Advice
The technology
The technology
TriageHF Plus (Medtronic) is a care pathway that uses a heart failure risk score, an online data management platform and telephone assessment to remotely monitor people at risk of heart failure or worsening heart failure. It can only be used for people who have a Medtronic cardiac implantable electronic device (CIED) and needs the CareLink network service (see NICE's medtech innovation briefing on CareLink network service for remote monitoring of people with cardiac devices).
TriageHF Plus uses health-related data collected from a person's Medtronic CIED. Data is transferred from the Medtronic CIED using the advice in NICE's medtech innovation briefing on CareLink network service. TriageHF Plus uses this data to categorise the person's risk (low, medium or high) of hospitalisation from heart failure events. The risk status reported for the next 30 days is based on the maximum daily risk status from the previous 30 days. The company claims that people with a high-risk score are 10 times more likely to be hospitalised within the next 30 days than those with a low-risk score. People who have high risk of heart failure events are contacted for a telephone appointment with a heart failure nurse.
TriageHF Plus creates a risk status by assessing the following parameters: atrial tachycardia (AT) or atrial fibrillation (AF) burden, ventricular rate during AT or AF, OptiVol fluid index (which tracks changes in thoracic impedance over time), patient activity, night ventricular rate, heart rate variability, percent of ventricular pacing, treated ventricular tachycardia or ventricular fibrillation, and defibrillator shocks.
Innovations
Unlike other risk scores, the TriageHF score is automated and updated every 30 days. Remote monitoring data is collected from Medtronic CIEDs, and people with a high-risk score are contacted by telephone. The company claims that the combination of a CIED, risk score and telephone assessment could better detect people at risk of heart failure, heart failure decompensation or fatal mortality events.
Current care pathway
NICE's technology appraisal guidance on implantable cardioverter defibrillators and cardiac resynchronisation therapy for arrhythmias and heart failure recommends using implantable cardioverter-defibrillators (ICDs), cardiac resynchronisation therapy (CRT) with defibrillator, or CRT with pacing as treatment options for specific groups that overlap with the intended population for TriageHF Plus. TriageHF Plus can only be used with Medtronic devices. One expert said that eligibility for the technology will vary between centres, because use of Medtronic CIEDs varies.
NICE's guideline on chronic heart failure in adults: diagnosis and management recommends that all people with chronic heart failure should have monitoring. Monitoring should include a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status, nutritional status, a medication review and an assessment of renal function. The monitoring frequency should depend on the stability of the condition but is needed at least 6-monthly for stable proven heart failure.
The British Heart Rhythm Society's clinical standards and guidelines for the follow up of cardiac implantable electronic devices (CIEDs) for cardiac rhythm management states that managing heart failure is a multidisciplinary process. It recommends that monitoring includes a regular technical review of device function, monitoring of symptoms, and management of new and changing conditions. For suspected worsening heart failure, centres should have a clear local protocol for people with CIEDs. Device follow up can be done face to face or remotely.
People at risk of heart failure or worsening heart failure who have a CIED are usually managed in multiple clinics. For example, a heart failure clinic manages the medication review, and a cardiac physiologist lead clinic manages the follow up of the CIED. The extent to which these services overlap varies between centres.
The following publications have been identified as relevant to this care pathway:
Population, setting and intended user
TriageHF Plus is intended to be used with standard care to remotely monitor people at risk of heart failure or worsening heart failure. The technology can only be used in people with OptiVol-enabled Medtronic CIEDs but the software can be added to devices retrospectively.
TriageHF Plus can be used in primary, secondary or tertiary care depending on local heart failure management protocols and pathways. The technology can be used by different healthcare professionals including cardiologists, cardiac physiologists, clinical pharmacists, GPs, and heart failure nurses in a hospital or community setting. The company provides face-to-face training and access to online and paper educational resources. The company also provides ongoing support from a team of heart failure specialists.
Costs
Technology costs
TriageHF Plus costs approximately £43 (excluding VAT) per person per year (based on an estimated average number of eligible people per centre). The company has an annual license fee of £17,113 per hospital site. This includes data management and software upgrades within the year of purchase. The company also has annual fees for IT maintenance, support, and data analytics of £6,994, and an initial IT governance and activation fee of £1,651.
Resource consequences
The company states that 6 NHS Trusts are currently following the TriageHF Plus care pathway.
TriageHF Plus is used with standard care and so it initially costs more than standard care alone. The company claims that the technology could lead to cost savings by reducing healthcare professional's time per assessment, optimising heart failure medication use, reducing the number of outpatient visits, reducing unplanned hospital admissions and preventing full heart failure decompensation that needs managing in hospital.
The company states that adoption of TriageHF Plus could need re-allocation of resources. If a person with disease classified as high risk cannot be contacted by telephone, the company recommends notifying their GP to make them aware. The company states that the CareLink remote monitoring platform and the TriageHF Plus data management platform are needed for people with TriageHF Plus enabled CIEDs.