BackgroundPrevious trials of telemonitoring for heart failure management have reported inconsistent results, largely due to diverse intervention and study designs. Mobile phones are becoming ubiquitous and economical, but the feasibility and efficacy of a mobile phone-based telemonitoring system have not been determined.ObjectiveThe objective of this trial was to investigate the effects of a mobile phone-based telemonitoring system on heart failure management and outcomes.MethodsOne hundred patients were recruited from a heart function clinic and randomized into telemonitoring and control groups. The telemonitoring group (N = 50) took daily weight and blood pressure readings and weekly single-lead ECGs, and answered daily symptom questions on a mobile phone over 6 months. Readings were automatically transmitted wirelessly to the mobile phone and then to data servers. Instructions were sent to the patients’ mobile phones and alerts to a cardiologist’s mobile phone as required.ResultsBaseline questionnaires were completed and returned by 94 patients, and 84 patients returned post-study questionnaires. About 70% of telemonitoring patients completed at least 80% of their possible daily readings. The change in quality of life from baseline to post-study, as measured with the Minnesota Living with Heart Failure Questionnaire, was significantly greater for the telemonitoring group compared to the control group (P = .05). A between-group analysis also found greater post-study self-care maintenance (measured with the Self-Care of Heart Failure Index) for the telemonitoring group (P = .03). Brain natriuretic peptide (BNP) levels, self-care management, and left ventricular ejection fraction (LVEF) improved significantly for both groups from baseline to post-study, but did not show a between-group difference. However, a subgroup within-group analysis using the data from the 63 patients who had attended the heart function clinic for more than 6 months revealed the telemonitoring group had significant improvements from baseline to post-study in BNP (decreased by 150 pg/mL, P = .02), LVEF (increased by 7.4%, P = .005) and self-care maintenance (increased by 7 points, P = .05) and management (increased by 14 points, P = .03), while the control group did not. No differences were found between the telemonitoring and control groups in terms of hospitalization, mortality, or emergency department visits, but the trial was underpowered to detect differences in these metrics.ConclusionsOur findings provide evidence of improved quality of life through improved self-care and clinical management from a mobile phone-based telemonitoring system. The use of the mobile phone-based system had high adherence and was feasible for patients, including the elderly and those with no experience with mobile phones.Trial RegistrationClinicalTrials.gov NCT00778986

Volume 9November 18, 2002 Document Number 7 Purpose(1) The purpose of this paper is to construct a comprehensive framework of research dissemination and utilization that is useful for both health policy and clinical decision-making.

Reviews have repeatedly noted important methodological issues in the conduct and reporting of cluster randomized controlled trials (C-RCTs). These reviews usually focus on whether the intracluster correlation was explicitly considered in the design and analysis of the C-RCT. However, another important aspect requiring special attention in C-RCTs is the risk for imbalance of covariates at baseline. Imbalance of important covariates at baseline decreases statistical power and precision of the results. Imbalance also reduces face validity and credibility of the trial results. The risk of imbalance is elevated in C-RCTs compared to trials randomizing individuals because of the difficulties in recruiting clusters and the nested nature of correlated patient-level data. A variety of restricted randomization methods have been proposed as way to minimize risk of imbalance. However, there is little guidance regarding how to best restrict randomization for any given C-RCT. The advantages and limitations of different allocation techniques, including stratification, matching, minimization, and covariate-constrained randomization are reviewed as they pertain to C-RCTs to provide investigators with guidance for choosing the best allocation technique for their trial.

Organizational performance remains an elusive concept despite its importance to health care organizations' (HCOs') management and analysis. This paper uses Parsons' social system action theory to develop a comprehensive theoretically grounded framework by which to overcome the current fragmented approach to HCO performance management. The Parsonian perspective focuses on four fundamental functions that an HCO needs to ensure its survival. Organizational performance is determined by the dynamic equilibrium resulting from the continual interaction of, and interchange among, these four functions. The alignment interchanges allow the creation of bridges between traditional models of organizational performance that are usually used as independent and competing models. The attraction of the Parsonian model lies in its capacity to: (1) embody the various dominant models of organizational performance; (2) present a strong integrative framework in which the complementarity of various HCO performance perspectives are well integrated while their specificity is still well preserved; and (3) enrich the performance concept by making visible several dimensions of HCO performance that are usually neglected. A secondary objective of this paper is to lay the foundation for an integrative process of arbitration among competing indicators and perspectives which is absolutely necessary to make operational the Parsonian model of HCO performance. In this matter, we make reference to the theory of communicative action elaborated by Habermas. It offers, we think, a challenging and refreshing perspective on how to manage HCO performance evaluation processes.

