Adherence, adaptation and acceptance of elderly chronic heart failure
patients to receiving healthcare via telephone-monitoring
Robyn A. Clarka,b, Julie J. Yallopc,d, Leon Pitermane, Joanne Croucherc, Andrew Tonkinc,
Simon Stewartf, Henry Krumc,⁎
On behalf of the CHAT Study Team
aNational Heart Foundation South Australian Branch, Australia
bFaculty of Health Sciences, University of South Australia, Australia
cDepartment of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Prahran, Victoria, Australia
dDepartment of General Practice & Primary Health Care, The University of Auckland, New Zealand
eSchool of Primary Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, East Bentleigh, Vic, Australia
fDepartment of Preventative Cardiology, Baker Heart Research Institute, Prahran Victoria, Australia
Received 1 February 2007; received in revised form 27 May 2007; accepted 16 July 2007
Available online 17 October 2007
Background: Although the potential to reduce hospitalisation and mortality in chronic heart failure (CHF) is well reported, the feasibility of
receiving healthcare by structured telephone support or telemonitoring is not.
Aims: To determine; adherence, adaptation and acceptability to a national nurse-coordinated telephone-monitoring CHF management
strategy. The Chronic Heart Failure Assistance by Telephone Study (CHAT).
Methods: Triangulation of descriptive statistics, feedback surveys and qualitative analysis of clinical notes. Cohort comprised of standard
care plus intervention (SC+I) participants who completed the first year of the study.
Results: 30 GPs (70% rural) randomised to SC+I recruited 79 eligible participants, of whom 60 (76%) completed the full 12 month follow-
up period. During this time 3619 calls were made into the CHAT system (mean 45.81 SD±79.26, range 0–369), Overall there was an
adherence to the study protocol of 65.8% (95% CI 0.54–0.75; p=0.001) however, of the 60 participants who completed the 12 month follow-
up period the adherence was significantly higher at 92.3% (95% CI 0.82–0.97, p≤0.001). Only 3% of this elderly group (mean age 74.7±
9.3 years) were unable to learn or competently use the technology. Participants rated CHAT with a total acceptability rate of 76.45%.
Conclusion: This study shows that elderly CHF patients can adapt quickly, find telephone-monitoring an acceptable part of their healthcare
routine, and are able to maintain good adherence for a least 12 months.
© 2007 Published by Elsevier B.V. on behalf of European Society of Cardiology.
Keywords: Chronic heart failure; Telephone support; Acceptance
CHF affects up to 2% of the adult population and this rate
is consistent throughout the world [1–3]. The effectiveness
of multidisciplinary non-pharmacological approaches for
improving outcomes in patients with chronic CHF have been
well established in over 30 randomised trials [4–8].
However, as most of these trials have tested multi-faceted
European Journal of Heart Failure 9 (2007) 1104–1111
⁎Corresponding author. Department of Epidemiology and Preventive
Medicine, Monash University, 3rd Floor, Burnet Tower, AMREP Precinct,
Commercial Road, Melbourne, VICTORIA 3004, Australia. Tel.: +61 9903
0046; fax: +61 9903 0576.
E-mail address: firstname.lastname@example.org (H. Krum).
1388-9842/$ - see front matter © 2007 Published by Elsevier B.V. on behalf of European Society of Cardiology.
by guest on June 12, 2013
approaches it is difficult to identify the incremental benefits
of the particular components of each intervention .
Nevertheless, it is clear that within most populations there
is limited access to these programmes due to barriers related
to funding and/or geography . As a result, there is
increasing interest in care-delivery models which incorporate
information/communication technology, either in the form of
telemonitoring—the transfer of physiological data (such as
blood pressure, weight, electrocardiogram, oxygen satura-
tion) via normal telephone lines or digital cable (or satellite)
from home to health care provider—or simply standard
telephone contacts between patients and health care
providers, which may or may not include data transfer.
