A Randomized Controlled Trial Comparing Telehealth Self-Management to Standard Outpatient Management in Underserved Black and Hispanic Patients Living with Heart Failure

Abstract

Background: Although the American Heart Association promotes telehealth models to improve care access, there is limited literature on its use in underserved populations. This study is the first to compare utilization and quality of life (QoL) for underserved black and Hispanic heart failure (HF) patients assigned to telehealth self-monitoring (TSM) or comprehensive outpatient management (COM) over 90 days.Methods: This randomized controlled trial enrolled 104 patients. Outcomes included emergency department (ED) visits, hospitalizations, QoL, depression, and anxiety. Binary outcomes for utilization were analyzed using chi-square or Fisher's exact test. Poisson or negative binomial regression, repeated-measures analysis of variance, or generalized estimating equations were also used as appropriate.Results: Of 104 patients, 31% were Hispanic, 69% black, 41% women, and 72% reported incomes of <$10,000/year. Groups did not differ regarding binary ED visits (relative risk [RR] = 1.37, confidence interval [CI] = 0.83–2.27), hospitalization (RR = 0.92, CI = 0.57–1.48), or length of stay in days (TSM = 0.54 vs. COM = 0.91). Number of all-cause hospitalizations was significantly lower for COM (TSM = 0.78 vs. COM = 0.55; p = 0.03). COM patients reported greater anxiety reduction from baseline to 90 days (TSM = 50–28%; COM = 57–13%; p = 0.05).Conclusions: These findings suggest that TSM is not effective in reducing utilization or improving QoL for underserved patients with HF. Future studies are needed to determine whether TSM can be effective for populations facing health care access issues.

Rapid review: Identification of digital health interventions in atherosclerotic-related cardiovascular disease populations to address racial, ethnic, and socioeconomic health disparities

“…Patient-reported outcomes included improvement in diet quality (+3.5 points, p<.03) and total energy expenditure (+80 kcal/day, p<.03) in hypertensive urban black populations with low SES in an RCT. 43 However, non-significant changes in health outcomes were observed for medication adherence in this same trial, 43 quality of life (QoL) in a separate RCT, 46 and hospital admissions in a pre-post study 51 following telemedicine interventions; BP control had mixed results in racial and ethnic minorities in separate RCTs. 24,43 The impact of telemedicine on healthcare utilization (HCU) in the form of technology protocol adherence and use of services had mixed effects on disparate populations.…”

“…Included studies were conducted primarily in the US, 18,[20][21][22][24][25][26][27][28][29][30][31][32]34,35,37,38,[40][41][42][43][44][45][46]48,50,51,[53][54][55] but other countries included Cameroon, 39 Bolivia, 49 Honduras, 47,48 India, 19 Lebanon, 52 Mexico, 47,48 Pakistan, 36 and South Africa. 23,33 Most studies focused on race/ethnicity (n=35, 92%) [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32]34,…”

“…22,33,34,49,53 Within low SES populations, some studies were conducted exclusively in either urban (n=7, 18%) 21,24,27,32,34,43,45 or rural (n=2, 5%) 39,52 settings. HTN (n=28, 74%) [19][20][21][22][23][24][25]28,31,[33][34][35][37][38][39][40][41][42][43]45,[47][48][49][50][52][53][54][55] and HF (n=8, 21%) 26,27,29,30,32,44,46,51 The types of digital health technologies identified as interventions were telemedicine (n=16, 42%), 18,20,21,…”

“…Thirteen studies used combinations of technologies to provide an intervention. 20,21,24,27,29,31,40,41,[47][48][49][50]54 Most studies measured intervention effects on health outcomes (n=32), 18,[20][21][22][23][24][25][26][28][29]31,[33][34][35][36][38][39][40][41][43][44][45][46][47][48][49][50][51][52][53][54][55] many assessed utilization of care (n=17), 22,[29][30]32,37,[41][42][43][45]…”

“…20,24,34,35,37,38,42,43 Other studies assessed the impact of remote monitoring of an implantable cardioverter defibrillator 18 and telemonitoring for HF management. 27,30,32,46,51 Eight telemedicine studies reported improved health outcomes (clinical, intermediate, or patient-reported) primarily observed in hypertensive or HF patients. 18,20,21,34,35,38,39,43 Of these studies, six were conducted exclusively in a disparity group 21,34,38,39,43 and one intended to address disparity in a heterogeneous population.…”