Running head: THE EFFECT OF TELEMEDICINE ON READMISSION RATES IN 1

The Effect of Telemedicine on Readmission Rates in Heart Failure Patients

Courtney Covert, Michele Moore, Lindsey Parker, Lindsay Perkins, Tara Phelan, and Alyssa

Williams

James Madison University

THE EFFECT OF TELEMEDICINE ON READMISSION RATES IN 2

Abstract

In hopes of decreasing readmission rates, nurses are turning to new interventions such as

telemedicine to provide follow up care for congestive heart failure (CHF) patients. The purpose

of this literature review is to determine if telemedicine follow up care decreases heart failure

patient readmission rates within 30 days after discharge from the hospital. A wide variety of

conclusions can be drawn from reviewing the literature for telemedicine use in heart failure

patients. While the majority of the articles supported the effectiveness of telemedicine in this

patient population, other researchers found minimal or no significant effects on the readmission

rates. It is recommended that patients be more thoroughly assessed prior to use of telemedicine

as an intervention. Healthcare professionals should be educated and trained before

implementation of certain telemedicine platforms in patient follow-up. Finally, telemedicine

should be used in conjunction with other forms of patient follow up care to prevent CHF

readmissions into the hospital. Although there are mixed findings in the articles, it is safe to

suggest that the potential benefits outweigh the risks since none of the articles reported any

patient harm or deterioration as a result of telemedicine use. Further research needs to be

completed in order to identify a clinically sound solution using evidence-based practice (Smith,

2013).

Keywords: heart failure, CHF, readmission, telemedicine, telehealth

THE EFFECT OF TELEMEDICINE ON READMISSION RATES IN 3

The Effect of Telemedicine on Readmission Rates in Heart Failure Patients

Introduction

Congestive heart failure (CHF) accounts for over one million hospital admissions each

year in the United States (Long, Babbitt, & Cohn, 2017). Not only is CHF the leading cause of

initial admission, but it also accounts for an outrageous number of hospital readmissions (Long

et al., 2017). Over half of hospitalized CHF patients will return to the hospital within six months

of discharge (Rosen, McCall, & Primack, 2017). Readmission rates have become a top concern

for hospitals. Since implementation in 2012, the Hospital Readmissions Reduction Program

(HRRP) encourages hospitals to take responsibility for their quality of care and their impact on

readmission rates (Centers for Medicare & Medicaid Services, 2018). CHF readmissions

depleted federal funds by $7.2 billion in Medicare and $1 billion in Medicaid in 2013, in addition

to straining hospital resources (Rosen et al., 2017). In hopes of decreasing readmission rates,

nurses are turning to new interventions such as telemedicine to provide follow up care for these

CHF patients.

The process of obtaining routine and follow up healthcare is being revolutionized due to

the increase use of technology. New technological advancements in the health field allows quick

accessibility to information and services (Simkins, 2017). Telemedicine is an electronic

infrastructure used to provide services and promote communication amongst patients in various

remote locations and their associated healthcare providers (Simkins, 2017). Telemedicine is a

less traditional approach to face-to-face meetings, but is a cost-effective means to provide patient

education and health promotion. Telemedicine can be used in real-time via audio and video

chatting or asynchronously (Simkins, 2017). With the evolution of technology in the modern

world, telemedicine “is the natural evolution of healthcare” (The American Telemedicine
THE EFFECT OF TELEMEDICINE ON READMISSION RATES IN 4

Association, 2018). The purpose of this literature review is to determine if telemedicine follow

up care decreases heart failure patient readmission rates within 30 days after discharge from the

hospital.

Synthesis of the Literature

After reviewing the literature for telemedicine use in heart failure patients, a wide variety

of conclusions can be drawn. Based on the method of telemedicine used, some studies show that

readmission rates decline with telemedicine follow-up. Three articles (Maeng et al., 2014;

Smith, 2013; Stampehl et al., 2017) concluded that telemedicine decreases readmission

rates. Maeng et al. (2014) found this evident in both 30 and 90 day readmission rates, while

Stampehl et al. (2017) saw a decrease below average for heart failure patients. Hale, however,

focused primarily on medication compliance through telemedicine, which led to a decrease in

readmission rates (Hale, Jethwani, Kandola, Saldana, & Kvedar, 2016). Feltner et al. (2014)

found telemedicine follow up care to be more effective in heart failure patients than any other

diagnosis. Hobbs found telemedicine effective in combination with a multidisciplinary follow-

up approach (Hobbs, 2016). Although these articles found telemedicine beneficial in reducing

readmission rates of those with CHF, not all articles reached the same conclusion.

Four articles found telemedicine use helpful in decreasing readmission rates, however it

did not produce a statistically significant result (Blum & Gottlieb, 2014; Phelps & Sutton, 2018;

Rosen et al., 2017; White-Williams, Unruh, & Ward, 2014). Similarly, Mosi and colleagues

found telemedicine helpful; nevertheless, this intervention did not have the greatest influence on

readmission rates (Mosi, Shao, & Gorodeski, 2015). In addition, they found confounding factors

such as physiological differences between patients to also play a large role in readmission rates.
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The review of the literature also found gaps within the research. Long et al. (2017) found

inconclusive results to the effectiveness of telemedicine and stressed that no implications to

practice can be drawn until further research is conducted to determine effectiveness of

telemedicine in CHF patients.

Several limitations existed in the articles included in the synthesis of the literature. Many

studies possessed a small sample size (Blum & Gottlieb, 2014; Hale et al., 2016; Hobbs, 2016;

Mosi et al., 2015; Phelps & Sutton, 2018; Rosen et al., 2017; Smith, 2013; Stampehl et al.,

2017). Since telemedicine is a continuously growing and expanding field, many different

methods and forms of telemedicine exist; consequently, this creates a challenge in comparing the

results of each study (Blum & Gottlieb, 2014; Long et al., 2017; Mosi et al., 2015). Some

studies also rely on patient’s self reporting, leading to possible bias, inaccuracy, or incomplete

recording of information (Feltner et al., 2014). A final limitation seen in five articles includes

that many additional factors influence readmission rates and follow-up care outside of

telemedicine such as adherence to a heart healthy diet, daily weight monitoring, and medication

compliance (Hale et al., 2016; Hobbs, 2016; Maeng et al., 2014; Phelps & Sutton, 2018; White-

Williams et al., 2014).

Recommendations

Although the research discussing the impact of telemedicine on heart failure readmission

rates differs, many recommendations can be made based on the conclusions of the research

reviewed. As a result of the lack of research, Long et al. (2017) and White-Williams et al.

(2014) suggest waiting on implementing telemedicine as a sole intervention until more research

is conducted. In addition, Blum and Gottlieb (2014) emphasized the need to research and

compare different telemonitoring systems to assess their impact on managing CHF patients.
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More research is needed to conclude whether telemonitoring can be used as the primary

intervention. Telemonitoring can be used in collaboration with other interventions and programs

such as in-person visits and case management while also using other outcomes to assess the

effectiveness of the interventions including cost, symptom management, quality of life, etc.

(Blum & Gottlieb, 2014; Feltner et al., 2014; Hobbs, 2016; Maeng et al., 2016). In order to

implement telemedicine in the most effective manner, patients should be assessed before

beginning telemedicine to conclude that telemonitoring is an appropriate intervention for patient

situation, co-morbidities, and their environment (Smith, 2013). Furthermore, there should be

education and training for nurses, physicians, and other health-care professionals for proper

implementation of telemedicine as an intervention for CHF patients. These recommendations for

nursing practice need to be considered in order to use telemedicine as an effective intervention

for these patients based on current research.

Conclusions

Current research is being completed in order to find solutions that will reduce the

nationwide influx of hospital readmissions of those with heart failure complications. Through

the literature review, the research was inconclusive overall in suggesting that telemedicine

follow up decreases CHF patient readmission rates within 30 days after discharge from the

hospital. While the majority of the articles supported the effectiveness of telemedicine in this

patient population, other researchers found minimal or no significant effects on the readmission

rates. Although there are mixed findings in the articles, it is safe to suggest that the potential

benefits outweigh the risks since none of the articles reported any patient harm or deterioration

as a result of telemedicine use. Further research needs to be completed in order to identify a

clinically sound solution using evidence-based practice (Smith, 2013).

THE EFFECT OF TELEMEDICINE ON READMISSION RATES IN 7

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