The Use of the Internet to Remotely Monitor

O RIGIN AL RESEARCH
TheIJseof the Internetto Remotely
MonitorPatientswith HeartFailure
BiljanoMoric,M.Sc.,lAnnemorie
Koon,R.N.,M.C.N.,2
YurikoAroki,M.A.,tAndrewlgnoszewski,
M.D.,3
ond ScottA. Lear,
Ph.D.t'3
1Deportment
of Biomedicat
Physiology
and Kinesiotogy,
SimonFroserUniversity,
Vancouver,
BritishColumbio,
Conqda.
2Schoolof Nursing s
ond Divisionof Cordiology,
Universityof BritishColumbio,
Voncouver,
BritishCoIumbiq,Conodo.
Abstract
Heart failure (HF) results in high hospitalization rates and healthcare
costs. Telemonitoring of HF has been shown to result in improued
outcomesbut usually inuoluesthe use of erpensiueequipment.A morr
feasible alternatiue may be the use of a Web site. The purpose of this
study is to inuestigate the use of a Web site designedfor HF telemonitoring. Patients newly referred to a heart function clinic were
screenedfor eligibility. Twenty participants were recruited and entered
their weight ond symptoms onto the Web site for 6 months. A nurse
monitored the Web site for changes in participant health status
and telephoned the participants as necessary. Self-care, quality of
Iife, 6-minute walk test, and N-terminal prohormone brain natriuretic
peptide (NT-proBNP) were assessed.
Interuiews were conductedto as^
sessinteruention uptake. Seuenteenparticipants completedthe study,
A significant change was obseruedon the maintenance subscaleof the
Self-Care of Heart Failure Indet (p: 0.039). Therewas a trend toward
improuement on the confidence subscale of the Self-Care of Heart
Failure Inder (p:O.069), Minnesota Liuing With Heart Failure@
Questiannaire(p:O.SSZ), 6-minute walk test (p:O.lZS), and NTp roBNP (p : 0. 2 1a). Parti cip ants and nur ses dem on strated afau orable
uptake of the Web site. A Web site that facilitates the telemonitoring
of patients with HF was fauorably acceptedand its use in this pilot
study was associatedwith improued self-care skills. Howeuer,further
inuestigation is warranted in a larger study population,
z6 TEL EMEiIICINE
an d e- HEALTHJ ANUARY/ FEBRUAR
2o1 oy
Key words: heart failure, telemonitoring,Internet
!ntrcduetisn
eart failure (HF)resultsfrom ventricular dysfunction and is
characterizedby fatigue, dyspnea,and edema.rHF affects
5 milllon people in the United Statesr and 10 million in
Europe2and resuitsin high rates of mortality and hospltal
readmission.'Self-monitoring (such as seif-weighing, monitoring of
symptoms, and the interpretation of changes in weight and symptoms4), in addition to specialized clinical care, has demonstrated
improved outcomes inciuding decreased hospital readmission.5
However,such specializedresourcesmay not be accessibleto many
patients with HF. Enhanced care for patients with HF can also be
provided using specializeddevices.Studies investigating these devices, where patients enter their signs and symptoms, which are
monitored by nursesor physicians,have shown improved outcomes
such as decreasedhospitaiizationand increasedquality of1ife.6'7The
use of such equipmentis limited due to expenseof both the units and
monitoring, the logistics of patient setup (including training) and
retum of the unit, and the number of patients being monitored is
iimited by the number of units.