BackgroundMobile phone-based remote patient monitoring systems have been proposed for heart failure management because they are relatively inexpensive and enable patients to be monitored anywhere. However, little is known about whether patients and their health care providers are willing and able to use this technology.ObjectiveThe objective of our study was to assess the attitudes of heart failure patients and their health care providers from a heart function clinic in a large urban teaching hospital toward the use of mobile phone-based remote monitoring.MethodsA questionnaire regarding attitudes toward home monitoring and technology was administered to 100 heart failure patients (94/100 returned a completed questionnaire). Semi-structured interviews were also conducted with 20 heart failure patients and 16 clinicians to determine the perceived benefits and barriers to using mobile phone-based remote monitoring, as well as their willingness and ability to use the technology.ResultsThe survey results indicated that the patients were very comfortable using mobile phones (mean rating 4.5, SD 0.6, on a five-point Likert scale), even more so than with using computers (mean 4.1, SD 1.1). The difference in comfort level between mobile phones and computers was statistically significant (P< .001). Patients were also confident in using mobile phones to view health information (mean 4.4, SD 0.9). Patients and clinicians were willing to use the system as long as several conditions were met, including providing a system that was easy to use with clear tangible benefits, maintaining good patient-provider communication, and not increasing clinical workload. Clinicians cited several barriers to implementation of such a system, including lack of remuneration for telephone interactions with patients and medicolegal implications.ConclusionsPatients and clinicians want to use mobile phone-based remote monitoring and believe that they would be able to use the technology. However, they have several reservations, such as potential increased clinical workload, medicolegal issues, and difficulty of use for some patients due to lack of visual acuity or manual dexterity.

BackgroundPrevious trials of heart failure telemonitoring systems have produced inconsistent findings, largely due to diverse interventions and study designs.ObjectivesThe objectives of this study are (1) to provide in-depth insight into the effects of telemonitoring on self-care and clinical management, and (2) to determine the features that enable successful heart failure telemonitoring.MethodsSemi-structured interviews were conducted with 22 heart failure patients attending a heart function clinic who had used a mobile phone-based telemonitoring system for 6 months. The telemonitoring system required the patients to take daily weight and blood pressure readings, weekly single-lead ECGs, and to answer daily symptom questions on a mobile phone. Instructions were sent to the patient’s mobile phone based on their physiological values. Alerts were also sent to a cardiologist’s mobile phone, as required. All clinicians involved in the study were also interviewed post-trial (N = 5). The interviews were recorded, transcribed, and then analyzed using a conventional content analysis approach.ResultsThe telemonitoring system improved patient self-care by instructing the patients in real-time how to appropriately modify their lifestyle behaviors. Patients felt more aware of their heart failure condition, less anxiety, and more empowered. Many were willing to partially fund the use of the system. The clinicians were able to manage their patients’ heart failure conditions more effectively, because they had physiological data reported to them frequently to help in their decision-making (eg, for medication titration) and were alerted at the earliest sign of decompensation. Essential characteristics of the telemonitoring system that contributed to improved heart failure management included immediate self-care and clinical feedback (ie, teachable moments), how the system was easy and quick to use, and how the patients and clinicians perceived tangible benefits from telemonitoring. Some clinical concerns included ongoing costs of the telemonitoring system and increased clinical workload. A few patients did not want to be watched long-term while some were concerned they might become dependent on the system.ConclusionsThe success of a telemonitoring system is highly dependent on its features and design. The essential system characteristics identified in this study should be considered when developing telemonitoring solutions.Key Words

Objective: To determine the extent to which systematic reviews of public health interventions influenced public health decisions and which factors were associated with influencing these decisions.Methods: This cross-sectional follow-up survey evaluated the use of five systematic reviews in public health decision making. Independent variables included characteristics of the innovation, organization, environment, and individual. Primary data were collected using a telephone survey and a self-administered organizational demographics questionnaire. Public health decision makers in all 41 public health units in Ontario were invited to participate in the study. Multiple linear regression analyses on the five program decisions were conducted.Results: The systematic reviews were perceived as having the greatest amount of influence on decisions related to program justification and program planning, and the least influence on program evaluation decisions. The greater the perception that one's organization valued the use of research evidence for decision making and that ongoing training in the critical appraisal of research literature was provided, the greater the perception of the influence the systematic review had on public health decisions.Conclusions: Organizational characteristics are important predictors of the use of systematic reviews in public health decision making. Future dissemination strategies need to promote the value of using systematic reviews for program decision making as well as promote ongoing training in critical appraisal among intended users in Ontario.

Providing health care through home care programs creates unintended harm to patients. The incidence rate of AEs of 13.2% suggests a significant number of home care patients experience AEs, one-third of which were considered preventable. Improvements in patient and informal caregiver education, skill development and clinical planning may be useful interventions to reduce AEs.