Patients
Forty-three patients of the 62 recruited (70%) agreed to participate. Information about participants is noted in Table 2, selected quotes from the interviews in Table 3.
Table 2
| Interview Group | Respondent Count | % Respondent | Caucasian | % Caucasian | Black | % Black | Other | % Other | Male | % Male | Female | % Female |
| High Adherence, NO Readmission | 16 | 37.21% | 9 | 56.25% | 6 | 37.50% | 1 | 6.25% | 6 | 37.50% | 10 | 62.50% |
| High Adherence WITH Readmission | 17 | 39.53% | 13 | 76.47% | 3 | 17.65% | 1 | 5.88% | 9 | 52.94% | 8 | 47.06% |
| Low Adherence, NO Readmission | 7 | 16.28% | 1 | 14.29% | 6 | 85.71% | 0 | 0.00% | 4 | 57.14% | 3 | 42.86% |
| Low Adherence WITH Readmission | 3 | 6.98% | 0 | 0.00% | 3 | 100.00% | 0 | 0.00% | 1 | 33.33% | 2 | 66.67% |
| TOTAL | 43 | 100.00% | 23 | 53.49% | 18 | 41.86% | 2 | 4.65% | 20 | 46.51% | 23 | 53.49% |
Table 3
| Health Perception |
| I had to always constantly go in the hospital… It just – it helped, the program. (LA/NR) There’s been no shortness of breath or no swelling in my legs – because now I know what to look for when it comes to having congestive heart failure again and I haven’t had any of those symptoms at all for over a year now. (LA/NR) Exercising more…more walking and less driving a lot times. A lot of times when I always go to the corner store, might be two or three blocks away, I used to drive. Then I decided to walk a lot more instead of driving to the corner store. Doing that will make me feel better and be healthier for me. (LA/WR) Well, because I was weighing myself every day, I was knowledgeable of how much I weighed in the morning, so I knew how much I could eat during that day...(HA/ NR) I would – I think I was still working a couple days a week at the time when I enrolled. So if it wasn’t a workday, I would get up in the morning and, in the beginning, I didn’t do too much because I couldn’t really walk up steps. I found it difficult to do that. But later on in the program, because I lost a lot of weight and I kept my weight down, I – my sodium level was very good, I had my energy back…. (HA/WR) |
| Disease Management and Routine |
| The pill bottle was the biggest asset in the program for me because I would forget to take my medication on a regular basis… the pill bottle every morning at 8 o’clock the buzzer would go off and light up purple and I knew it was time to take my medication. So that put structure in my life as far as taking my medication. (LA/NR) The program really kept me on the ball as far as taking my medicine, and plus they checking my weight… it made me look forward to it every day.(LA/WR) … I still weigh myself everyday still. I guess I got into the habit, so it’s kinda hard to break. The pill bottle, I did throw in the trash because the pill bottle was like, it was kinda – it was a little heavy. So, I kinda, I threw that in the trash, but yeah. (H/NR) I thought it was great, it was very helpful. I mean, it actually reminded me to take the pills. And I would step on the scale, I was more conscious of stepping on the scale…. (HA/WR) |
| Effectiveness |
| I think it kinda helped me stay out of the hospital because… it would send the messages to my doctor when I gained the weight and they would call me and tell me like take an extra pill, take a half a pill. Whatever to do to try to get the extra water weight... (HA/NR) I think it prevented me, probably, maybe from lapsing into the bad health. I was in the hospital when I got put on the program. It kept me from going back into that state that I was in, which was a bad state brought on by bad eating, lack of moving, lack of exercise…the program, which got me to maintaining, stabilizing a weight instead of going up or going down on a steady basis down, steady basis up too high. It helped keep me in line, eating the way I should so that I would stay at the weight I was supposed to stay for optimum health with the heart. (HA/R) It kept me out of the hospital, it kept me a little bit more healthier and it always reminded me when I forgot. (LA/NR) |
| Lottery |
| It didn’t change how I felt about the program. I was still going to be in it. But it just made it a little bit better... (LA/WR) … I mean, when you have a condition like mine – when you damn near die, you get kind of scared and you just do what you’re supposed to do to try to take care of yourself. So it was more a case of making sure I did what I was supposed to do as opposed to worrying about whether I was going to get money for it. (HA/WR) I did get some days that… today I’ve made this much money or whatever. And it was kind of like, yes, I took my medicine yesterday and stepped on the scale. And then it’s like – so it was kind of like a reward for doing that, that way, so it was a nice little thing to see, and it was like, yes, I did what I was supposed to do yesterday and it’s like – and got rewarded for doing so. (HA/WR) Well, I mean, it was fun. The little monies here and there, the little checks here and there with the lottery was …the little money was on top, but it wasn’t never about the money. It was always about – but I think initially it helped motivate me, those little couple of dollars. But eventually I don’t even think it was about the money, it was about me learning how to adapt to my sickness. (HA/NR) |
Health Perception
As a condition of intervention enrollment, all participants had been hospitalized for HF-related issues. Most respondents had co-morbidities including diabetes, hypertension, atrial fibrillation, stroke, and peripheral artery disease. Most participants perceived improved health status because of the intervention. All respondents felt that the intervention helped them manage their heart failure and improved or helped to maintain their routines, “…so I knew if I had to eat more salad.” Post intervention perceptions of health status varied by patient, but not by adherence level. About a third of patients missed the intervention and believed it helped them to improve their health.