Internet use has steadily increasedand may be an alternative to
monitoring devices.Accessto the Internet is quite high, with penetlation estimatedat 74.40/oin North America and 48.90/oin Europe.s
Only a handful of small studieshave examined the use of the Internet
for HF telemonitoring and have reported favorable uptake,e improved quality of life,e and decreasedemergency room visits and
hospitalizations.l0In contrast, another study found increased hospitalization for planned proceduresamong those using the HF Web
site regularly comparedto nonusers.tt'1' Given the limited amount of
evidenceto support the use ofthe Internet for patients with HF, and
the iimited outcomes investigated, additional investigations are
warranted.In addition, the previous studiesused a model in which al1
patients with HF received active intervention from health professionalseven ifthey were stable.The purposeofour investigation was
D OI: 1o.1o89 / t mj . z o o 9 . o o 9
4
HEARTFAILUREMONITORINGUSINGTHEINTERNET
to assessthe feasibility of a Web site to support self-management and
monitoring in patients with HF where the monitoring nurse was only
alerted when patients indicated a worsening of HF signs and/or
symptoms,
Materiaisand Methods
PARTICIPANT RE CRUITMENT
Participants were recruited from a Heart Function Clinic in Vancouver, British Columbia. Charts of newly referred padents were
scanned for inclusion criteria including a diagnosis ofsystolic FIF (left
ventricular ejection fraction (400/o), home Internet access,and the
ability to provide informed consent. Exclusion criteria included the
presence of cognitive impairments, untreated depression,a planned
surgical intervention scheduied during the study's duration, being
on the heart transplant list, plans to leave the treatment area for a
prolonged duration, and the presenceof any other medical condition,
which in the clinic physician's opinion makes the participant's survival for the duration of the study unlikely, or would interfere with
optimal participation. Interested patients received physician approval and provided informed consent before enrollment. Ethical
approval was obtained from Simon Fraser University and University
ofBritish Columbia-ProvidenceHealth CareResearchEthics Boards.
PARTICIPANT ASSESSMENT
computeruse,medBaselineassessment
includeddemographics,
andwereconductedin personby
ication use,and physicaimeasures,
a researchassistant.Blood pressureand heart rate were obtained
using the automatedBPtrumonitor (VSMMedTechLtd.,Vancouver,
Canada).Following 5 minutes of seatedrest, the BPtru monitor
conductedfive successivemeasuresat 1-minuteintervalsin which
the averageofthesefive readingswasrecorded.Heightin centimeters
with the
was obtained using a stadiometer.Weight was assessed
participantwearinglight clothingwheneverpossible.
Hip andwaist
wereobtainedusinga flexibletapemeasure.
circumferencemeasures
NT-proBNPlevels,a natriureticpeptideproducedby the ventricuiar
wall in responseto stretch,ventricular dilation, or fluid overload,
13
wereobtainedpertheprotocolprovidedby RocheDiagnostics.The
productionof NT-proBM is increased
in individualswith HFtaand
poorer
with
survival.l5Functionalcapacitywas
levelsarecorrelated
assessed
using the 6-minute waik test and is positively correlated
using
skills wereassessed
with patient survival.16Self-management
patient's
which
measures
a
the Self-Careof HeartFailureIndex,rT
ability to self-managetheir condition with questionsabout skills
requiredto live with HF at home.For this study,the questionnaire
(consistent
wasslightlymodifiedto an easierleveiof comprehension
with our study population) to facilitate understanding. Agreement
was obtained from the creator of the questionnaire with regard to
minor rewording of the questions without altering their interpretaby the Minnesota Living with Heaft
tion. Quality of life was assessed
which uses 21 items to determine how
Failure Questionnaire@,18'1e
the individual has been affected by their HF in the previous 4 weeks.
Fo1low-up assessmentswere conducted in person by the research
assistantat the clinic in Vancouver at 3 and 6 months; however, NTproBNPwas assessed
only at intake and at 6 months. At 6 months, a
semistrucfured interview was performed to assessparticipant uptake
of the intervention. Nurses involved in the intervention were also
interviewed.
DESCRIPTION OF THE INTERVENTION
Study participants continued to receive care in the FIF ciinic and
accessto the Web site. Participants were provided a unique username and password, and were trained how to use the Web site,
Participants were asked to login at a consistent time every day to
enter their morning weight and answer "Yes"/"No" to the following
flve questions related to their HF symptoms: Compared to yesterday,
{1) Do you feel your breathing is more difflcuit? {2) Are your ankles
more swoilen, or do you feel bloated? (3) Did you wake up feeling
more short of breath? (4) Have you felt your heart racing, fluttering,
or missing beats more than normal? (5) Do you have less energy or
feel more tired or dizzy?
The Web site generatedan alert if the participant's weight changed
2 kg or more in 2 days, 5 kg or more in 7 days, if they answered "Yes"
to any one of the five questions, or if data entry was missed for
3 consecutivedays. If an aiert was generated,participants were directed to a Web page that contained a messagereiterating their responsesand indicating that the nurse will contact them on the next
working day for follow-up. When the nurse logged onto the Web
site, she saw all participant alerts in the nurse's inbox. Alerts were
resolved through telephone consultation betvveen the nurse and
participant, The nurse reinforced self-monitoring skilis but if the
symptoms required medical management,the nurse consulted with
clinic nurses to determine appropriate action. If the padicipant's
weight did not change and ifthey answered"No" to the five questions, then no alert was generated and the subsequent Web page
contained a messagestating that they are doing well according to
their responses,but that they should seek medical assistanceifthey
feel unwell. Participantscould aiso view their progresspage, which
included a chart of their weight over time along with highlighting
the days on which they generatedalerts.Using the principles of selfmanagement,participants were able to visually see the connection
l n d e - H EAL TH
z7
r oY T [ L E M [ l ] i C l N a
@ M ARY ANN L IEBERT , IN C . . V OL. r 6 N O ,1 o J {N U A R Y / F E B R UzAoR
MARICETAL.
between changes in their weight and their symptoms,thus reinforcing the need for maintaining thelr weight through medication adherence,and salt and fluid restriction.
DATA ANALYSIS
Continuous variables are presentedas mean and standarddeviations and categoricaivariablesas counts and percentages.
The resuits
of the Minnesota Living with Heaft Failure questionnaire,Self-Care
of Hearl Failure Index, and 6-minute walk test resultswere analyzed
using repeated-measuresanalysis of variance. NT-proBNP results
were analyzed using a Wilcoxon Signed-Rankstest. The results for
NT-proBNP are presentedas median and 25th and 75th quafiiles as
the data are nonparametric. Data were analyzed using the SPSS
version 16 statisticaipackage (SPSSInc,, Chicago,IL).
Results
A total of 140 potentially eligible patientswere approached.Fiftyone patients (mean age:66.5 + 12.4 years,36 male) were inellgibie (44: no Internet access,2: away for extended periods, 3 :
improved ejection fraction )>4}olo,7 nonambulatory, 1 : not going
to be foilowed by the Heart Function Clinic for 6 monthsJ.0f the
remaining 89 patients(meanage:61.6 + 10.6years,65 male),63
refused consent [26 were not interested, 10 could not come for
follow-up, 9 were "too busy," 11 refused pa{icipation for other
reasons,and 7 either could not be contacted or chose not to enroil
for nonspecified reasons).Six patients were denied participation
by the physicians fsickle cell anemla: 1, dialysis: 1, and cognitive
issues:4J. Twenty participants were enrolled with 14 {700/olmales
and an average age of 61.2 + 9.7 years. Three male participants
were consideredlost to follow-up {2 withdrew and 1 did not attend
the final assessment)as outcome data at 6 months were not available. The averageage for the dropouts was 54.0 + 8.7 years. One of
thr dropouts reported using the comput€r daily, 1 once a week, and
1 three times per month. Participant demographicsare displayedin
Table 1. The remaining 17 participantscompletedthe study and were
followed for an average of 194 + 25 days, Demographicsfor these
participants are displayed in Table2 stratified by gender.Computer
use resultsare reportedinTable 3. Eight parlicipants(47.lok)reported
being the primary computer user and B reported using the Internet
daily.
For the 17 participants who completedthe study, 456 alerts were
generated,of which 295 (64.70/0)
were for lack of data entry {Tablea).
The number of total alerts generatedper participant ranged from 1 to
87 and the number of alerts generatedper participant for lack of data
entry ranged from none to 67.
28 T.ITMfDICI'{E
ZOrO
ANdE.HEALTHIANUARY/FEBRUARY
Age
62.3t 9.6
54,0:l-8.7
5ex
Mal e
NYHAclass
1 [330/o]
I (47.10/o)
2 (67010)
8 [47.10/o]
2 (67oto)
Ejection
fraction
0- 100/o
31-400/o
1 (330/o)
Maritalstatus
Marri ed/common
l aw
2 tlToloj
Divorced/sepa
rated
I (330/ol
0ther
Educational
status
Lessthan highschool
3 (i 7.6ok)
H i ghschool
3 (17.60/0)
Postsecondary
0ther
Employment
status
Retired
job
Full-time
1 (3390)
2 (11.80/0)
2 (660/0)
0ther
NYHA,
NewYorkHeartAssociation,
Therewas a significant changein the maintenancesubscaleofthe
Self-CareofHeart Failure Index from 74 + 16 to 81 + 11 to 78 + 12
from intake to 3 to 6 months (p:O.O:S) (Table 5). Nonsignificant
trends toward improvement were observed in the 6-minute walk
HEARTFAILUREMONITORINGUSINGTHEINTERNET
I (47.1otol
l aw equal l y
P arti ci pant/spouse/common
P arti ci pant/chi l d/chi l dren
equal l y
D o you know how to
2 [47.1olo)
S earchfor heal thi nformati on?
Maritalstatus
Printdocuments?
Mar r i e d / c o m m olna w
in a week?
Howofiendo you usethe Internet
8 (47.10/o)
Educational
status
4 [23.so/o]
Lessthanhighschool
3 (17.60/0)
2 [19.20tol
< 1 day/w eekor never
for?
Whatdoyouusethelnternet
for heal thi nformal i on
S earchi ng
2 l41.Zoto)
NYHA.New York HeartAssociaiion
test { fro m 4 28 .1+ 9 5.8m t o 463. 5+ 73. 0m t o 460. 8 +7 9 . 4 m ,
p : O.na) from intake to 3 to 6 months, in the MinnesotaLiving with
Heart Failure questionnaire lfrom 44 ! 24 ta 41 + 2t to 38 + 24,
p-0.3371, in the confidence subscale of the Self-Care of Heart
Failure Index (from 63 + 10 to 65 + 14to 72 t 13,p:4.969), and
for the managementsubscaleof the Self-Careof Heart Failure Index
(from 64 + 19 to 69 + 19 to 69 + 21, p:0.239). NT-proBNPalso
showed nonsignificant trends toward improvement (p:O.ZtO).
Diastolic blood pressure demonstrated a signiflcant change from
68 + 9 to 71 + 9 to 64 + 10mmHg from baselineto 3 to 6 months,
respectively( p : O.OZ|).
Exit interviews were conducted with 13 participants and were
stopped as we confirmed that no new themes emerged.In general,
participantsstatedthat the Web site was easyto use and that it made
them feel connectedto their healthcare professional.Sample comments from participants include:
O M ARy ANN L tEBERT , tN C . . V OL. 16 119.1 e JA N U A R Y /FE B R U Azoro
RY
?i l [4{i ]*l {i Fl E
and e-H E A LTH z 9
MARICETAL.
