Feasibility of a noninvasive heart failure telemonitoring system: A mixed methods study

Quantitative data

We used one self-generated questionnaire to assess the end-user experiences and demographics of the patients. There was no completely applicable validated questionnaire for this purpose, so we had to plan our own. The clarity and comprehensibility of the questionnaire were pilot-tested with one heart failure patient. The collected demographic characteristics included age, gender, height, weight, time with heart failure, cardiovascular comorbidities, treatments for heart failure, and former use of digital devices. The questionnaire assessed the feasibility of the telemonitoring system using a Likert scale (from 1 meaning “complete agreement” to 5 meaning “complete disagreement”). We used statements about the reliability and ease of using the scale, tablet, and application as well as the relevance, comprehensiveness, and comprehensibility of the content in the application. We also asked how telemonitoring had affected the patient's life generally. We used a net promoter score to assess how likely patients would recommend the telemonitoring system to a friend or relative. The questionnaire is included in its entirety in Appendix 2.

The data was collected at a single timepoint. The questionnaire and the informed consent declaration form of the study were sent by post in December 2021 to all patients attending noninvasive heart failure telemonitoring at the Heart Hospital unit in Tampere (47 patients). A reminder was sent in March 2022 to those patients who had not answered the first time. In the end, 29 patients (61.7%) answered the questionnaire and signed the informed consent form.

Qualitative data

Semi-structured focus group interviews were conducted to obtain more detailed information about the user experiences of patients and nurses using the telemonitoring system.

We carried out five interviews between February 2022 and May 2022, three for patients and two for nurses. For the interviews, we purposefully selected patients from all patients who had answered the questionnaire and signed the informed consent form. We invited patients of varying ages, digital skills, and answers in the questionnaire to achieve more discussion and different opinions in the interviews. In addition, we invited all nurses using the telemonitoring system to interviews. Patients were contacted by telephone and nurses by email.

In the end, eight patients and eight nurses attended the interviews. Due to last-minute absences, two patient interviews were conducted with three patients and one interview with two patients. One nurse interview was with five nurses and the other with three nurses. The nurses and patients were interviewed separately because their questions varied to some extent.

All interviews were conducted face-to-face in a meeting room of the Heart Hospital unit in Tampere. Due to the long travel distance, one nurse attended the interview via remote connection. All nurses signed an informed consent form before the beginning of their interviews. The male interviewer (TE) is an MD and an employee of one health center in Tampere. He conducted the interviews as part of his PhD studies on heart failure telemonitoring. He had used the telemonitoring system before and was a colleague of two of the interviewed nurses. He was instructed to organize focus group interviews by an associate professor of general practice at Tampere University (TK), who is experienced in research and conducting focus group interviews. Only the interviewer and the invited patients or nurses were present in the interviews.

The frameworks for the interviews and the interview questions were planned in the fall of 2021 by the research group. They were modified by the answers to the questionnaire and the gathered experience between the interviews. The eventual frame for the patient interview is included in Appendix 3, and the eventual frame for the nurse interview is included in Appendix 4.

The nurses and patients were aware of the goals for the interview and TE's reasons for conducting the interviews. The topics for the interviews and questions were provided by the interviewer. The interviews were audio-recorded with a recorder and a smartphone. An official service provider transcribed the recordings verbatim in the summer of 2022. The recordings were disposed of securely after transcription, and the answers were anonymized in the transcribed versions. The transcripts were not returned to the participants. No field notes were made. The interviews took from 38 to 95 min (38, 74, 85, 86, and 95 min). In the last interview, the data seemed to be saturated as new issues regarding our research question did not appear in the discussion. The last interview also took the shortest time.

In addition, the questionnaire for patients had some open-ended questions about general comments, development ideas, and technical challenges with the telemonitoring system.

Quantitative data

We used descriptive statistics to assess the quantitative data from the questionnaires. We analyzed the data with IBM SPSS Statistics Version 28.

The quantitative data was reported according to the STROBE checklist for cross-sectional observational studies, as applicable. The STROBE checklist is included in Appendix 5.

Qualitative data

We analyzed the transcribed interviews and used inductive thematic analysis to identify the codes and themes that derived from the data.

First, the transcripts were read by the authors (TE, VV, and TK) separately. The authors searched for meaningful sentences and coded them in Excel. Then, they examined them and collated the most frequent and relevant items together. Thereafter, they separately clustered the codes into themes. These steps were done first for the patient interview transcripts and then for the nurse interview transcripts. Then all authors compared and discussed the codes and themes together and in consensus categorized them into facilitators and barriers to telemonitoring. From the interview transcripts, the authors also identified factors affecting the patient selection for telemonitoring and development ideas for telemonitoring. Finally, TE named and translated these themes, factors, and development ideas from Finnish to English, and the names were validated by the other authors (TK and VV). All authors are MDs. TK is an associate professor of general practice at Tampere University and VV is a docent of cardiology and a part-time employee and a former chief physician of the Heart Hospital.

