American Heart Journal Plus: Cardiology Research and Practice 10 (2021) 100045

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american-heart-journal-plus-cardiology-research-and-practice

Research paper

Remote monitoring for heart failure: Assessing the risks of readmission

and mortality
Amber E. Johnson a, *, Andrew L. Bilderback b, Michael Boninger b, Kathryn Y. Beatty c,
Johanna Bellon b, Meagan C. Leopold d, Andrew R. Watson e, Ravi N. Ramani a
a
Division of Cardiology, Department of Medicine, UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, United States
b
Wolfe Center, UPMC, Pittsburgh, PA, United States
c
Innovative Homecare Solutions, UPMC, Pittsburgh, PA, United States
d
Community Provider Services, UPMC, Pittsburgh, PA, United States
e
Clinical Analytics Department, UPMC, Pittsburgh, PA, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Study objective: Remote monitoring (RM) can help patients with heart failure (HF) remain free of hospitalization.
Heart failure Our objective was to implement a patient-centered RM program that ensured timely clinical response, which
Hospitalization would be associated with reduced mortality.
Physiologic monitoring
Design: This was a retrospective, observational, propensity-matched study.
Setting: A large regional health system between 9/1/2016–1/31/2018.
Participants: Patients admitted with acute HF exacerbation were matched on key variables. Up to two comparison
patients were selected for each RM user.
Interventions: We used an algorithmic approach to assess daily physiologic data, assess symptoms, provide patient
education, encourage patient self-management, and triage medical problems.
Main outcome measures: We assessed all-cause mortality using Kaplan-Meier and log rank analysis. We used Cox
proportional hazards to compare risk of death.
Results: Our cohort of 680 RM users and 1198 comparisons were similar across baseline characteristics except age
(74.7 years versus 76.6 years, p < 0.001, respectively). Having one or more admissions in the preceding 120 days
was more prevalent in the RM group (35.9% versus 29.8%, p = 0.013). The 30- and 90-day all-cause readmission
rates were each higher among the RM users compared with the comparison patients (p = 0.013 and p < 0.001 for
30 and 90 days, respectively). Mortality was lower in the RM group at 30 and 90 days post-discharge (p < 0.001).
Conclusions: RM that responds to biometric data and encourages patient self-management can be used in a large
hospital system and is associated with decreased all-cause mortality. Our findings underscore RM technology as a
method to improve HF care.

1. Introduction important aspect often collected by RM interventions. RM is a useful

Patients admitted to the hospital with acute decompensated heart
failure (HF) are at high risk for hospital readmissions and mortality in
the post-discharge period [1]. Remote monitoring (RM) and mobile
health technologies have been employed as strategies to help
community-dwelling patients with HF remain free of hospitalization
[2–5]. RM tools often incorporate physiologic measures like patient
weight, blood pressure, and heart rate, which have been shown to be
associated with worsening HF [1,6,7]. Symptom monitoring is also an
complement to usual HF care because it allows for early detection of
worsened disease while the patient remains outside of the hospital.
Despite these conceptual benefits, RM for HF has shown mixed re­
sults in clinical trials [8–10]. Two previously documented reasons for
RM's limited success have involved both patient and provider factors
[2,11]. Regarding patient factors, selection of higher risk patients sug­
gests trends toward significant improvements in clinical endpoints in
randomized controlled trials [2,12]. On the other hand, a focus on low-
risk, ambulatory patients has been associated with neutral results [13].

* Corresponding author at: 200 Lothrop St., Presbyterian South Tower, Third floor, WE353.9, Pittsburgh, PA 15213, United States.
E-mail address: Johnsonae2@upmc.edu (A.E. Johnson).