It mademe understand
to look for any of the symptomsI used
to shrugoff asjust somethingelse.NowI'm moreconcerned
with
what my body is actualiy doing. So that I'm more aware of
whethermy heartis reallybotheringme or whetherit's something
else.lmale,48 years]
Totalalertsgenerated
"Yes"to one symptomquestion
Difficultybreathing
Swelling
of theankles
or bloating
Wokeup feelingshortof breath
Lessenergeticor more tired or dizzy
("Yes"
questions
Multiplereasons
to multiplesymptom
or changein weightplus"Yes"to oneor more
questions)
symptom
Lackof data entry
Incorrectdata entry
Other/noalertdescription
I enjoyed it, I found it usetul and I thought somebodyout
thereis looklng at it. . . and giving me a call [if] somethingis
wrong.. . .You wouldn't normallyphonea doctorand say my
foot is sweliinga bit. [male,73 years]
Minnesota
Livinqwith HeartFailure@
Questionnaire
The5 nursesinvoivedin the interventionfelt that the Websitewas
usefulfor patientmonitoring,particularlyfor participantsliving in
remoteareasor thosewho were newly diagnosed.Nursesalso felt
that becausemany participantswere dealingwith a number of comorbidities,the Web site shouldbe tailoredto eachpatient'sparticuiar conditionand there shouldbe integrationbetweenthe hear-t
specialists,
the primarycarephysician,and otherswhen necessary.
It
wassuggested
that a nursepractitionermightbe a goodcandidatefor
monitoringthe Website.Anotherissueraisedby the nurseswas the
reportingof symptomsnot relatedto heartfailure,Both participants
and nursessuggesteda free text box whereparticipantscould elaborateon their answers.
Ofthe dropouts,1 entereddataon two occasions
despiterepeated
attemptsby the studynurseto encouragedataentry.Theparticipant
did not showup for his 3-monthfollow-upand when contactedto
reschedule,
he requested
to withdrawfrom the study.Theparticipant
statedthat the Websitewaseasyto usebut that hejust could not get
himself to use it. A secondparticipant entereddata regularly but
experienced
a changein scheduleandrequested
to withdraw afterthe
3-monthfollow-up.He statedthat he wouid participatein a similar
programin the future.A third participantentereddataregularly but
did not showup for the 6-month follow up on three occasionsand
was considered
lost to follow-up.He was not questionedregarding
his experiences.
0.337
41+21
Self-caremaintenance
74+ 16
81+11
S elf -c a r em a n a g e m e n l
5elf-careconfidence
Six-minute
walktest(m)
(pSlmt)"
NT-proBNP
o.124
428.1t 95.8
813( 38 9 . s , 2 , 1 7 6 . 5 )
represent
medianandinterquartile
values.
"Values
2o1o
30 Tf L e & i € D l C l N ial n d e -HEAL T H JANUARY/F EBRUARY
i,704.0)
1,017[397.0,
0.210
HEARTFAILUREMONITORINGUSINGTHEINTERNET
$iseussion
This investigation demonstrated the feasibility of patient selfmonitoring using the Internet. The Web site was able to effectively
alert the monitoring nurses regarding participant symptoms and
supported participant self-management.After 6 months of use,participants exhibited improvement in self-caremaintenanceand trends
toward improvement in other facets of self-managementand functional capacity. Participantsand nursesstatedthat the Web site was
useful and easy to use.
We obseweda high number of alertsgenerated,and this was due to
a number of reasons.One participant generated63 alerts for lack of
data entry, many of which were generatedbecausehe was unable to
weigh himself due to a broken scale.Another participantgenerated67
alerts for lack ofdata entry due to lnconslstent data entry. Participants
sometimesentered data every severaidays, such that often an alert was
generatedearly in the day, with the participant subsequentlyresuming
data entry later in the day, and on sevetaloccasionsparticipantsneglected to enter a leave of absence,thus further contributing to the
number of alerts generated.For this pilot study, we requiredparticipants to enter their data every day so that we could ensure active
monitoring and timely feedback to the patient. However, this requirement may not be necessary for every patient. We noticed that
someparticipantsappearedto becomemore stableas the intervention
progressed.In these participants,less frequent data entry and monitoring may be appropriate(i.e.,onceper week).While parlicipantswho
did not enter data for 7 or 2 consecutive days did not generatean alefi,
the Web site was not programmedwith the ability to alter the period of
required data entry individually for each participant. The ability for
the nurse to allow participants who were consideredto be stable to
enter data weekly without generating an alert is a function that would
have likely reduced the number of "irrelevant" alerts and will be
consideredin the next Web site iteration.
