Result card

  • ORG11: How is structured telephone support (STS) for adult patients with chronic heart failure accepted?

How is structured telephone support (STS) for adult patients with chronic heart failure accepted?

Authors: Valentina Prevolnik Rupel, Taja Čokl, Eleftheria Karampli

Internal reviewers: Ulla Saalasti - Koskinen, Elle Kisk, Ricardo Ramos

To answer the questions in the assessment elements we mainly used the basic literature search provided for the whole project. Additionally, two more systematic searches were used: one performed by ORG and ECO domains (described in methodology of ECO domain) and one perfomed by EFF, SAF and ECO domains (described in SAF domain). A qualitative handsearch (google; keywords: structured telephone support, heart failure, telemedicine) was done adding further information for this question. The results are provided in descriptive way.

Adherence to STS programs differs in HM to HH STS programs. It seems that interpersonal interaction with a care provider is an important active component of STS (adherence is higher in HH than HM STS) {40}. Adherence is reported from 55,1% to 84% across the studies, adaptation to the technology to 90% or higher, more than 90% of patients are statisfied with the use of technolgy. Acceptance of automated voice interactive system was poor, mostly due to technical failures. Patients were generally very satisfied with various STS programs across studies.


The clinicians, on the other hand, have several reservations, such as potential increased clinical workload, medicolegal issues, and worries of difficulty of use for some patients due to lack of visual acuity or manual dexterity. The clinicians believed that the telephone interactions is as effective as face-to-face interactions. The clinicians fear that system would result in a significant increase in their workload {91}.

Acceptance by patients

Pandor et al. {40} included in their systematic review RCTs or observational cohort studies with a contemporaneous control group published from 1999 to January 2012 that evaluated TM or STS programmes compared with usual post-discharge multidisciplinary care for adults who have been recently discharged (within 28 days) from an acute care setting to home (including a relative’s home, nursing home or residential care home) after a recent exacerbation of HF. They included 11 studies of STS: 10 used standard telephone equipment and HH contact and one provided support via an automated telephone interactive response system (HM) with an alert system. One study compared both STS and TM to usual care. Their review has overlaps with that of Inglis et al. {490}. In STS programmes regular scheduled telephone contact between patients and healthcare providers was performed usually on a weekly/monthly basis and incorporated telephone-based education and monitoring of signs and symptoms of worsening HF. Studies took place mostly in the US (8), one in Brazil, one in Canada and the rest took place in sites from Germany, Netherlands and the UK. Patient’s mean age varied from 63y to 75y. Adherence rates for the interventions were reported in few studies. Adherence for STS programmes ranged from 55.1% to 84%. According to the authors, patient adherence could be related to the type of STS programme (HH or HM). In their review, the low (55%) adherence rate (i.e. use of the system 3 times/week) was observed in the study of HM STS programme (the Tele-HF trial) which could indicate that interpersonal interaction with a care provider is an important active component of STS. In the same trial, 14% of patients in the intervention arm never used the system {40} {960}.


Patient satisfaction was measured in few studies {40}, {490} in which satisfaction among STS patients was higher than among usual care patients (p < 0.01).


Inglis et al. {490} reviewed 16 studies of STS and 2 studies that involved both STS and TM as intervention arms. They included only RCTs that evaluated STS programmes compared with usual post-discharge care for adults who have been recently discharged from an acute care setting to home (including a relative’s home but not including nursing home or convalescent homes) or have been recruited while managed in the community setting. One study {29} reported patient adherence with STS at 65.8%, adaptation to the technology was measured at 97% and total acceptability of the project as rated by the participants was 76.45%. 


In a study by Wakefield et al. {1}, patient satisfaction was relatively high with both telephone and videophone communication. The interventions had high scores in items related to the technologies’ potential to save both patients and the healthcare agencies time and money, patients’ ability to use the equipment, and the interventions’ level of convenience as a form of care provision and a possible addition to regular care. A limitation, however, of the study was the small number (28) of participants.

In a study by Clark et al {1280} only 2 trials on STS (out of 9) reported acceptability of the intervention. In Cleland et al (Ten-HMS study) {9} 4.1% of patients refused to accept technology in their homes, 2.9% of patients asked for equipment to be removed, and 1.8% discontinued recording. Overall patient acceptance was 91.2%. 96% of patients were well satisfied with the system and 97% found the devices easy to use. In Riegel et al. {26} patient satisfaction was significantly higher among people assigned to intervention group compared with UC group (p<0.01).