https://doi.org/10.1016/j.ahjo.2021.100045
Received 16 May 2021; Received in revised form 23 July 2021; Accepted 12 August 2021
Available online 11 September 2021
2666-6022/Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A.E. Johnson et al.
Patients who are admitted in the hospital at the time of study enrollment
are considered more unstable and higher risk than patients whose HF is
effectively managed in an ambulatory setting. Regarding provider fac­
tors, clinician interaction has been critical to the success of studies that
have shown a decrease in readmission rates [3,5,13]. RM programs that
generate alerts to which no actionable response is achieved have
generally been less successful at reducing readmissions [2].
Aside from readmission, mortality is another important clinical
outcome that could be affected by RM programs. When assessing risk of
mortality, complimentary clinical factors must be adequately assessed
and adjusted for, such as comorbid diseases. Similarly, patient gender
and race have been associated with HF outcomes including mortality,
thus accurate reporting of such baseline characteristics should be
acknowledged when assessing risk for poor HF outcomes. Notably,
predictors of mortality are different from those for readmission [1]. For
example, systolic blood pressure predicts mortality whereas weight gain
more accurately predicts readmission [1]. To date, attempts to show that
RM improves outcomes have been met with disappointing results due to
difficulty in selecting the appropriate patient population and measuring
the most relevant clinical variables [8,11,14]. Propensity-matching
methodology can be applied to retrospective data to help overcome
logistical barriers to studying a high-risk patient population while
adjusting for multiple baseline variables and comorbid conditions.
Therefore, to understand how RM could benefit a cohort of patients
hospitalized with HF, we designed a program to be implemented upon
discharge after acute HF exacerbation. The objective was to implement a
pragmatic RM program that could be easily and widely deployed at our
large, multi-hospital, academic medical system. We aimed to ensure
patient adherence and timely clinical response. We hypothesized that
use of our RM program would be associated with reduced all-cause
readmission and mortality.
2. Materials and methods
2.1. Study design
This was a retrospective, observational study wherein the association
of RM with cardiac outcomes was determined by propensity matching
on key variables using available data within the hospital system's elec­
tronic medical record.
2.2. Setting and data collection
The UPMC (University of Pittsburgh Medical Center) Health System
is a large not-for-profit academic system located in the Pittsburgh,
Pennsylvania region. Over 1 million unique patients are seen annually
within UPMC, leading to approximately 5.6 million outpatient en­
counters and 382,000 hospital admissions per year. [15] We analyzed
data from 929 patients who enrolled in the RM program between 9/1/
2016 and 1/31/2018 and who were identified as having had inpatient
HF admissions within the 14 days prior to enrollment. Patients with a
primary admission diagnosis of HF were identified by referral from their
providers or their insurance company. To be enrolled, a remote moni­
toring order was required from either the primary care physician or
primary cardiologist. RM program recruiters used the following criteria
to screen patients, and if present, determined them to be poor candidates
for the program: psychosis, dialysis, physical inability to provide bio­
metric data, lack of permanent home address, end-stage HF (palliative
inotropes, heart transplant candidate, ventricular assist device), life
expectancy less than six months, weight greater than 400 pounds, or
lack of provider to respond to alerts. The UPMC Quality Review Com­
mittee approved this observational study as quality improvement and
informed consent for research was not required. The data that support
the findings of this study are available from the corresponding author
upon reasonable request.
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American Heart Journal Plus: Cardiology Research and Practice 10 (2021) 100045
2.3. Remote monitoring program
The intervention consisted of a kit-based program including a tablet,
external blood pressure monitor, pulse oximeter, and scale. Using the
tablet, the patient would respond to a short series of multiple-choice
questions and input their home vital sign readings daily Saturday
through Sunday. In response to the patient's input, the RM protocol
featured an algorithmic, pragmatic approach. If the patient's data fell
outside the normal range, an alert would be triggered to the UPMC Call
Center. The Call Center is a group of nurse-level patient educators who
are trained to encourage patient self-management, assess symptoms, and
triage medical problems over the phone. Prior to the current HF RM
initiative, the Call Center helped to remotely manage other clinical
conditions, and was repurposed for HF as the RM program was devel­
oped. If an alert required non-emergent medical attention, the Call
Center nurse would notify the ordering physician via the outpatient
electronic health record. The ordering physician would then manage the
condition at the physician's clinical discretion.
2.4. Outcomes of interest
Patients were enrolled in the program for a 90-day period. The pri­
mary outcome was all-cause readmission (including observation visits)
at 30 and 90 days following program enrollment to hospitals within our
health system. We abstracted electronic medical record data for number
of emergency department visits. Secondary outcomes included 90-day
mortality and death, which was measured by the social security death
index data available in the electronic health record.
2.5. Statistical analyses
We used the following assumptions in our matching approach. The
extent of covariate overlap and balance is shown in Table 1. Exact
matches were required within diagnosis-related group (DRG) code,
readmission risk score category, [16] and the activity outcome mea­
surement for post-acute care (AMPAC) mobility category. [17] Patients
were also matched on mortality risk using the All Patient Refined
Diagnosis Related Groups risk of mortality. [18] This is a product
applied to the medical record that determines one of four possible risk
categories (minor, moderate, major, extreme) for each patient based on
available clinical data. The closest mathematical matches were accept­
able for matched variables (nearest neighbor). [19] Up to two compar­
ison patients were selected for each RM user to decrease the risk of
unobserved confounding variables. [19,20] These outcomes were
compared using two-tailed t-tests. We also assessed mortality using
Kaplan-Meier survival and log rank analysis. We used Cox proportional
hazards to compare risk of death in the RM versus comparison group.
Statistical analyses were performed with Stata version 15.0.
3. Results
3.1. Baseline characteristics
Using the nearest neighbor method, suitable matches could not be
found for 249 RM users. Our cohort therefore consisted of 680 RM users
and 1198 comparison patients. Demographic data and baseline char­
acteristics for the analyzed cohorts are shown in Table 1. The baseline
characteristics for the entire cohort of RM users are shown in the Sup­
plementary Table. Those excluded from analysis on average younger,
more likely to identify as Black or Other, have commercial insurance,
and have an extreme risk of death and more mobility limitations. Of
those included in the propensity-matched analysis, RM users were on
average two years younger (74.7 years versus 76.6 years, p < 0.001).
The average Elixhauser morbidity index score was 0.2 higher in the RM
group (p = 0.04). BMI was 1.4 units higher among RM users (p < 0.001).
Having one or more admissions in the preceding 120 days was slightly
A.E. Johnson et al. American Heart Journal Plus: Cardiology Research and Practice 10 (2021) 100045