A recent systematic review of telemonitoring and
structured telephone (as opposed to non-specific telephone
conversations) has shown significant potential for the use of
this technology within a CHF disease management
The impact of structured telephone support on the risk of
CHF-related hospitalisations can be attributed in part to the
triage of patients at the first sign of clinical deterioration by
the specialist nurse, and the consequent immediate interven-
tion of a primary care physician [12,13]. Alternatively
“telemonitoring” trials involving daily transmission of vital
signs, symptoms and weight lead to earlier detection and
management of clinical deterioration by both the patient and/
or the managing health professional [14,15]. A recent study
from Spaeder reported that symptoms indicating deteriora-
tion in heart failure were detected 8–12 days before
admission to hospital .
Although the potential to reduce mortality and hospita-
lisation in CHF is well reported in these trials, the
acceptability and adherence and satisfaction of receiving
healthcare by telephone or telemonitoring are not [11,17].
Consequently, this study reviewed the involvement of
participants in the Chronic Heart Failure Assistance by
Telephone study (CHAT) [18–20] with the following aims:
1. To determine the adherence (compliance) of participants
to the CHATstudy protocol by reviewing call patterns and
rates and to determine if there were any significant
demographic characteristics within various levels of
2. To determine the adaptation rates within our study
population and to describe the characteristics of partici-
pants who could not learn or master the use of the
3. To determine the acceptability (satisfaction) of partici-
pants to receiving healthcare via an IT supported
computerized telephone-monitoring system of care in-
cluding telephone interaction with specialist CHF nurses.
To address these aims a mixed method, triangulation 
of descriptive statistics, qualitative analysis of the partici-
pants' feedback and clinical notes was used. The sample for
this study was taken from participants who completed the
first 12 months of follow-up in the Chronic Heart Failure
Assistance by Telephone (CHAT) study. During the first year
of this study participants were pre-dominantly recruited from
rural and remote areas throughout Australia.
2.1. The CHAT study
The CHAT study is an Australian national, stratified,
cluster randomised trial (cRCT) involving 400 General
Practitioners (GPs). The overall study target was to recruit a
total of 534 eligible patients . Inclusion criteria were;
age≥18 years; confirmed diagnosis of CHF by echocar-
diograph (LV Ejection Fraction≤40% for systolic dys-
function or features of diastolic dysfunction) and /or a
primary hospital diagnosis; New York Heart Association
(NYHA) Class II–IV. Patients were also required to have a
touch dial phone and be able to operate it. Exclusion
criteria were; enrolment in any other CHF disease
management programme; planned cardiac surgery or
coronary angioplasty within the next 3 months; hypertro-
phic cardiomyopathy or constrictive pericarditis; eligible for
transplantation; life expectancy b12 months; untreated
thyroid disease; pregnancy or peripartum cardiomyopathy;
other problem likely to limit compliance. All GPs volun-
teered to participate and each GP practice was randomised
to one arm of the trial by computer generated allocation.
Although neither GPs nor participants were blinded, the
research assistant who collected all health related quality of
life (HRQOL) data was blinded to participant group
allocation. In addition, adequate measures were taken to
conceal the study group allocation to those who evaluated
and administered the process. (Fig. 1) The primary outcome
was to determine whether the intervention improved the
participants' health status using the Packer Clinical
Composite Score . Secondary outcomes included total
hospitalised days, the proportion of participants on target
doses of ACE inhibitors, changes in brain natriuretic
peptide (BNP) levels and cost-effectiveness. A detailed
methodology paper has been published  and final
outcomes will be presented in future publications.
The CHAT study interventions and timings are presented
in Fig. 1. All participants received standard care (SC) and
those allocated to the intervention group also received nurse-
coordinated telephone-monitoring support (SC+I). The
telecommunication software used in the CHAT study was
adapted and modified (Australian language and metric
measurements), from the John Hopkins TeleWatch™
Upon enrolment, each participant in the intervention
group received an initiation and training call from the nurse
to ensure competence in the independent use of the telephone
technology. Once initiated, participants were instructed to
1105 R.A. Clark et al. / European Journal of Heart Failure 9 (2007) 1104–1111
by guest on June 12, 2013
call at least monthly or more often if they wished. Monthly
reporting was considered by the research team as the
minimum contact time. Patients were required to respond to
pre-recorded questions on the computer, using the telephone
key pad. The questions, which were based on the national
CHF guidelines [24,25], included assessment of weight,
signs, symptoms and reports on self-management issues such
as medicine, diet and fluids. A toll free number was provided
for a period of 12-months follow-up (Fig. 1).
