Telemonitoring was associated with greater mortality and did not reduce hospitalizations or ED visits in high-risk elderly patients

A trial in four Minnesota primary care clinics randomized 200 elderly patients who were deemed high-risk due to their past hospitalizations and comorbid conditions (including diabetes) to home telemonitoring (using peripheral scales, blood pressure cuff, glucometer, pulse oximeter, and peak flow meter) or usual care.

They found that the telemonitoring group had a higher mortality (14.7%) compared with usual care (3.8%) and did not have fewer hospitalizations or ED visits.

The study was published in Archives of Internal Medicine on May 28. The following commentary by William J. Hall, MD, MACP, was published in the ACP Journal Club section of the Sept. 18 Annals of Internal Medicine.

The results of the study by Takahashi and colleagues will probably curb the enthusiasm of many health care systems considering investing in home-monitoring systems to reduce costly ED visits and acute hospitalizations. Why have innovative telemonitoring interventions not proven to be of more value for “bending the cost curve”? This may be an indictment of misalignments in current health care systems rather than inadequacy of the technology. Telemonitoring of health status in community-living, older adults at high risk for hospitalization is an example of a sustaining innovation—that is, it replaces costly ambulatory visits with potentially more cost-effective, remote visual communication with patients and uses ancillary technology to assess vital signs and some laboratory studies. Where telemonitoring seems to fail is that the responsibility for follow-up is left to busy primary care offices that do not have provisions or incentives to act other than the customary referral to EDs or hospitals. However, better alignment of incentives for all participants is being proposed in medical home models and accountable care organizations. Health systems that have aligned incentives among their entire health care workforce may embrace telemonitoring as a key strategy for providing care and reducing costs. At that point, any technology that facilitates more human communication with patients with chronic illness and, most important, has resources to ensure appropriate follow-up will be considered a disruptive innovation and will probably enhance health delivery for both patients and providers. Meanwhile, the study of Takahashi and colleagues does provide evidence that technology cannot substitute for sound health care delivery design and function—and may even accentuate delivery deficiencies. Future proposals for telemonitoring will need to be developed, realized, and tested before they can be recommended and should not ignore the lessons learned along the way.