Disease Monitoring and Routine
Participants generally liked the monitoring devices and experienced few issues during set-up and use. All respondents were able to get their medication without problems. Most participants stated that they appreciated the daily reminders to take medication, “The pill bottle… put structure in my life.” Some participants did not weigh themselves regularly prior to enrolling in the intervention; some participants did not have a scale, while others only weighed themselves when they had symptoms or remembered to do so. All participants stated that the intervention helped them to remember to weigh themselves and take their medication more regularly. Most integrated these activities into their daily routines, and some felt that the pill bottle reminder helped them remember to weigh themselves, “It actually reminded me … I would step on the scale.” Almost all highly adherent patients continued to weigh themselves daily after the intervention ended, “I still weigh myself every day,” while all low adherence patients reported weighing themselves less after the intervention ended.
Effectiveness
All patients stated that participation in the intervention helped them increase their awareness about their heart failure, although some did not understand the connection between their weight and heart failure. One respondent stated “And I’m not sure how just taking the medicine and getting weighed told you anything about the heart...”
Although the trial showed no statistically significant effect of the intervention on readmissions,3 almost all of the high adherence, no readmission patients felt that intervention helped them stay out of the hospital, “I think the EMPOWER program helps you not go to the hospital,” while a majority of the low adherence, no readmission patients felt that way. Almost all of the high adherence, readmission patients felt that the intervention kept them out of the hospital more than would have been the case if they had not been in the program, while low adherence patients who were readmitted did not mention the program or its impact on hospitalizations.
Lottery
All respondents cited their desire to better manage their heart failure as their motivation for enrolling. No patients cited the lottery as their main reason for joining the intervention, but many stated that it factored into their decision, “I was still gonna be in it. But it just made it a little better.” Others said that, while the lottery did not affect their decision to enroll, they liked and appreciated it. Most patients said that they found the lottery to be motivating/encouraging to stick with weighing themselves daily and taking their medications as prescribed, “it was more a case of making sure I did what I was supposed to do.” Two patients also cited an altruistic desire to help other heart failure patients as a motivation for joining the EMPOWER research study.
Alerts
Over 3,500 alerts were triggered among 237 intervention patients during the trial (Fig. 1). Among patients who experienced severe symptoms associated with exacerbated heart failure such as chest pain or shortness of breath (8.4% of alerts), the majority (65.1%) received outreach from the clinician’s office; however, among those with other heart failure symptoms such as edema or nausea (20.9% of alerts), only 35.4% received a response from clinicians. Patients with symptoms not associated with worsening heart failure or no symptoms were the least likely to receive any response from clinicians’ offices. Over 60% of alerts were triggered for patients who had no symptoms; of those, fewer than 30% of alerts received a response from a clinician. Telephone encounters were the primary method of interaction between clinicians and patients after alerts were triggered. The most common intervention was a change to diuretics; however, that only occurred in a small number of incidents (12%).
Clinicians
Thirty-four clinicians were recruited, and 16 (47%) participated in interviews. Respondents included 9 physicians, 5 nurses, and 2 nurse practitioners. We conducted 15-30-minute semi-structured interviews via telephone.
Workflow
All respondents felt that managing alerts integrated easily into their existing clinic workflow. Clinicians appreciated that the alerts were in the EMR and could be managed utilizing existing processes. Each patient had a weight flowsheet in the EMR that clinicians could access to review trends over time. Clinicians reviewed alerts, previous encounters, and flowsheets to see if they had recently interacted with the patient before reaching out. If there were no symptoms, some clinicians would make a note to check in on the patient in a week or two. Other clinicians could not really recall reviewing flowsheets of patient weights. A few clinicians felt that the data were hard to analyze in a meaningful way. All clinicians felt that only a small number of alerts were actionable, “I would say maybe out of like ten people, maybe three were – need – required sort of action.”
Alert Management Process
Clinicians’ responses to alerts varied widely because they had different criteria for responding. As noted in Fig. 1, some responded to every alert with a phone call, but only made clinical changes some of the time, typically based on symptomology. One challenge was the fact that alerts occurred whenever there were significant weight changes, rather than when there were trends in weight fluctuations, making them unreliable in identifying actual problems. Clinicians sometimes did not pay attention to alerts at “off” times or alerts that were lost in the shuffle of clinic flow, “One is the weekend and two is that not every provider or every person who gets the alerts necessarily checks that area all the time.” Additionally, some patients did not answer when the clinician’s office called, making clinical interventions difficult if not impossible. A couple of clinicians noted that the regularity of alerts could be overwhelming sometimes, “I get a ton of inputs, I just can’t localize it to where I’m getting it from easily.”
Patient Adherence
One quarter of clinicians noted that some patients may be more likely to benefit from a remote monitoring intervention than others because of their likelihood to be adherent; however, one respondent felt that the intervention helped patients manage their own health by giving them ownership of their wellbeing, “get them used to taking ownership of their care.” Twenty-five percent of clinicians thought that, while this intervention was helpful, patients must still be responsible for their health, “I do sometimes have concerns with the patients then learning to take responsibility.” A quarter of respondents also did not think that this, or similar interventions, would be helpful because patients do not understand their illness, and do not feel a sense of responsibility for their health. This was identified as a key barrier to success in the EMPOWER intervention, “Most of the barriers that I see in my practice is adherence to medication and to diet and sodium restrictions.”