2.1.2. Measurement of adherence to telephone-monitoring
Adherence was calculated from the total number of calls
per participant. The study protocol required the participant to
call the CHAT line at least monthly, during the pre-
determined 12 month follow-up period. Two scales of
adherence were used: 12 calls or more was classified as
“Adherence” to the study protocol and 11 calls or less was
rated as “Non Adherence”. Potential correlations between
adherence patterns and participant baseline demographics
were examined in order to determine if there were
differential characteristic in the adherent and non-adherent
2.1.3. Measurement of adaptation to telephone-monitoring
Data from three sources were used to identify participants
who were unable to learn or master the use of the CHAT
Fig. 1. CHAT study design.
1106 R.A. Clark et al. / European Journal of Heart Failure 9 (2007) 1104–1111
by guest on June 12, 2013
technology.(1) Response to the pre-recorded question asking
the participant if they had any difficulties using the system
and a second question which asked how many times they had
with the participant. (3) Six questions from the acceptability
survey which related to difficulty in using the system.
2.1.4. Measurement of acceptability of telephone-
To determine the acceptability (participant's satisfaction)
of receiving healthcare via telephone interaction with
specialist CHF nurses, a questionnaire was developed,
using a 27-item satisfaction tool adapted from the original
John Hopkins' project . A five point Likert scale was
used. For negatively worded items, the scores were reversed
so that high scores always indicated satisfaction and to assist
with Factor Analysis . The questionnaire was adminis-
tered by telephone; within approximately 2–3 weeks of
completion of the study by an independent researcher after
the final 12 month HRQOL survey had been performed.
2.1.5. Statistical analysis
Data were analysed using the Statistical Package for
Social Science™ (Version 14 2004) and the STATA
Statistical software for professionals (Version 9 2006).
Descriptive statistics are presented as means, percents or
proportions with 95% confidence intervals. The relationship
between adherence and participant characteristics was
examined using Chi square (X2) tests and STATA was also
used to determine a cumulative incident probability by
Poisson negative binomial regression analysis. An explor-
atory factor analysis was completed to determine whether
scale items measured a single construct and whether those
Cronbach's Alpha coefficient was calculated to measure the
reliability of the multidimensional aspects of the acceptance
survey. Cronbach’s Alpha coefficient was calculated to
measure the reliability of the multidimensional aspects of the
acceptance survey. Cronbach's Alpha should be above 0.7,
however Cronbach’s Alpha coefficient is quite sensitive to
Cronbach’s Alpha coefficient values ofless than0.5.Clinical
notes were analysed using a qualitative iterative strategy
based upon the method proposed by Huberman and Miles
. Using an iterative approach, emerging patterns and
themes were identified. Eleven themes describing the
subjects of the outgoing calls were identified.
Ethics approval was gained from all of the institutions
involved in this research including Monash University, The
University of South Australia and the Aboriginal Health
Council of South Australia. Individual informed consent was
obtained, from each participant, by their GP during a
Between May 4th 2004 and May 2nd 2005, 79 eligible
participants with a diagnosis of CHF were recruited by the 30
GPs who were randomised to the SC+I group. Within the
SC+I group 19 patients (24%) withdrew from the study
during the first 12 months. The remaining 60 patients (76%)
completed the 12 month follow-up period. Reasons for non-
completion included withdrawal due to poor health;
difficulty with understanding and speaking English on the
telephone; transfer to a nursing home; some finding the
programme not acceptable and death. The overall withdraw-
al rate for voluntary reasons was 11%.
The mean age of the participants was 74.7 (SD± 9.3)
years. There were 51(65%) males and 28 (35%) females.
