Simulated case management of home telemonitoring to assess the impact of different alert algorithms on work-load and clinical decisions

Abstract

BackgroundHome telemonitoring (HTM) of chronic heart failure (HF) promises to improve care by timely indications when a patient’s condition is worsening. Simple rules of sudden weight change have been demonstrated to generate many alerts with poor sensitivity. Trend alert algorithms and bio-impedance (a more sensitive marker of fluid change), should produce fewer false alerts and reduce workload. However, comparisons between such approaches on the decisions made and the time spent reviewing alerts has not been studied.MethodsUsing HTM data from an observational trial of 91 HF patients, a simulated telemonitoring station was created and used to present virtual caseloads to clinicians experienced with HF HTM systems. Clinicians were randomised to either a simple (i.e. an increase of 2 kg in the past 3 days) or advanced alert method (either a moving average weight algorithm or bio-impedance cumulative sum algorithm).ResultsIn total 16 clinicians reviewed the caseloads, 8 randomised to a simple alert method and 8 to the advanced alert methods. Total time to review the caseloads was lower in the advanced arms than the simple arm (80 ± 42 vs. 149 ± 82 min) but agreements on actions between clinicians were low (Fleiss kappa 0.33 and 0.31) and despite having high sensitivity many alerts in the bio-impedance arm were not considered to need further action.ConclusionAdvanced alerting algorithms with higher specificity are likely to reduce the time spent by clinicians and increase the percentage of time spent on changes rated as most meaningful. Work is needed to present bio-impedance alerts in a manner which is intuitive for clinicians.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-016-0398-9) contains supplementary material, which is available to authorized users.

Algorithms used in telemonitoring programmes for patients with chronic heart failure: A systematic review

“…30 Several research groups reported that simple rules of sudden bodyweight change in patients with heart failure were demonstrated to generate many alerts with poor sensitivity. 6,[30][31][32] Different methods are being used to interpret values outside thresholds in telemonitoring chronic heart failure. Some telemonitoring programmes depend only on knowledge of the healthcare professional interpreting the data.…”

“…It stands to reason that when set too wide, then there is a high risk that the patient is decompensated before an alert trigger is generated whereas thresholds which are set too tightly could lead to many 'false' alert triggers. 6 The aim of this systematic review was, first, to assess how algorithms in non-invasive telemonitoring programmes were reported and, secondly, which subsequent thresholds for biometric parameters (bodyweight, blood pressure, heart rate) and symptom questions were used to monitor symptoms of heart failure and/or guide titration of heart failure medication.…”

“…bodyweight, blood pressure and heart rate), measured on a regularly basis by patients at home. 6 The use of biometric measurements in non-invasive telemonitoring are based on the clinical presentation of patients with deterioration of heart failure, such as fluid overload (increased bodyweight), hypo- or hypertension, or brady- or tachyarrhythmias.…”

Changes in Daily Measures of Blood Pressure and Heart Rate Improve Weight-Based Detection of Heart Failure Deterioration in Patients on Telemonitoring

“…Therefore, comparisons between various studies are difficult and, as a result, many issues remain unresolved. Improved detection of deterioration could help telemonitoring nurses to more effectively direct their attention to patients at higher risk and provide better care through telemonitoring if properly integrated [16]. This study aimed to determine if there was any additional value of including trends in blood pressure (BP) and heart rate (HR), which are often captured in conjunction with weight, into the detection of deterioration.…”

Telemonitoring Devices and Systems: Current Status and Future Trends

“…The use of telemonitoring devices and systems can provide a safe and effective monitoring of these patients. The measurement of physical and biological parameters essential for the analysis of the evolution and treatment of the disease prescribed by the health professionals, allows them to evaluate the data and take decisions to change or maintain prescriptions or health care for the monitored patient [4], [7].…”