the evidence-based data to guide therapy in these groups (Heart Failure Society of America, 2010).

Furthermore, the US population aging has major implications for the prevalence of HF. The survival rate among the hospitalized elderly was about 2.5 years with 25% of the patients dying within one year (Heart Failure Society of America, 2010). CHF was also considered to be a common condition in women. The prevalence of HF in the elderly women was much greater than in men with men having worse survival rates. Diabetes and coronary disease were identified as the independent risk factors. It was noted that women were generally underrepresented in clinical trials related to HF (Heart Failure Society of America, 2010).

Comparative Effectiveness and Efficiency of Telemedicine for HF patients

Kotb et al. (2015) derived from the acknowledgement that little had been done to learn about the comparative impact of the different telemedicine options. To this end, the authors engaged in the network meta-analysis to examine the key comparisons across five major aforementioned forms of telemedical intervention. The findings from this analysis indicated that telemonitoring ranked first in terms of reducing death odds and it was followed by structured telephone support. The structured telephone support with telemonitoring were not found to have any significant impact on the reduction of the all-cause hospitalization as compared to the usual care. Kotb et al.(2015) emphasized that the “structured telephone support and telemonitoring interventions may be of significant benefit for rehabilitating heart failure patients” (p. 11).

Anker, Koehler & Abraham (2011) addressed the challenges and risks of successful application of telemedicine in solving HF-related issues. The latter were divided into categories of medical-legal issues and financial issues. The first are associated with the overall underdevelopment of telemedicine. Obtaining a vital medical data does not itself solve the issue of determining the agent responsible for the proper response to the problems related to this data. Thus, telemedicine must aim at achieving the fundamental legal principles and medical standards of physician-patient relationship. The technical failure related issues must be properly addressed. On the other hand, there is a significant lack of reimbursement strategies for telemedicine, which may affect the update of its systems. The researchers remained confident about the future of the telemedicine. It was said to play an important role as a means of HF management. The authors emphasized the need to redefine the organization of medical care systems in order to improve the clinical outcomes.

Critical Assessment of the Review

The evidence from the discussed studies indicated that telehealth/telemedicine systems monitoring the CHF patients lead to significantly better outcomes compared with the usual care system. However, the application of the said remote systems is a complex issue that has various problems associated with their incorporation into a specific setting, effectiveness, and sufficiency. Based on the latest literature reviewed, it is clear that most of the mentioned problems are related to the underdevelopment of telemedicine.

The review used two databases to select the studies for it. However, it did not mention any limits as to the date of the search. While there was a large number of key words searched using different Boolean operators, no data from the Web was included simply because it was not considered to have any value. The presentation of the studies was carried out in the inductive fashion avoiding bias of anticipatorily developed expectations and topics but rather used the studies to generate the key factors of telehealth relegated to clinical outcomes of the patients with CHF. However, the review was not sufficiently strict to the quality methodologies of the studies.

Analysis of the Case Study

The selected work is titled “Telemonitoring for Chronic Heart Failure: The Views of Patients and Healthcare Professionals - A Qualitative Study” by Fairbrother et al. (2014). The authors conducted an empirical evidence based study in the context of day-to-day trials. They evaluated the comparative effectiveness of the application of telemonitoring system in the treatment of patients with chronic heart failure. The evidence based study assessed the experience of 18 heart failure patients (61% male, mean age 75) and five healthcare professionals through semi-structured interviews. The patients and exerts were involved in telemonitoring home-based management. The results of the interviews were thematically analyzed under the Framework approach.

The experiment indicated that both respondents had found that the new technology was easy to use. While the patients expressed their feeling of reassurance due to the increase of the level of information and knowledge related to their current condition, the health experts asserted that the new data had provided more detailed picture of patients’ condition. However, the latter were concerned about the grown patients’ dependence on practitioner support. The patients proved to place an unreasonable faith in the value of what they had perceived as a constant surveillance despite the frequently occurring technical issues. It was unclear whether the service designed to increase personal responsibility of the patients, in fact, assigned it to the healthcare professionals.

The authors recognized the importance of creating a formalized education system to support patients’ self-management. Both groups expressed their concerns about the difficult access to the technology and the lack of interoperability between telemonitoring and existing patient care systems as well as the overall expensiveness of equipment, its installation, and support. It was mentioned that “the expected cost saving in using telemonitoring may be offset by the actual costs of operating such services” (Fairbrother et al., 2014, p. 139). The authors pointed out to the fact that certain process were alleged to require minimum attention but, in fact, resulted in adding to the health experts’ workload (Fairbrother et al., 2014, p. 139). Telemonitoring was concluded to be effective only as a short-term intervention to support stabilization in patients. According to this case study, the independent centralized ‘relationship free’ telemonitoring service is not feasible (Fairbrother et al., 2014, p. 139). The effectiveness of telemonitoring requires the relationship based continuity of care.

The study did not mention any vested interest and potential conflicts of interest. It complied with ethical standards of medical research and developed a firm data analysis approach. The authors considered the non-compliant patients and provided the information about the participants throughout different stages of the experiment. They also collected a feedback on various aspects of the application of the new technology and claimed the areas for the further research. However, they ceased to mention clear inclusion/exclusion criteria for the participants of the trial as well as specify the potential factors of bias. The study discussed very broad information related to strengths and weaknesses of the trial. Moreover, such an approach to the comparison of pros and cons of telemonitoring will be somewhat one-sided if it is not supplemented by the comparative analysis of the data on clinical outcomes of telehealth and usual means of care of heart failure patients.

Nonetheless, this case study can be productive for my clinical practice. It is important to learn that the application remote telehealth systems being a major game changer in monitoring patients, requires certain training. The authors listed specific technical problems, but they are limited by the scope of the analyzed study. It would be also necessary to address the attitudes of the patients towards the new technologies. They have to be educated about its limitations, which entails the need to approach them responsibly.

Implications for Writer’s Current Practice and Future Research

The review suggests that the appropriate population-based therapy clinical guidance should be developed for treatment of the target groups of patient with CHF. The efforts should be made to create a successful algorithm of solving issues that are associated with the potential technical failures of telemonitoring equipment. The health care policies must be legally secured. It has to be made sufficiently clear who is to be held accountable for the violation and compliance with the procedures related to the data obtained through the telemedicine systems. The progress in incorporation of telehealth systems should be evaluated in accordance with the principles of health care competencies. It is important to retain involvement, active engagement, and cooperation of all stakeholders groups considering the feedback from patients and professionals when implementing remote technologies in clinical practice.

Given the said stipulations, the application of telehealth for the treatment of the CHF patients can significantly improve the overall clinical outcomes. It should be noted that each of the reviewed articles had cautioned against any hasty generalizations related to determining the specific interrelations between HF patients’ conditions and effective telemedicine means. Such caution is caused by the limited empirical data. It also remains unclear how the different telehealth systems can compete against each other providing healthcare services for the HF patients in improving clinical outcomes compared with the usual care. Most of the reviewed studies made multiple arrangements to avoid bias and intention to treat. However, many of the discussed issues are challenging and require further empirical research. In particular, the technical and attitude-related issues associated with the application of the remote technologies by both the CHF patients and healthcare experts, as well as the opportunities for a long-term intervention require further specification.

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