Fifty eight participants (74%) lived with a spouse, partner or
a supportive relative; and nearly 70% were from rural or
remote areas. Mean weight was 83 ±24 kg and NYHA class
ranged from II (42%) to IV (18%). The most common co-
morbidities were hypertension (58%), ischaemic heart
disease (68%) and myocardial infarction (54%). (Table 1)
by the 79 SC+I participants into the CHAT telemonitoring
system (mean 45.81, range 0–369 calls per patient). There
were 9outliers who called almostdailyduringthe study,with
between 115 and 369 calls over 12 months. When these
outliers were excluded from the analysis, the mean call rate
per participant was 20.9 (range 0–94). Overall the adherence
participants classed as adherent to the CHAT telemonitoring
protocol in the first year (65.8%, 95% CI 0.54–0.75,
p≤0.001). However, within the group of 60 participants
who completed the first 12 months of follow-up (minimum
monthly contact) the adherence was significantly higher at
92.3% (95% CI 0.82–0.97, p≤0.001). There was no
significant correlation between any baseline characteristics
in those participants who maintained adherence to the study
protocol and those who were not adherent.
Of the 3619 calls made by the participants, there were
only 60 (1.65%) calls which suggested difficulty in
connecting to the system and 51(1.40%) calls suggesting
multiple attempts to get connected. The analysis of the
clinical notes differentiated between the inability to connect
to the system because the system was down (98 calls, 2.7%)
and incidents where the patients themselves were having
difficulty (82 calls, 2.2%). In addition to these technical
difficulties, two other issues that affected adaptation emerged
from the clinical notes. Firstly, 30 of the initial 79 SC+I
participants (38%) did not have a set of functioning
bathroom scales at the time of recruitment into the study.
1107 R.A. Clark et al. / European Journal of Heart Failure 9 (2007) 1104–1111
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Secondly, six of the participants (7.6%) reported having
difficulty using the phone due to a hearing impairment. Six
questions within the acceptability survey referred to the “user
friendliness” of the CHAT system. The overall rating of
acceptability of these six questions was 82%.
Sixty participants (76%), completed the first year of the
CHAT study, and were therefore eligible to complete the
satisfaction questionnaire, which was administered by
telephone within 2–3 weeks of completion of the 12 month
study period. The total response rate for the survey was 90%
(57 participants). These participants rated the CHAT service
with a total acceptability rate of 76%. There were no
significant demographic characteristics related to the satis-
within the CHATsystem, a total of 1463 outgoing calls were
made to the 79 (SC+I) participants by the CHAT nurses. The
mean number of outgoing calls to a participant was 17.92
(SD±11.3, mode 18, range 3–61). Thematic analysis of the
clinical notes revealed two broad themes and eleven sub
themes in the CHAT nurse outgoing calls; these were heart
failure management (73%) and technical failure and
reminders to call-in (27%). Fig. 2 presents a more detailed
break down of the outgoing calls.
The positive aspects of the CHAT intervention that rated
most highly (81%–86%) were: 1) the ease of getting
connected; 2) understanding the pre-recorded questions
and pressing the right buttons; 3) the time spent by the
CHAT nurse and the confidence in the advice they offered.
The Cronbach's Alpha reliability coefficient for this set of
questions was 0.89 indicating reliability and internal
consistency of the responses. Conversely, the most nega-
tively perceived aspects of the intervention (50%–68%)
were 1) helping to understand medicines and take medicines
and 2) whether the participant thought that the CHAT nurse
or GP was checking up on them.
Upon completion of the survey, participants were given
the opportunity to make open ended comments about the
service. Examples of “general comments” which reflect
positive and negative feelings about the CHAT intervention
and “critical incidents” reporting on significant events, in
which the participant and the CHAT nurse interacted, are
shown in Table 2.
This study examined adherence; adaptation and accep-
tance to a telephone-monitoring system in a representative
cohort of CHF patients participating in the CHAT study.
Participants lived pre-dominately in rural and remote areas of
Australia. Consistent with the demographics of chronic heart
failure in Australia .
