Heart failure remote patient management was associated with increased provision of elective care but no additional unplanned admissions

Abstract

Remote patient management (RPM) is increasingly adopted for heart failure (HF) care, with proposed benefits including reduced emergency healthcare utilisation​, and reduced hospitalisation​​. However, the benefit of RPM on reducing hospitalisations has been inconclusive​. The magnitude of benefits varies by modality and implementation: invasive hemodynamic monitoring demonstrated no reduction in HF hospitalisations, while non-invasive monitoring with structured follow-up by care providers showed significant benefits​. Distinguishing unplanned admissions through emergency departments (ED) from overall (i.e., planned and unplanned) admissions is critical for understanding care pathways and how patients may benefit from RPM. This study examined HF and cardiovascular (CV) hospitalisation patterns in RPM versus non-RPM patients, comparing unplanned to overall admissions to distinguish emergency from planned care pathways.

We conducted a 1:1 propensity-matched study of 1191 adults with HF enrolled in RPM at a tertiary care institution (2015-2023) compared to patients not enrolled in RPM in Ontario, Canada using provincial administrative databases. RPM protocols included ED referral instructions for specified clinical parameters. Non-RPM comparators were patients with HF who underwent an echocardiogram, also at an Ontario tertiary care centre (2004-2021). Cohorts were propensity-matched on confounders within broad categories of sociodemographic characteristics, co-morbidities, laboratory values, left ventricular ejection fraction and history of hospitalisation prior to enrolment. We investigated unplanned and overall HF and CV hospitalisations, and ED and out-patient clinic visits. In a propensity-score matched analysis, we performed cause-specific hazard regression accounting for the competing risk of death to determine the hazard ratio of outcomes among RPM versus non-RPM patients.

We matched 904 RPM (76% matching rate) to 904 non-RPM patients (mean age 63.7 ± 15.1 years; 67.9% female). The rate of subsequent ED visits did not differ between groups (HR 1.09, 95% CI 0.99–1.20, p=NS), nor did the rate of unplanned hospitalisations (HF: HR 0.99, 95% CI 0.829–1.21, p=NS; CV: HR 0.92, 95% CI 0.78–1.09, p=NS). However, RPM patients demonstrated a significantly higher rate of hospitalisations compared to matched controls (HF: HR 1.71, 95% CI 1.44–2.03, p<0.001; CV: HR 1.72, 95% CI 1.50–1.96, p<0.001) (Figure 1). The divergence between overall and unplanned heart failure admissions is illustrated in cumulative incidence curves (Figure 2). The number of outpatient clinic visits were significantly higher in RPM patients (median 13 vs 3, p<0.001).

Planned admissions, not emergency presentations, drove higher overall admissions in RPM patients. The benefit of RPM may be derived from early detection of opportunities to provide elective and preventative interventions to improve overall HF care.Figure 1.Forest Plot of HRsFigure 2.CIF curve HF admissions