Telehealth care teams could reduce unnecessary readmissions after acute coronary syndrome
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Key takeaways:
- Telehealth visits with CV care teams reduced unnecessary readmissions after acute coronary syndrome.
- Patients initiated calls themselves for guidance when they felt concerning symptoms.
ATLANTA — Telehealth visits with CV care teams initiated when patients with prior ACS experienced concerning symptoms reduced unnecessary readmissions, guided them when seeking emergency care and reduced CV events, a speaker reported.
The results of the TELE-ACS trial were presented at the American College of Cardiology Scientific Session and simultaneously published in the Journal of the American College of Cardiology.
“Our hypothesis is a novel telemonitoring system-based algorithm would reduce hospital readmissions for patients post-ACS by using well-validated technologies coupled with an urgent remote consultation with a cardiologist,” Nasser S. Alshahrani, MSc, clinical research fellow in the Khamis group at the National Heart and Lung Institute, Imperial College London, and flight medic and lecturer at King Khalid University in Abha, Saudi Arabia, said during a presentation. “We tried to answer two questions. No. 1, does telemonitoring have the capacity to provide data to guarantee effective assessment of symptomatic patients following ACS, eliminating the need for a hospital visit? And No. 2, does a remote telemonitoring system reduce hospital readmissions in patients post-ACS?”
Alshahrani and colleagues enrolled 337 patients with ACS diagnosed with elevated high-sensitivity troponin I at a large tertiary center in London (mean age, 58 years; 86% men; 46% white).
Included participants underwent coronary intervention for STEMI, non-STEMI or unstable angina; had at least one additional CV risk factor; and had access to a smartphone or smart device. Patients were randomly assigned to the telehealth intervention or usual care.
A 12-lead ECG, BP monitor and a pulse oximeter were distributed to participants in the intervention arm who then received device training at 2, 4 and 8 weeks.
When a patient in the intervention arm reported worrying symptoms, they were instructed to contact an on-call telehealth cardiology team. The team would then assess ECG, BP and oxygen measures as provided by the trained participant. Using a predesigned algorithm, the cardiology team would provide reassurance, advise the patients to visit their general practitioner, advise them to go the ED or call emergency services.
The intervention team was available for telehealth calls Monday through Friday from 7 a.m. to 11 p.m.
Those assigned to usual care received remote follow-up over the phone at 3, 6 and 9 months.
The primary outcome was 6-month hospital readmission risk. Secondary outcomes included 6-month risk for ED visit and MI, and 9-month risk for ED visit and readmission.
Most cases were STEMI, followed by non-STEMI and unstable angina.
From Jan. 06, 2022, to Oct. 03, 2023, 169 calls from patients were made, of which 63.9% were during intervention team’s call hours.
The most commonly reported symptoms were chest pain/discomfort followed by palpitations, general weakness, shortness of breath and dizziness.
Overall, 54.62% of patient-initiated telehealth visits resulted in reassurance from their care team; 26.85% resulted in recommendations to visit their general practitioner; 13.88% resulted in ED visits; and 4.62% resulted in emergency services being called.
Risk for hospital readmission was lower among participants in the intervention arm compared with the usual care group at 6 months (HR = 0.24; 95% CI, 0.13-0.44; P < .001) and remained lower out to 9 months (HR = 0.35; 95% CI, 0.21-0.59; P < .001).
Six-month risk for ED visit was lower in the telehealth intervention group compared with usual care (HR = 0.59; 95% CI, 0.4-0.89; P = .01) and also remained lower out to 9 months (HR = 0.66; 95% CI, 0.46-0.94; P = .02).
In addition, 6-month risk for MI was also lower in the intervention group compared with the usual care arm (HR = 0.27; 95% CI, 0.14-0.53; P < .001), according to the presentation.
“The team was able to aid in preventing unnecessary presentations and advised the patients to seek emergency care whenever was necessary,” Alshahrani said during a presentation. “The TELE-ACS protocol provided a significant reduction in readmissions rates post-ACS and other adverse events. Further studies need to establish the feasibility of implementation in different health care systems.”
Reference:
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The study supports what we often suspect that patients who have a heart attack and get stented and then back home are different than when they come into the hospital. There’s a lot of fear, anxiety and there’s a lot of unknown. What I found interesting about this study is they built a telehealth package that included a portable ECG machine, a BP cuff and a way to tell oxygen levels. The second part is they built a mechanism for someone to call in when they have a symptom.
Often, we know when we see patients in the office after a heart attack, they have lots of different feelings. They know that their body is different than it was before, and there’s a lot of anxiety that goes along with that. This package was able to assuage a lot of fear. They even report that when there were symptoms, over half of them were noncardiac symptoms. They also noted that when people would call in and get advice, over 80% didn’t have to go to the hospital. Of those who had a symptom and had a call back from the doctor, all they needed was reassurance. Another percent were told to go for nonurgent primary care follow-up and less than 20% were told to go to the emergency room.
That supports what we see when we have conversations with the patients in the office after the hospital. But there’s so much time that occurs between when they go home and when they have that follow-up. What this study reminded me is that with that anxiety and that time at home, the ability for patients to have a feedback loop soon after, to be able to get objective information like their blood pressure, ECG and oxygen levels gives reassurance. You can minimize the amount of nonrelated symptoms. You could decrease the anxiety associated with them and then still be able to treat those need help.
This study was innovative because it shows us a pathway forward of how we can innovate medical care. The medical care of the future is not episodic care, but rather continuous in nature. Our challenge is going to be how we modify and innovate the health care system to allow this continuous care. The personnel expenses are real and what will have to come out of further exploration is the balance between the upfront costs for implementation vs. the downstream savings in unneeded hospitalizations.
We know that this is not going to be a one-size-fits-all solution, and no technology is. Every day in my practice, there’s a conversation with patients about digital health technology. It’s become a major part of the conversation. There’s also a constant conversation about what the follow-up is and how we use [electronic health record] communication that’s evolved over the last couple of years in a dramatic way. There are always going to be a subset of patients who can’t technologically adapt to that change. It never becomes 100%. But what we’ve seen, even in utilization, EHRs have been tremendous. I remember 6 to 7 years ago, half of my patients would be willing to have communication via the computer, and now it’s north of 90%.
In many different areas, we’re seeing technological advances that require different levels of involvement from the patients. But the cumulative component of it is that we’re going to be treating patients better than we ever did before.
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Alshahrani NS, et al. Featured clinical research I. Presented at: American College of Cardiology Scientific Session; April 6-8, 2024; Atlanta.
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