Personalised remote monitoring for people at high risk of rehospitalisation

The Centro Hospitalar Universitário Lisboa Norte in Lisbon, Portugal operates a telemonitoring programme individually tailored for people with chronic HF and considered at high risk of hospitalisation.

Each person in the programme has access to medical equipment at home and a mobile app to transmit a range of parameters including heart rate, body temperature and blood pressure, along with the readings from a three-lead electrocardiogram (ECG), which is performed three times per week. Every day, data are transmitted automatically (and manually, if needed) to an intermediary team of cardiopneumologists and HF‑trained nurses. This team receives an alert if any parameters fall outside of predefined limits, which are tailored to each person based on readings taken when they join the programme and are adjusted monthly.

When an alert is received, a member of the intermediary team immediately contacts the person with HF (or their carer) to confirm the readings and collect further information using a validated questionnaire. This questionnaire is used to decide whether a member of the cardiology team at the hospital needs to be involved. In this case, all members of the cardiology team receive an alert, and a prespecified member of the team takes responsibility for the case – they contact the person with HF and make a clinical decision, such as adjusting treatment or asking them to come to the hospital for a consultation.

The programme currently has 30 participants and there are plans to expand it. Adherence has been high, at approximately 92% per year. Both mortality and HF rehospitalisations have been significantly reduced, and other outcomes including quality of life and functional capacity have improved.

References

Brito D. 2020. Interview with Taylor Morris at The Health Policy Partnership [telephone]. 18/03/20