For the Self-Careof Heart Failure Index maintenanceand confldence subscales,participants demonstratedimprovementsof 4 and
9 points, respectively,indicating that they were better able to maintain their self-managementtrehaviorsand more confidently adhere
to them. This improvement is consistentwith the observednonsignificant improvement in functional capacity, as determinedby the
6-minute walk test. These differencesin self-managementare considered to be clinically relevant as they are associatedwith improvement in self-management skills in patients newiy diagnosed
with HF compared to patients with previously diagnosed HF who
have greater experience in managing HF.r7 The changes on the
management subscaleare more difficult to determine as scoresare
OM ARYANNL IEBERT ,tN C ..V OL.15
affected by whether or not participants did or did not experience cefiain symptoms. Thus, scoreson this subscalemay change
even though there was no change in management ability. For the
Minnesota Living With Heart Faiiure questionnaire, we noted a
nonsignificant change of 6 points indicating a trend toward an improvement in quality of life. This improvement in quality of iife is
consistentwith changesin quality of life reported in some ciinical
trials but is much lessthan that repofted in more comprehensiveHF
management studies (combined self-management, specialist care,
and medical management).teTherefore,integration of this Web site
with specialistcare and medical management may have a greater
potential for improving patient outcomes.
There do not appearto be guidelines for a significant change for
the 6-minute walk test or NT-proBNP,The improvement of approximately 33 m in the 6-minute walk test from baselineto 6 months is in
line with a difference of 35m reported between a control and an
intervention group examining the use of perindopril,2osuggesting
an improvement in functional capacity.NT-proBNPlevels decreased
by 2}olofrom baselineto 6 months. Bayes-Geniset a1.21examined an
intensiveclinic follow-up, which included medical management,and
found that in patientswho did not experiencecardiovascularevents,
and 370/oat 1, 2, 3,
NT-proBNPlevel decreasedby 300/0,360/0,34o/o,
and 4 weeks from baselineand each relative decreasewas a significant predictor of events.Theseresults are difflcult to compare with
the curent study, as in the current study levels decreasedby approximately 28oloover 6 months. Irrespective of this, NT-proBNP
levels did show a trend toward decreasing,and may suggest decreasedHF severity.
Several comparablestudies using Web sites exist; however, the
methodologiesfor those studies differed from ours, making direct
compadsonsdifficult. Delgado et al.e found significant differences
on the Minnesota Living with Heart Failure questionnaireand high
levels of satisfactionwith the Web site among pafticipants. While in
agreementwith our results, each patient's data were reviewed and
patients were sent back individualized responsesthrough the Web
examinedthe use of the sameWeb site as Delgado
site.Wu et al.11'12
et al. and found greaterhospitallzationin the "user" group (tt :26) of
patients comparedto the "nonuser" group (n:36), due to planned
hospitalizations.Kashemet al.1oinvestigateda different Web site and
reported decreasedemergency visits, hospitalizations, and total
hospital days among their participants.Taken together with our results,thesestudieslend suppoft to the feasibility of an Internet based
Web site for the monitoring of patientswith HF. It demonstratesthat
a Web site-basedmodalily can support patient self-monitoring, and
this study demonstratesthat following up with only those patients
N O.ToJA N U A R Y /FE B R U A R Y zoTofE l "E S {E B l C l l J[ande-H E A LTH3r
MARICETAL.
who experiencechanges in signs and symptoms does not result in
adverse outcomes.
