Devices Used for Non-Invasive Tele Homecare for Cardiovascular

Patients

A Systematic Literature Review

Jessica van der Zweth

, Marjan Askari

1,2

, Marco Spruit

and Christof van Nimwegen

Department of Information and Computing Sciences, Utrecht University, Utrecht, The Netherlands

Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands

Keywords: Devices, Tele-Health, Tele Homecare, Cardiovascular Diseases.

Abstract: The aim of this Systematic Review (SLR) was to provide an overview of devices used for non-invasive tele

health care by patients diagnosed with heart failure (HF). All English studies published in the past 10 years

that focused on tele home care for coronary heart diseases, cardiac arrhythmia or heart failure patients were

systematically searched in Scopus and Pubmed. Articles were selected if added value of tele-monitoring for

these patients was studied. Selected titles and abstracts were screened to determine eligibility for further

review. Types and number of devices per disease were then withdrawn and categorized for the three

diseases. Eight devices were found in the literature to be used in non-invasive tele homecare for patients

diagnosed with heart failure, of which weight scales and blood pressure monitors were most commonly used

and are the most frequently occurring combination. The knowledge on which tele homecare devices are

most commonly used gives insights into which devices are the best choice needed for patients with heart

failure, where product suppliers and healthcare providers can respond to. The results create future directions

for studying different aspects of tele homecare devices, such as usability aspects, which is an important

factor for acceptance of telemedicine.

1 INTRODUCTION

Due to the aging and growth of the population, the

prevalence of most diseases especially chronic

diseases has been increased in the past decade, and

this increase is expected to continue (RIVM, 2014).

In 2011, there were more than 5.2 million people

with a chronic disease in the Netherlands, which

accounts for 32% of the population (RIVM, 2014).

One of the main chronic diseases is cardiovascular

disease (CVD). Worldwide, cardiovascular diseases

have the highest prevalence of all chronic diseases

(WHO, 2010), and are the main cause of death

(Bashi, 2017). Within cardiovascular diseases the

highest burden is caused by coronary heart disease,

stroke, and heart failure (RIVM, 2014). The

prevalence of CVD in the Netherlands is expected to

increase to 1,426,000 in 2040 due to aging and

growth of the population (Bots, 2015).

To keep healthcare affordable despite these

demographic changes, self-management and self-

care are suggested to be utilized (Lorig, 2001). The

application of technology in the home setting can

have positive effects on the self-care and self-

management of patients, and may result in saving

costs, better care access and improving outcomes

(Peeters, 2016). An example of the application of

technology in the home setting is tele homecare,

which is a technology that aids in self-care and self-

management. It is often used by people with a

chronic disease, like diabetes or CVD (Schers,

2012). Tele homecare, which is a form of

telemedicine, is increasingly used in healthcare. Few

studies creating awareness of the importance of

success factors of telemonitoring have been

published in the last few years (Inglis, 2011). There

is no overview of current demand of the market,

which is an important aspect for both care providers

and product suppliers in this rapidly growing sector.

No Systematic Literature Review (SLR) has been

performed yet that researches the devices that are

used for tele homecare of coronary heart disease,

cardiac arrhythmia, or heart failure. The objective of

this SLR is therefore to provide an overview of these

devices.

300

Zweth, J., Askari, M., Spruit, M. and Nimwegen, C.

Devices Used for Non-Invasive Tele Homecare for Cardiovascular Patients - A Systematic Literature Review.

DOI: 10.5220/0006541603000307

In Proceedings of the 11th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2018) - Volume 5: HEALTHINF, pages 300-307

ISBN: 978-989-758-281-3

2 METHODS

The systematic search was performed in March

2017, using the PubMed and Scopus databases for

English-language, full-text articles with focus on

devices that were used for healthcare professionals

and patients with coronary heart diseases, cardiac

arrhythmias, or heart failure.

