A significant challenge posed by continuous monitoring of HF patients is the burden of information overload. Resources to manage and act on the transmitted information from these patients are vital to the success of home monitoring. Studies have shown that the amount of information in a controlled, limited-time trial setting already seems overwhelming. The legal implications of timely follow-up of continuously monitored information and the scope of false positives with health care utilizations is a daunting aspect for handling the information. Moreover, the cost of phone monitoring with no reimbursements might make this modality less lucrative as opposed to using already available ICD/CRT-D technology. Also, the presence of multiple vendors and proprietary algorithms of each device company poses a challenge in creating a universally simplified approach to implement a structured algorithm. For those who do not need an implantable device, advancements in wearable monitors and Bluetooth transmission of information seems promising, yet with no strong evidence. Patient compliance issues with these technologies might be overcome by emerging piezo crystal sensors. Recently, Benett et al.30
reported the feasibility of using the EarlySense’s EverOn®
(EarlySense, Waltham, MA) under-the-mattress sensor system to track physiological information such as respiratory rate, heart rate, and movement rate during sleep in three patients. Also, advancements in implantable wireless technology seen with the pulmonary capillary pressure monitoring device CardioMEMS®
(CardioMEMS, Inc., Atlanta, GA) and the left atrial pressure monitor HeartPOD™
System (St. Jude Medical, Inc., St. Paul, MN) or Promote®
LAP System (St. Jude Medical, Inc., St. Paul, MN) bring us closer to finding the holy grail of home monitoring systems.
Attempts at shifting the burden of self management to patients have not been very effective due to the complexity of the therapies and the advancing age of HF patients in the United States. Between 27–44% of Medicare enrollees have marginal or inadequate health literacy,31
making this task more challenging. Powell et al.32
in the HART study found that the addition of self-management counseling to an educational intervention did not make a difference in death or HF hospitalization in patients with mild to moderate HF. Earlier smaller studies also have not shown any convincing evidence for self-management.33
Therefore, a strategy that minimizes patient responsibility in monitoring and care might be more pragmatic. All strategies should still aim at having a patient-centered care plan along with stressing patient education.37
Moreover, there is overwhelming evidence that a multidisciplinary approach to HF care reduces hospital readmissions and improves outcomes in these patients.38
Hence, it is recommended in both U.S. and European guidelines.39
Irrespective of the parameters and modes of home monitoring, a patient-tailored and disease management approach needs to be a complimentary aspect of any initiative to minimize healthcare burden and readmissions. More importantly, it stresses the fact that perhaps we should not wait for a readmission but, rather, focus on the first admission by developing outpatient strategies that include quality assurance in the outpatient clinic setting and effective education for the patient, caregiver, and community at large. The focus of all remote monitoring seems to be skewed towards avoiding acute exaggerations and optimizing diuretics. A more sustainable impact could be made by focusing on effective uptitration of medical therapy upon discharge or new diagnosis. The explosion of social media and smart phone applications is a potentially untapped resource in creating a patient centered system.