A limitation of this study is that patients without Intemet access
were excluded, and this resulted in a number of otherwise eligible
patients not participating. It is well-recognized&at Inttrnet access
decreaseswith age and with socio-economicstatus,22so our tesults
may not be applicable to the broader HF population. However, it is
anticipated that Internet accesswill increase in the elderly asthe baby
boomersage.Future studieswiii investigatethe useof this Web site in
patients who may not have home Internet accessbut do so at work or
at their local iibrary or communitSrcenter.As this was a feasibility
study, our main purposewas to assessthe use of the Web site.In the
with
monitor their signsand syrnptomswas feasibleand associated
in patientoutcomes.
TheWebsitewaseffective
modestimprovements
andsymptoms,andits useis
at detectingchangesin participants'signs
associated
with improvedself-monitoringskills. Participantsstated
that &e Website madethem awareof their symptoms,they felt connectedto medicalcare,andit waseasyto use,whilenursesreportedthat
it wasusefulfor patientmonitoring.Furtherresearchshouldbe conthe advantages
ductedusinga randomizedcontrolleddesignto assess
of theWebsiteoverusualcareandshouldexamineoutcomessuchas
qualityof life, self-careability, 0-minutewaik test,and NI-proBNP.
future, we anticipate that this and similar Web sites can be accessible
through wireiess devices such as cell phones and personal data assistants, thereby making it more accessibleto patients. In addition,
allowing patients to enter their data through a regular telephoneIine
Ms. B. Maric is the recipient of a Michael Smith Foundation for
Health ResearchJunior Graduate Studentship and a Canadian In*
stitute ofHealth ResearchCanadaGraduateScholarship.Dr. S. Lear is
a CanadianInstitutes ofHealth ResearchNew Investigator. Funding
for &is study was supportedin part by the Michael Smith Foundation
for Health Research.This study was supported in part by an unrestricted grant by Astra Zeneca.
may also be feasible.
We must also considerpossiblelimitations associatedwith patient
self-report that may include patients not fuily appreciaiing their
symptoms and/or responding "No" to the daily questionsso as to
avoid contact from the study nurse. However, we believe it was more
likely that the participants in our study may have actuaily overreported their symptoms, given that patients enroiling in studies tend
to be more health conscious.In addition, participants also reported
during the interviews that they would have iiked the opportunity
to include free text comments along with their answers to the five
daily questionsin order to communicateto the nursemore accurateiy
how they are feeling and why they may be feeling that way. 1'Vhile
healthcare providers rely heavily on a patient's report of symptoms,
in-person examinations allow for the provider to make note ofphysical signs and measuresto fully assessa patient's progress.In our
study, all alerts were followed up by the nurse consulting with the
participant by teiephone, which allowed for further assessmentof the
participant's condition with the possibility of referralto their primary
care physician if warranted.
Lastly, we must also recognize that the participants were receiving
optimized medical management, and therefore we recognize the
iimitations that the small samplesizeand lack of a control group have
in assessingthe effect attributable to the interuention. Based on the
successof this investigation, we plan to conduct a larger randomized triai.
Conclusions
Among thosepatientswith FIFfailurewho hadIntemetaccessand
consentedto this study, the use of an Intemet-basedWeb site to
zo lo
32 T f L f H E O l C l l { Fa n d e- HEAL T H JANUARY/F EBRUARY
Acknowtedgments
Disclosure
Statement
No competing financial interestsexist.
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ScottA. Lear,Ph.D.
Physiologyand Kinesiology
Departmentof Bionted.ical
-Harb our Centre Campus
Fras
er
Uniuersitv
Simon
515West HastingsSieet
Vancouuer,British ColumbiaV6B 5K3
Canada
E- mail: [email protected]
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Y
@ M ARY ANN L IEBERT, IN C . . V OL, 16 116.1 o l A N U A R Y /FE B R U A R
JulY B, 2009
Receiued:
September
3, 2OO9
Reuised:
3, 2OOg
Accepted:September
Y E LE MID IC IN EA N d C .H E A LTH33