2.1 Search Strategy

The following search query was used in the final

search to search as broad as possible:

((telemonitor* OR telehealth OR telemedicine OR

telehomecare* OR tele-mon*) AND (heart failure*

OR coronary* OR arrhythmia*) NOT (implement*

OR machine learning OR robot* OR meta-analys*

OR review OR ICD OR pacemaker* OR child*

OR infant*)).

After applying the search strategy and

identifying possible hits, duplicate articles were

removed. Next, the articles were reviewed based on

title and abstract and irrelevant articles were

excluded. Finally, the full-text articles were assessed

to determine the appropriateness for inclusion.

2.2 Inclusion and Exclusion Criteria

For this study we included papers which focus on

non-invasive tele homecare for cardiovascular

diseases. Since the literature on tele homecare (and

it’s added value) began to expand during the past 10

years, only articles that were published in the last 10

years (i.e., from January 2007 to March 2017) were

included. All observational and experimental

studies, as well as randomized clinical trials and

quasi experimental studies were included. We

selected English language articles that investigate

ambulant adult patients who are diagnosed with one

of the cardiovascular diseases with the highest

prevalence in the Netherlands (i.e. coronary heart

disease, cardiac arrhythmia and heart failure (Public

Health & Care, 2017)), and who are able to

independently use tele homecare devices. Articles

that address the added value for patients or

healthcare professionals for one of these diseases

were included. Grey literature, opinion papers, and

letters were excluded to ensure the quality of the

included studies. Additionally, SLRs and meta-

analyses were excluded as well, but their reference

lists were checked for any additional articles to be

included in our study. Articles investigating the

usage of tele homecare outside of the home setting

or using invasive devices/interventions were

excluded.

2.3 Analysis

The following data were extracted from the final

included articles: (1) study design; (2) country; (3)

study duration; (4) participant characteristics; and

type of cardiovascular disease; (5) study objective;

(6) description intervention group; and the control

group (7) tele homecare devices used; (8) added

value; (9) usability aspects.

In the next phase, demographic data of the

included studies were described. The added value of

tele homecare was reported generally. The number

of devices and their types were categorized per

disease to give an overview of what types of devices

were used. We also investigated the prevalence of

common combinations of devices.

3 RESULTS

3.1 Search Outcome

After the initial search, a total of 1,463 studies were

identified for this review, of which 1,461 were found

by the initial search of the databases and 2 were

additionally identified through other sources. After

the removal of duplicates, the titles and abstracts of

remaining articles were screened. In this screening

stage, 1195 studies were excluded, resulting in 156

studies for the full-text assessment for eligibility. In

the full-text assessment, 112 studies were eliminated

because they did not meet the inclusion criteria. As

such, 44 studies remained in the final set for data

extraction, which are included in this systematic

literature review.

3.2 Study Characteristics

As shown in Table 1, a total of 44 studies remained

in the final set to be examined for the devices for

coronary heart disease, cardiac arrhythmia, and heart

failure. Most of these studies were conducted in

Europe (48%) and the United States (48%).

Of the included studies, only eight studies paid

attention to the feasibility or usability of the devices.

However, no in-depth results were provided.

No studies were found in this SLR that focused

on cardiac arrhythmia. The given percentage of

coronary heart disease and heart failure is based on

the total number of included studies for that specific

Devices Used for Non-Invasive Tele Homecare for Cardiovascular Patients - A Systematic Literature Review

301

disease (coronary heart disease: n=5. heart failure:

n=39).

For coronary heart disease, significant positive

results were found for 10 aspects of the added value

(91% of the total measured values were positive)

and 1 aspect gave significantly negative results (9%

of the total measured values was negative).

For heart failure, 26 aspects were significantly

positively proven (90% of the total measured values

was positive)) and 24 were significantly negatively

proven (10% of the total measured values was

negative).

Table 1: Demographic data related to the included studies.

Coronary

Heart

Disease (CHD)

Heart

Failure

Total

number of

studies

(100%)

Location

Europe

(80%)

(44%)

(48%)

North-

America

(20%)

(54%)

(50%)

Asia

(0%)

(3%)

(2%)

Publication period

2007-

2012

(40%)

(64%)

(61%)

2013-

2017

(60%)

(36%)

(39%)

Sample size

> 100

patients

(60%)

(59%)

> 100

healthcare

professionals

(20%)

(0%)

(2%)

Gender

Male

(100%)

(49%)

(55%)

Female

(0%)

(39%)

(34%)

3.3 Tele Homecare Devices

A total of eight different devices were used in the

included studies. The number of included devices,

and the types of these devices can be found in Table

2. Most of the included studies (74%) studied 1 to 3

devices in their study. Weight scale and blood

pressure devices (BPDs) were by far the most

commonly used devices in the included studies,

followed by heart rate and ECG devices. Pedometers

and motion sensors were only used once. The given

percentage of coronary heart disease and heart

failure is based on the total number of included

studies orf that specific disease (coronary heart

disease n=5, heart failure n=39).

The most commonly occurring combination of

used devices is blood pressure devices (BPDs) with

weight scales (57% of the studies included this

combination). The combination of BPDs and heart

rate devices occurred in 39% of the papers. This is a

noticeable result, since the heart rate monitor is only

used in combination with BPDs. The combination of

weight scales and heart rate devices occurs in 36%

of the articles, indicating that the combination of

heart rate monitors and weight scales occurs in all

articles but one. Lastly, the combination of pulse

oximeters and BPDs occurs often, in 23% of the

articles. Pulse oximeters are used in 10 of the

articles, and in all these, it occurred in combination

with the BPD.

When looking at a combination of three devices,

the BPD, weight scale, and heart rate monitor is

noticeable. This combination occurs in 36% of the

articles. In a combination of 4 devices, BPDs,

weight scales, heart rate devices, and ECG devices

occurs most commonly: in 9% of the articles. A

combination of 5 devices occurs in 5% of the

articles, with the combination of BPD, weight scale,

heart rate monitor, ECG device, and a device

measuring the urine output data being the most

common.

3.3.1 Disease Specific Analysis

When specifically focusing on CHD, it can be seen

that none of the included articles used more than

three devices. The combination of two devices is

found with the BPD and pedometer, and with the

BPD and ECG device (20% of the articles). When

looking into a combination of three devices the

BPD, ECG device, and pulse oximeter is most often

used (20% of the articles).

When looking into heart failure, the most

commonly used combination of devices is BPDs

with weight scales (64%), followed by BPDs and

heart rate devices (44%) and BPDs and pulse

oximeters (26%). When looking into the

combination of three devices, BPDs, weight scales,

and heart rate monitors are often used together

(41%). The combination of four devices can be

found with BPDs, weight scales, heart rate monitors,

and ECG devices (10%) and BPDs, weight scales,

heart rate monitors, and pulse oximeters (8%).

Additional information is available on request.

We found an increase in the average number of

devices that are used for tele monitoring over the

past few years (Figure 1).

HEALTHINF 2018 - 11th International Conference on Health Informatics

302

Table 2: Types and Number of Tele Homecare Devices.

Coronary

Heart Disease

Heart

Failure

Total

# of included devices

1 – 3

devices

(100%)

(74%)

(77%)

4 – 5

devices

(0%)

(26%)

(23%)

Device used in # of studies

Blood

Pressure

Monitor

(40%)

(74%)

(70%)

ECG

Device

(60%)

(26%)

(30%)

Heart

Rate

(0%)

(44%)

(39%)

Monitor

Sensor

(20%)

(0%)

(2%)

Pedomet

(20%)

(0%)

(2%)

Pulse

Oximete

(20%)

(23%)

Urine

Output

Data

(0%)

(5%)

Weight

Scale

(0%)

(87%)

(77%)

4 DISCUSSION

4.1 Main Findings

In this systematic review we synthesized recent

evidence on the used devices for tele homecare for

patients diagnosed with heart failure (HF). Eight

devices were found in the literature to be used in tele

homecare for patients diagnosed with the coronary

heart diseases, cardiac arrhythmia, or heart failure.