The qualitative data was reported according to the COREQ criteria. ²⁸ The COREQ checklist is included in Appendix 6.

Responses to the open-ended questions of the questionnaire were analyzed by the author TE.

Thematic analysis of the focus group interviews

In the thematic analysis of the focus group interviews, we identified 10 themes from the patient interviews and 15 themes from the nurse interviews. We categorized all themes into facilitators and barriers in regard to telemonitoring. In addition, we identified factors affecting patient selection for telemonitoring and development ideas for telemonitoring that arose from the focus group interviews. The themes and factors affecting patient selection are shown in Figure 4, while the development ideas are shown in Figure 5. The themes with patients’ and nurses’ quotations are described below.

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Figure 4.

Themes including facilitators and barriers to telemonitoring and factors affecting patient selection arising from the focus group interviews.

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Figure 5.

Development ideas for telemonitoring arising from the focus group interviews.

Easy to use

In our study, the answers to both the questionnaire and discussions in the focus group interviews highlighted that it is easy to start and continue using the telemonitoring system. These findings are similar to other studies.^20,22,23,25 The telemonitoring systems used in the previous studies have had similar features as the system in our study. The systems have included mobile applications for patients and web-based interfaces for professionals, and they have monitored different parameters including weight, blood pressure, and heart rate.^20,22,23,25 It seems that at least these kinds of telemonitoring systems are easy to use.

In the UTAUT and UTAUT2 models by Venkatesh et al., ease of use (i.e. effort expectancy) is suggested to be an important factor especially for women, people of older age, and those with little prior experience of the system.^29,30 This should be considered when developing heart failure telemonitoring systems since the majority of heart failure patients are elderly. ² However, an older age does not necessarily correlate with lower experience. In our study, approximately 60% of the patients were over 60 years old, but 89.7% of the patients had used digital devices daily before the study.

Supports self-care and self-monitoring and increases the feeling of safety

In our study, both the quantitative and qualitative data show that telemonitoring supports the self-care and self-monitoring of heart failure. These findings are in line with earlier studies.^18–20,25 In a study by Ware et al. (2019), almost all (95.8%) patients agreed that the telemonitoring system is important for managing their heart failure. In the interviews, the most commonly mentioned benefit of the telemonitoring program was supporting patients in their ability to self-manage their heart failure. ²⁰ In other studies, patients have noted that telemonitoring promotes confidence in self-management,^18,25 and there have been improvements in SCHFI (the self-care of heart failure index) maintenance and management scores. ¹⁹

The patients in our study also reported an increased feeling of safety with telemonitoring in both the questionnaire and interview answers. In earlier studies, patients have similarly mentioned that telemonitoring has given them a sense of safety^18,25 and peace of mind^18,20 and has reduced anxiety. ²⁶

Facilitates communication

In the focus group interviews of our study, both patients and nurses indicated that the chat tool of the telemonitoring system offers an easy way to communicate. It lowers the threshold of contact because the patient does not need to try to contact nurses by phone. This can increase the number of contacts but can also reduce the amount of phone calls to healthcare. It is also easier for nurses to schedule their day to answer messages than to wait for phone calls. Both patients and nurses considered the chat tool one of the most important features of the telemonitoring system.

The telemonitoring systems in prior feasibility studies did not enable this kind of chat tool.^20,22–27 Additionally, in previous studies, there was little data on how telemonitoring affects communication. In a study by Prescher et al. (2013), it was found that 52.6% of patients noticed an improvement in contact with their primary physician. ²⁵ In our study, 97% of patients who answered the questionnaire felt that it is easier to contact healthcare with the system's chat tool. The difference between these two studies might result from the facilitating effect of this tool in our study.

Technical challenges

One of the possible barriers to telemonitoring is the technical challenges of the system. In our study, 41% of patients experienced some technical problems with telemonitoring. According to the answers to the open-ended questions of the questionnaire and the focus group interviews, the technical problems were mostly connection problems between the scale and tablet computer. Similar Bluetooth connectivity problems have been reported in previous studies.^20,31 Different telemonitoring systems also seem to display slightly varying technical issues according to earlier studies.^20,32

Despite the technical challenges, the patients and nurses in our study and also in earlier studies stated that the telemonitoring systems are reliable, the quality of the systems is high, and the data transfer in the main works well.^20,24 It seems that the technical problems with the systems in previous studies and in our study were so minor that they did not affect the experience of the reliability of the system in general. However, even though the technical challenges were mild, it is important to have easy and fast access to technical support. If not taken care of quickly and easily, technical problems can weaken trust in telemonitoring and thus lead to decreased satisfaction and adherence according to the answers in our study and previous studies.^18,20,32

Increased workload

In the focus group interviews of our study, especially nurses, but also one patient, reported the risk of increasing the nurses’ workload. While telemonitoring can make work easier and more satisfying, patient guidance on using the telemonitoring system, continuous follow-up, and the easy chat tool can also increase the workload. The increased workload as a possible barrier to telemonitoring has also been raised in some previous studies. In those studies, professionals described an increased workload due to alarms, particularly inappropriate alarms.^26,33 The difficulty of setting alarm limits for weight changes was reported also in our study.

