Telehealth Management of Chronic Heart Failure Optimizes the Use of Diuretic Therapy

Schofield RS, Kline SE, Schmalfuss CM, Carver HM, Aranda JM, Pauly DF, Hill JA, Neugaard BI, Chumbler NR. Telehealth Management of Chronic Heart Failure Optimizes the Use of Diuretic Therapy. Paper presented at: Heart Failure Society of America Annual Scientific Meeting; 2004 Sep 13; Toronto, Canada.

Background: Most decompensations of chronic heart failure (HF) are related to volume overload. Optimization of diuretic therapy is therefore important in controlling patient symptoms and in preventing hospitalizations. Methods: We designed an outpatient HF management program using telehealth technology to improve the care of veterans with refractory HF. Patients enrolled in our program were given HF-specific education and disease self-management instruction by a HF nurse care coordinator. They also were provided with an in-home telehealth messaging device (Health Buddy, Health Hero Network, Inc) designed to provide HF education and to relay patient vital signs and symptoms daily to the care coordinator via a secure Internet website. Frequent vital signs obtained via the telehealth device were used to uptitrate HF medications. Symptoms or vital signs out-of-range led to phone contact with the patient and often to alterations in therapy. Results: A total of 100 patients were followed from 10/7/02 until 3/30/04 (mean follow-up 11.8 months). Patients were nearly all males (98%), were elderly (mean age 67), and all had systolic HF (mean LVEF 22%). The mean NYHA classification at entry was 2.9. Substantial increase was noted in the average daily dose of furosemide during the telehealth program (63 to 82 mg/day, P < 0.001), and this increase was associated with a reduction in patient weight (202 to 197 lbs, P < 0.01) and a reduction in symptomatic dyspnea (shortness of breath rating reduced from 4.2 at entry to 2.9 on a 0-10 scale, with 10 being most severe (P < 0.01)). Average daily dose of spironolactone was increased from 9 to 22 mg/day (P < 0.001). Only 15 patients were on spironolactone at baseline, which improved to 35 patients during the program (P < 0.01). Inpatient hospitalization days improved from 889 for the year prior to enrollment to 142 days during the first year of the program. Conclusion: Telehealth management of veterans with refractory HF resulted in a reduction in hospitalizations, an increase in loop diuretic dose, a fall in weight, and an improvement in patient dyspnea. These beneficial outcomes were likely the result of optimized volume management. Use of the life-prolonging diuretic spironolactone was optimized while under telehealth management, which could ultimately lead to improved morbidity and mortality.