Our results showed that most studies used one to

three devices in a study on tele homecare for heart

failure patients. In these articles, the weight scale

and blood pressure monitor are by far the most

commonly used tele homecare device, and also the

most commonly occurring used in combination with

each other. The second most occurring combination

is BPDs and heart rate monitors, of which it is

noticeable that the heart rate monitor only occurs in

combination with a BPD. Additionally, the

combination of BPDs, weight scales and heart rate

monitors occurred most often, when looking at the

combination of three devices. Of the included

studies, only eight studies paid attention to the

feasibility or usability of the devices, mentioning

that not much is known yet about this. However,

they stress the importance of this aspect in the usage

of tele homecare.

Figure 1: Average number of devices per year.

4.2 Implications

It is expected that this SLR will mainly have

implications for product suppliers, and healthcare

providers. It is expected that this SLR will give

product suppliers insight into the current demand of

the market regarding tele homecare devices for

patients with heart failure. This, in turn, enables the

product suppliers to better respond to the market

demand. Additionally, these results can be the

foundation for future research in which the reasons

why these devices are used could be investigated.

This will contribute to the overall knowledge on the

use of these devices.

Our results showed that only eight studies

created awareness of the importance of feasibility or

usability of the devices. It is important to study

usability, as it is one of the main success criteria of

implementing and utilizing tele monitoring. This

success depends on the features and design, which

are incorporated in the device (Seto, 2012). Usability

is however a fairly unknown topic in telecardiology

and future studies are needed to study this topic

more extensively. In addition, a set of

comprehensive usability guidelines for these devices

is needed to test the usability aspects of the devices

in a standardized manner. Future studies are needed

to generate these guidelines.

Our results also showed that there is an increase

in the number of devices that are used for

telemonitoring in the past fews years. This finding

also supports the fact that usability of the devices

Devices Used for Non-Invasive Tele Homecare for Cardiovascular Patients - A Systematic Literature Review

303

needs to be studied and improved in order to

guarantee the success of the complex telemonitoring

programs that utilize various devices.

The added value of the telemonitoring is studied

for some of the CVDs. More studies are needed to

generate more insight regarding the effect of the

interventions.

Besides implications for product suppliers, also

healthcare providers might benefit from the results

of this SLR. They can use this knowledge on which

devices are used worldwide. This could help

healthcare providers in deciding which devices they

should invest in.

4.3 Strength and Limitations and

Future Directions

To the best of our knowledge, this is the first SLR

systematically assessing tele homecare devices used

for patients diagnosed with heart failure. We only

included studies after 2007 to provide information

on the more recently used technology. Although the

search was accurate and thorough, it is still plausible

that we missed articles.

This study also has some limitations. This

research only investigated devices in the studies in

which the added value of tele homecare devices was

investigated. The inclusion of only these studies may

cause missing devices in our overview. We did not

investigate the added value of these devices

thoroughly; therefore future studies are needed to

study this aspect in depth. Lastly, future research is

recommended to provide more information on why

certain devices are more used than others, in order to

provide more information for product suppliers, and

healthcare providers. Gender related choices and

analysis should be performed to give more insight in

preferences and functionalities of devices. Usability

aspects of these devices is needed to be studied as

well, since usability is one of the success factors of

accepting and using the devices and therefore

telemedicine.

5 CONCLUSIONS

Having the knowledge on which tele homecare

devices are most commonly used gives insights into

which devices are mostly needed for patients with

heart failure, to which product suppliers and

healthcare providers can respond. The results create

future directions for studying different aspects, such

as usability of these devices as this is an important

factor for the acceptance of telemedicine.

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