Using intention to treat analysis, the overall adherence to
the CHATstudy protocol was 62%. However, the group who
completed the follow-up period had a much more committed
adherence rate of 92% and this compares well to other
telemonitoring studies such as de Lusignan  who
reported 75% adherence to telemonitoring of weight and
90% adherence to blood pressure monitoring. The WHARF
 telemonitoring trial reported 98.5% adherence and
Capomolla  reported an adherence rate of 81% to
telemonitoring. Although it would be preferable if overall
adherence was higher, it is important to remember that
telemonitoring adds other layer to the complex expectations
of chronic heart failure self-care (e.g. managing medicines,
diet, fluid, exercise and regular medical assessment). For
most of the participants in our study, this was the first
interaction with a specialist CHF management team and this
may explain the enthusiasm of some (Table 2).
Forty percent of the participants who died during the trial
period also showed good adherence to the protocol. Analysis
of the clinical notes (including the comments of their carers)
Baseline characteristics of the CHAT study first year cohort
CharacteristicSC+I (CHAT) N (%)
Male n (%)
Female n (%)
Living Status n (%)
NYHA n (%)
Capital city/Metropolitan n (%)a
Rural and remote n (%)
Co-morbidities n (%)
Ischaemic heart disease
123.8 ± 33
9.6 ± 13
33.8 ± 14
Pharmacotherapy (n and % of participants prescribed)
NYHA=New York Heart Association Classification, HBA1C=Haemoglo-
bin A1c, SD=Standard Deviation, mmol/l=millimole per litre, ACEI=An-
giotensin convertingenzymeinhibitor, ARB=angiotensin receptorblockers,
LVEF=Left ventricular ejection fraction percent,
a70% of the Australian population live in capital cities.
1108R.A. Clark et al. / European Journal of Heart Failure 9 (2007) 1104–1111
by guest on June 12, 2013
indicated that the CHATservice provided additional care and
support (by telephone) at the end stage of this syndrome.
This is an important issue, and highlights the fact that
patients with NYHA class IV should be considered for CHF
telephone support services.
Misconceptions of technophobia in the elderly were
dispelled by the analysis of call patterns and clinical notes,
which indicated that a very low number of participants
(b3%) were unable to learn how to use the technology
competently. We found that our elderly CHF participants
were more than able to cope with this type of technological
monitoring. However, some simply preferred not to add
healthcare technology into their busy lives. (Table 2)
Two important factors regarding adaptation were also
noted from the clinical records; the first was that one third of
the participants did not have bathroom scales in their homes
at the time of the initiation call. This finding questions the
level of self monitoring prior to enrolment into the CHAT
study. The second adaptation issue was that telemonitoring
and structured telephone health support requires the ability to
listen and hear important and complex instructions. Partici-
pants with diminishing hearing ability reported finding the
system very hard to use. During the first 12 months there
were many requests from participants to increase the volume
of the pre-recorded interactive messages. In light of this, a
test of telephone hearing ability should be conducted before
entry into future trials. A recent telephone-monitoring study
which lists hearing ability in the inclusion criteria demon-
strates support for this proposal .
The satisfaction (acceptability) of those participants who
completed the first 12 months of the study was 76%, which
reflected an overall satisfaction with receiving health care via
technology. The open ended responses and the critical
incidents from the survey (Table 2) demonstrated the
complexity of the lives of many of the participants who
not only have CHF but other co-morbidities such as cancer.
Also emerging from the clinical notes and the satisfaction
survey was the amount of interaction the CHAT nurse had
with family and supportive others. This wider effect of the
intervention, beyond the participant, is also supported by
data from Riegel et al. which also showed a considerable
number of interactions with family .
These findings are consistent with other CHF telephone-
monitoring studies such as the TEN-HMS study  where,
overall patient acceptance was 91.2% (96% of patients were
well satisfied with the system and 97% found the telecare
devices easy to use) and the first 150 patients in the
TeleWatch™ service, who reported an overall system
acceptance of 75.4%.. In addition, a systematic review
of patient satisfaction with telemedicine by Mair, 
reported that most patients were satisfied with the improved
accessibility to specialist care and decreased travelling
Fig. 2. CHAT nurse out-going calls theme analysis from clinical notes.
1109 R.A. Clark et al. / European Journal of Heart Failure 9 (2007) 1104–1111
by guest on June 12, 2013
(reducing travel to healthcare services was a very important
issue for our rural patients).
