Expert comments

Comments on this technology were invited from clinical experts working in the field and relevant patient organisations. The comments received are individual opinions and do not represent NICE's view.

All 4 experts were familiar with the technology and 3 had used the technology before.

Level of innovation

All experts agreed that TriageHF Plus is an innovative care pathway for managing risk of heart failure or worsening heart failure in people with cardiac implantable electronic devices (CIEDs). Two experts said that it is different to current standard care because patient symptoms can be monitored remotely. Another expert said that it varied from current standard care because a patient can be assessed for risk of heart failure or worsening heart failure automatically and more efficiently, which could lead to more people being assessed. Two experts felt that the technology could replace current standard care for people with compatible devices. Two experts said that the technology would be used in addition to standard care, with 1 stating that it needs clinician interpretation, assessment and action. All 4 experts said that other competing technologies are available that offer remote monitoring capabilities depending on the type or brand of device. One expert said that these competing technologies have less structured alerts and less validation than TriageHF Plus. Another expert said that TriageHF Plus was unique as it can measure OptiVol fluid index tracking thoracic impedance and it does not rely on the patient entering data to prompt or influence the timing of data collection.

Potential patient impact

All experts agreed that TriageHF Plus may lead to earlier identification of people at risk of heart failure decompensation, which could result in earlier intervention and fewer hospitalisations. Two experts said that it could lead to improved patient outcomes and health status. One expert said that people will benefit from reduced face-to-face reviews. The experts agreed that TriageHF Plus could be beneficial for people with Medtronic CIEDs who are at risk of heart failure. One expert specifically noted that it would be beneficial for people with a diagnosis of heart failure and reduced ejection fraction. One expert stated that the number of people eligible for TriageHF Plus will vary between centres depending on the usage of Medtronic CIEDs.

Potential system impact

All the experts agreed that TriageHF Plus could change the current care pathway and reduce the burden of monitoring and follow up for heart failure. Three experts felt that the technology could reduce hospitalisations, and 2 experts said it could also reduce the number of hospital visits and healthcare professional resources. All experts agreed that there would be an initial upfront cost for the technology, but that this could lead to cost savings over time by reducing hospitalisations.

All experts agreed that system benefits could be seen if a robust pathway is in place for the technology. Three experts said that multidisciplinary team involvement between heart failure and cardiac physiology services is necessary for successful implementation. One expert said that appropriate IT infrastructure and phone services should be in place for clinicians. One expert also said that a robust community heart failure service is likely to be needed, to ensure that risks identified as part of the TriageHF Plus care pathway result in action to improve patient care. One expert stated that the high number of alerts generated by the technology could lead to a high volume of additional work which would need additional staffing arrangements. They also said that chronic understaffing of heart failure services and recent increases in the number of heart failure patients may make implementation of TriageHF Plus difficult. Another expert agreed that the additional workload burden, as well as costs, could be a barrier for adoption. However, Garner et al. (2022) describes a small effect on workload, but with the challenge that some users became unfamiliar and less engaged with the pathway due to receiving few high alerts.

General comments

All 4 experts said that specific training for staff in cardiac physiology and heart failure services would be needed to use the technology. All the experts agreed that there are no potential harms from the technology if it is implemented effectively. Three experts said that the technology could produce false‑positive alerts, and 2 experts stated that this could lead to unnecessary contact from the heart failure nurse, which could lead to increased patient anxiety. One expert noted that in Ahmed et al. (2019), no concerning patient features were identified in 29% of high-risk alerts, which represents a relatively high rate of false-positive alerts. One expert also said that there was a potential risk of unactioned heart failure events if there was long-term sickness in the clinical team, or if they were unable to contact patients.

One expert felt that the evidence base for TriageHF is currently limited, and another stated the need for a randomised controlled trial comparing standard care with TriageHF Plus. The experts felt that future studies would benefit from including the following outcomes: heart failure hospitalisation, heart failure symptoms, response to alerts within 1 week, changes in medications or treatments arising from alert responses, healthcare resource use, quality of life and patient satisfaction. One expert also noted a need to establish the health economic case for using the technology in practice.