Our findings in the thematic analysis of the focus group interviews indicated some factors that might help to manage the risk of increased workload. These include enough resources, a clear care protocol for telemonitoring, and adequate integration of telemonitoring with other follow-ups. The nurses in our study pointed out that telemonitoring demands resources due to the increased communication channels with patients. The nurses also stated that there should be a clear care protocol already at the beginning of the telemonitoring. In addition, they desire a separate technical assistant for technical issues. The development ideas by the participants of our study include the better integration of telemonitoring with other follow-ups and better connectivity of the telemonitoring with the medical records system. Some earlier studies have also shown the challenges of integrating telemonitoring into other care.^26,33

Adherence and engagement with telemonitoring

In our study, the patients’ engagement with daily follow-up was one of the possible challenges to telemonitoring reported by both the patients and nurses. Daily follow-up can be distressing for patients, especially if there have not been any particular changes to the patient's condition for a longer time or if the patient does not see how he/she benefits from the follow-up.

In previous studies, the adherence of patients to telemonitoring has ranged from 53.3% to 98.5%.^{6,14,20,22,34,35} The differences in the adherence rates between studies might be due to the different types of telemonitoring systems used and the differences in population characteristics and follow-up times of the studies. The time that the telemonitoring has been used and the age of the patient seem to be predictors of adherence. In previous studies, adherence has been lower at the start of the telemonitoring, then increasing and peaking between 1 and 2 months after the start, but then gradually decreasing over time.^20,35 The decrease over time has been seen especially with younger patients. ²⁰

High adherence to telemonitoring is important for achieving its possible benefits. In a study by Haynes et al. (2020), higher adherence to weight telemonitoring was associated with a decrease in the rates of death and hospitalization in the following week. ³⁵ According to the patients’ and nurses’ answers in our study, possible ways to improve engagement and adherence would be regular feedback from professionals and alternating or more interactive daily questions in the application of the telemonitoring system.

Patient selection

Correct patient selection for telemonitoring is essential for gaining the best possible benefits. The patients and nurses in our study described many patient-related factors that can affect how patients profit from telemonitoring. They both considered that patients with adequate digital skills, patients with more symptoms or challenges with heart failure, and new heart failure patients might profit more from telemonitoring.

Only a few studies have reported these factors earlier. In a qualitative study by Sivakumar et al. (2022), healthcare professionals described several factors that may affect the use of mobile apps by patients. These included the patients’ age, access to a smartphone or the Internet, familiarity with technology, physical and cognitive function, and motivation and engagement in telemonitoring and self-management. ³⁶ The digital skills, motivation, and cognitive skills of patients were also addressed in our study. The subgroup analyses of two earlier RCT studies show that patients who have more challenges with heart failure (higher NYHA-class, CRT-pacemaker), have higher adherence to weight measurement, or are socially isolated might benefit more in regard to reduced mortality and hospitalizations.^15,16 These findings match the answers of the focus group interviews in our study.

However, there is no comprehensive data yet on which heart failure patients benefit most from telemonitoring systems. Further research and subgroup analyses with different heart failure patients are needed to better understand patient-related factors in this matter.

Development ideas

In the focus group interviews, the patients and nurses pointed out many development ideas for the system. These are very important to consider when developing the system and engaging and motivating the users within telemonitoring.

The development ideas from our participants include both technical and practical improvements. The most common ideas were adding blood pressure monitoring to the telemonitoring system and the desire that the telemonitoring system would consist of just a smartphone application. The patients would like to have an archive and diagram also for their blood pressure. The nurses, on the other hand, could use blood pressure to help with assessing the patient's condition and making medication dose changes. A simple smartphone application would ease use since the patient would not need to carry the heavy equipment everywhere. On the other hand, if only the application would be available, patients would have to have smartphones and other needed devices (e.g. scales) by themselves. This might reduce the reliability of the devices. Other themes the participants described included, for example, more motivating and individual features in the application, layout ideas for the application, more self-care instructions and videos, and more continuity of care.

A couple of studies have previously addressed patients’ and professionals’ suggestions for improvements.^27,32 Buck et al. (2017) studied older adults’ perceptions of one telerehabilitation program where the mobile application was not connected to healthcare. They had similar development suggestions as in our study, including adding blood pressure monitoring and more self-care instructions to the system. ³² The study by Bylappa et al. (2022) on a smartphone application reported some development ideas by healthcare professionals to improve functionality. The ideas included, for example, an alarm feature and chat tool within the app. ²⁷ These features were already included in the telemonitoring system in our study.