There are, however, several limitations to our study. Data
on primary outcomes in the CHAT study have yet to be
published; therefore, these results are an interim analysis and
should be considered in that context. On completion of the
CHAT study, a larger sample size may give statistical
significance and identify some of the key characteristics,
including ethnicity as identified by Riegel , that may
indicate which CHF patients are best suited to structured
telephone support or telemonitoring. The recruitment
process involved unblinded GPs selecting suitable partici-
pants according to the inclusion criteria. The potential
importance of a highly selected, voluntary group of elders
who may well represent the “techno-friendly” spectrum of
CHF patients-leading to high levels of acceptance and uptake
should also be taken into account. We would also strongly
recommend more reporting of adherence, acceptability and
adaptation in future trials, as these important secondary
outcomes are currently under-reported in published large
structured telephone and telemonitoring trails [32–34].
This study shows that elderly CHF patients can adapt
quicklytotelephone-monitoring,finditsuse anacceptable part
of their healthcare routine, and are able to maintain good
of structured telephone support and telemonitoring as part of a
comprehensive chronic heart failure management programme.
Robyn Clark is a PhD Scholar supported by the National
Institute of Clinical Studies (NICS) and the National Heart
Foundation (NHF) of Australia.
The author wishes to acknowledge the work and support which
has contributed to this paper from the CHAT Study teams both at
the National Heart foundation Call Centre South Australia and the
Department of Epidemiology and Preventive Medicine, Monash
The CHAT Investigators gratefully acknowledge the following
funding sources: the National Health and Medical Research Council
of Australia, the National Heart Foundation of Australia, Medical
Benefits Fund of Australia, a Pfizer CVL Grant and My Chemist.
The CHAT Study Team would also like to acknowledge, Dr
Edward Kasper and Dr Jeff Spaeder, Department of Cardiology
and Mr James Palmer, Applied Physics Laboratory, John Hopkins
University, Baltimore, Maryland, USA, for the use of the
TeleWatch™ telemedicine system along with ongoing expert
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Acceptance survey; examples of open ended comments about the CHAT
service made by participants
▪ I was someone who needed support especially when my defib went in.
▪ OK, same as banking with fingers! Easy to use but wanted to withdraw
when realised nurse would not ring me everyday.
▪ This is the first time expert advice came into our home after 25 years in the
▪ As a consequence of being involved with this study the CHAT team
organised deafness aids and a new phone so I have ongoing benefits apart
from knowing more about my heart.
▪ Excellent maintained and controlled my weight.
▪ Really not much added than current care from doctor.
▪ CHAT nurses were great Fluid education and other advice helped a lot.
▪ As the wife carer and companion. I really looked forward to the calls I
gaineda lot of informationandhelpwith manyaspects I didn'tunderstand
about my husband's condition.
▪ Diary is very useful and is used frequently for checking back on GP
▪ I hoped I helped I did not have a lot of interaction.
▪ I didn't quite get the purpose of this but I lost 6 kg.
the doctor who saw me straight away halved my ACEI now I am fine
2. Smokes a little marijuana in the afternoon but gave up cigarettes while on
3. Severely depressed patient stopped all diabetes treatment asked CHAT nurses
not to notify doctor. Practice nurse persuaded participant to come to surgery
at last doctor'svisit. Dr notifiedhomevisitmade and Warfarin dosetitrated.
5. Drinking 10 l of water and soft drink per day. CHAT nurse worked with
doctor to modify fluid management
6. Daughter said mother would not be able to cope with this system. CHAT
nurse taught mother the system within 3 min and had good adherence for
7. Wife had episode of unconsciousness at home. Husband reported doing
“resuscitation” Wife regained consciousness but couple did not call
ambulance. CHAT nurse reiterated the emergency management plan.
8. 56 year old man diagnosed with HF 5 years previously. Sudden death at
home. Wife reported that the CHAT programme was supportive before
and after this event
9. Participant had lap-banding during CHAT 12 months required high level
support for diet and fluid management
10. Participant's husbanddiagnosedwithlung cancerduring12 monthswith
11. Likes to have a few beers with the lads at the pub didn't realise 7 was too
12. Spent time in ICU after MI with multi-systems failure
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