In TELE-HF study {1150} patients in intervention group were assigned to automated voice interactive system and were required to make daily reports on symptoms and weight. The compliance was poor as 14% of patients actually never used the system at all, a further 10% were non-compliant by the end of the first week and only 55% of patients used the system at least three times a week by the end of the study. Perhaps the study reflects the dislike of patients for voice interactive systems.

Holly {16} in her summary found that the adherence to treatment plans was reported in 65.8% of patients in STS groups (three studies). A few elderly patients were unable to adapt to the use of the technology. Adaptation was rated at 96-97% accross 5 studies. Patients were reported to be satisfied with receiving health care for CHF remotely via technology at 57-97% across all studies (14 STS, 9TM, 2 STS and TM).

The medium telephone was well accepted by most patients in a study by Störk et al {200}. It enabled private communication from home environment, but also remote discussion on personal issues. Less than 10% of the respondents withdrew their cooperation throughout the study.The adherence was high and the patients developed healthy life style due to the development of personal relationship between patient and HF nurse through STS exercise.

The objective of one Canadian study {210} was to assess the attitudes of heart failure patients and their health care providers from a heart function clinic in a large urban teaching hospital toward the use of mobile phone-based remote monitoring. A questionnaire regarding attitudes toward home monitoring and technology was administered to 100 heart failure patients (94/100 returned a completed questionnaire). Semi-structured interviews were also conducted with 20 heart failure patients and 16 clinicians to determine the perceived benefits and barriers to using mobile phone-based remote monitoring, as well as their willingness and ability to use the technology. The survey results indicated that the patients were very comfortable using mobile phones (mean rating 4.5, SD 0.6, on a five-point Likert scale), even more so than with using computers (mean 4.1, SD 1.1). Patients and clinicians were willing to use the system as long as several conditions were met, including providing a system that was easy to use with clear tangible benefits, maintaining good patient-provider communication, and not increasing clinical workload.


Acceptance by healthcare providers

In the study by Wakefield et al. {1}, nurses’ satisfaction with both telephone and videophone interactions with the patients was high i.e. they believed that the interactions were both effective overall and as effective as face-to-face interactions, and believed that the patients were engaged in the procedure.

As telehealth provides greater access to care in more geographical markets, some physicians may feel financially threatened because patients will be able to access care from other sources, such as distant large health systems with sophisticated telehealth capacities {3}.

The objective of one Canadian study {210} was to assess the attitudes of heart failure patients and their health care providers from a heart function clinic in a large urban teaching hospital toward the use of mobile phone-based remote monitoring. Clinicians cited several barriers to implementation of such a system, including lack of remuneration for telephone interactions with patients and medicolegal implications. Furthermore, the clinicians thought that the proposed remote monitoring system could help them manage their patients’ condition by providing timely alerts to worsening health and additional information about their patients that they would otherwise not have. They also believed that the monitoring system could improve their patients’ self-care. The clinicians stated that they did not have further capacity to take on duties that would add to their already busy schedule.

One study described that telephone follow up with centralised call-in center addresses issues about the patient-physician relationship can be undermined or circumvented with telephone flow-up interventions. One study found that the lack of personal familiziation between the nurses who called the patients and the physicians involved in the direct care of the patients decreased the benefit of telephone follow-up interventions {1500}.

In a randomized, controlled clinical trial conducted in the U.S. {2} disease managers were employed by CorSolutions, Inc, which is an established DM company and was contracted for the study. A challenge that arised in such a setting was that physician did not welcome input from disease managers. A small number of potential patients for the trial withdrew from considering participation after they were advised by their physicians they should not enroll, some of whom stated they would no longer see the patient if the patient participated in DM.


Feedback from patients already using telemonitoring has been very positive. Here are some of the benefits they have experienced {19}:

  • added peace of mind that their condition is being monitored;
  • greater understanding of their condition and how to manage it;
  • greater freedom to get on with their day-to-day lives without the fear that their condition is deteriorating;
  • less risk of unplanned admissions to hospital;
  • less need to have contact with a clinician if their condition is stable;
  • reduced anxiety for their carers and family.
Rupel V et al. Result Card ORG11 In: Rupel V et al. Organisational aspects In: Jefferson T, Cerbo M, Vicari N [eds.]. Structured telephone support (STS) for adult patients with chronic heart failure [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali ; 2015. [cited 16 June 2021]. Available from: