Effectiveness of telemedicine in patients with heart failure according to frailty phenotypes: Insights from the iCOR randomised controlled trial

  • Sergi Yun
    Affiliations
    Community Heart Failure Program, Departments of Cardiology and Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain

    Department of Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
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  • Cristina Enjuanes
    Affiliations
    Community Heart Failure Program, Departments of Cardiology and Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain

    Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
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  • Esther Calero-Molina
    Affiliations
    Community Heart Failure Program, Departments of Cardiology and Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain

    Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
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  • Encarnación Hidalgo
    Affiliations
    Community Heart Failure Program, Departments of Cardiology and Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain

    Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
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  • Núria José
    Affiliations
    Community Heart Failure Program, Departments of Cardiology and Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain

    Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
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  • Elena Calvo
    Affiliations
    Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain

    Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Faculty of medicine and Health Sciences, School of Nursing, University of Barcelona (UB), Barcelona, Spain
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  • José María Verdú-Rotellar
    Affiliations
    Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain

    School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain

    Jordi Gol Primary Care Research Institute, Catalan Institute of Heath, Barcelona, Spain
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  • Paloma Garcimartín
    Affiliations
    Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain

    Outpatient Clinics, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain

    Escuela Superior de Enfermería del Mar, Parc de Salut Mar, Barcelona, Spain
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  • David Chivite
    Affiliations
    Department of Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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  • Francesc Formiga
    Affiliations
    Department of Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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  • Santiago Jiménez-Marrero
    Affiliations
    Community Heart Failure Program, Departments of Cardiology and Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain

    Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Department of Cardiology, Cardio-Oncology Unit, Bellvitge University Hospital and Catalan Institute of Oncology, L'Hospitalet del Llobregat, Barcelona, Spain
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  • Alberto Garay
    Affiliations
    Community Heart Failure Program, Departments of Cardiology and Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain

    Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Department of Cardiology, Cardio-Oncology Unit, Bellvitge University Hospital and Catalan Institute of Oncology, L'Hospitalet del Llobregat, Barcelona, Spain
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  • Lídia Alcoberro
    Affiliations
    Community Heart Failure Program, Departments of Cardiology and Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain

    Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
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  • Pedro Moliner
    Affiliations
    Community Heart Failure Program, Departments of Cardiology and Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain

    Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Department of Cardiology, Cardio-Oncology Unit, Bellvitge University Hospital and Catalan Institute of Oncology, L'Hospitalet del Llobregat, Barcelona, Spain
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  • Xavier Corbella
    Affiliations
    Department of Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain

    Hestia Chair in Integrated Health and Social Care, School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
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  • Josep Comín-Colet
    Correspondence
    Corresponding author at: Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, 19th Floor. Feixa Llarga s/n, Barcelona 08907, Spain.
    Affiliations
    Community Heart Failure Program, Departments of Cardiology and Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain

    Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Department of Clinical Sciences, School of Medicine, University of Barcelona (UB), Barcelona, Spain
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Published:October 13, 2021DOI:https://doi.org/10.1016/j.ejim.2021.09.021

      Highlights

      • Clustering enables to stratify heart failure (HF) patients in 5 frailty clusters.
      • eHealth-based HF-care is effective regardless of the frailty phenotype.
      • Telemedicine (TM) tools in HF are cost-effective in the 5 described frailty strata.
      • Frailty should not be an exclusion criteria to engage patients in TM programmes.

      Abstract

      Background

      The potential impact of telemedicine (TM) in the monitoring of patients with heart failure (HF) is still uncertain particularly in the frailest patients. The aim of this study was to define the efficacy of a TM-based managed care solution across different HF patient frailty phenotypes.

      Methods

      We performed a clustering analysis on the basis of 8 frailty-related dimensions to the HF-patients included in the ‘insuficiència Cardíaca Optimització Remota’ (iCOR) randomised study comparing TM vs. usual care (UC) in HF patients. The primary study endpoint was the incidence of a non-fatal HF event after 6 months of inclusion. The healthcare-related costs in each study group and cluster were also evaluated. The event rates of primary and secondary study endpoints were calculated for each cluster. Cox proportional-hazards regression models were used to evaluate the effect of cluster, treatment group and the interaction term cluster by treatment group on study endpoints.

      Results

      5 different frailty phenotypes were identified. The positive effect of TM compared to UC strategy was consistent across all frailty phenotypes (p-value for interaction 0.711). The risk of experiencing a primary event was significantly lower in patients that underwent allocation to the TM arm compared to UC (p-value = 0.016). Ultimately, the healthcare costs were significantly reduced in patients allocated to the TM compared to UC in all 5 frailty phenotypes (all p-value < 0.05).

      Conclusions

      Non-invasive TM-based follow-up tools are effective compared to UC follow-up in preventing HF events in the early post-discharge period, regardless of the 5 frailty phenotypes.

      Graphical abstract

      Keywords

      Abbreviations And Acronyms:

      ACEI (angiotensin-converting-enzyme inhibitor), ADL (activities of daily living), AF (atrial fibrillation), APGAR (adaptability partnership growth affection resolve), ARB (angiotensin II receptor blocker), CI (confidence interval), CKD (chronic kidney disease), COPD (chronic obstructive pulmonary disease), COVID (SARS-CoV-2 disease), CV (cardiovascular), EEMs (least-square (marginal) means), eHealth (electronic health), EHFScBS (European heart failure self-care behaviour scale), GDS (geriatric depression scale), HF (heart failure), iCOR (insuficiència Cardíaca Optimització Remota), IQR (interquartile range), LVEF (left ventricular ejection fraction), mHealth (mobile health), MLHFQ (Minnesota living with heart failure questionnaire), MMSE (mini-mental state examination), MRA (mineralocorticoid receptor antagonist), NYHA (New York Heart Association), PROMs (patient reported measures), QoL (quality of life), TEN-HMS (Trans-European Network-Home-Care Management System), SD (standard deviation), SPAN-CHFII (Specialized Primary and Networked Care in Heart Failure), TM (telemedicine), UC (usual care)
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