Table 1 eligibility criteria, patient expired, or patient no longer wished to

Baseline characteristics for remote monitoring (RM) users and propensity- participate. The RM program generated 129,450 alerts over an 18-
matched comparison patients. month period. This was an average of 139 alerts per RM user. Nearly
Characteristics RM group Comparison p- all patients had Medicare insurance with the remaining 3% of RM users
Mean (SD) or n (%) n = 680 group Value and 2% of comparison patients having commercial insurance (p =
n = 1198 0.132). The majority (67%) of patients had a documented ejection
Age 74.7 76.6 (11.2) <0.001 fraction listed in the available electronic medical record during index
(11.7) admission. Of the 453 RM users and 797 comparison patients the mean
Elixhauser comorbidity index 6.7 (1.9) 6.5 (1.7) 0.040
(SD) ejection fractions were 45.3 (15.9) and 42.6 (16.4), respectively (p
Female 354 (52%) 620 (52%) 0.899
Married 330 (49%) 555 (46%) 0.358 = 0.005).
Race
White 586 (86%) 1049 (88%) 0.392
Black 87 (13%) 123 (10%) 0.098 3.2. Readmissions
Other 7 (1%) 26 (2%) 0.060
Commercial insurance 22 (3%) 25 (2%) 0.132
Admissions in the preceding 120 0.013
At baseline, the overall a priori all-cause readmission prediction
days score [16] was 0.2 higher in the RM group. As displayed in Table 2, our
0 436 (64%) 841 (70%) analysis showed that 30- and 90-day all-cause readmission rates were
1+ 244 (36%) 357 (30%) each significantly higher among the RM users compared with the com­
Risk of mortality [18] 0.957
parison patients. Those with the highest risk for readmission as deter­
Minor 16 (2%) 26 (2%)
Moderate 259 (38%) 457 (38%) mined by the a priori readmission risk score had 59% higher odds of
Major 334 (49%) 598 (50%) readmission within 30 days (p = 0.02) and 82% higher odds of read­
Extreme 71 (10%) 117 (10%) mission within 90 days (p = 0.001). Women consistently had higher
Severity of illness 0.955 odds of readmission at 30- and 90-days (OR 1.54, p = 0.006 and OR
Minor 22 (3%) 35 (3%)
Moderate 212 (31%) 374 (31%)
1.72, p = 0.01, respectively). Fig. 1 shows 30- and 90-day all-cause
Major 377 (55%) 674 (56%) readmission rates for categories of patients in the RM and comparison
Extreme 69 (10%) 115 (10%) groups.
AMPAC [17] 0.945
Severe limitation (<11) 6 (1%) 9 (1%)
Moderate limitation (12 to 17) 67 (10%) 111 (9%)
3.3. Mortality
Some limitation (18 to 23) 249 (37%) 451 (38%)
No limitation (24) 349 (52%) 612 (52%)
Length of stay 5.8 (3.9) 5.6 (3.7) 0.400 Mortality was significantly lower in the RM group at 30 and 90 days
Discharge disposition post-discharge. The mortality rates for RM users were significantly lower
Home 93 (14%) 141 (12%) 0.232 for the overall cohort as well as each of the race and gender subgroups
Home with home health 573 (84%) 1001 (84%) 0.688
Skilled Nursing Facility 12 (2%) 43 (4%) 0.019
analyzed (see Table 3). Our survival analysis showed that 90-day sur­
Other 2 (0.3%) 13 (1%) 0.046 vival was higher in the RM group (94.4%) compared with propensity-
Readmit score [16] 4.5 (1.8) 4.3 (1.8) 0.048 matched comparisons (89.2%). Cox model hazard ratio ([95% CI] =
Readmit score risk category 0.390 0.49 [0.34,0.71], p < 0.001). Fig. 2 shows plotted covariate-adjusted
Low 345 (51%) 634 (53%)
survival curves based on the Cox models.
Medium 276 (41%) 480 (40%)
High 58 (9%) 83 (7%)

AMPAC = activity outcome measurement for postacute care. 3.4. Sensitivity analysis

more prevalent in the RM group (35.9% versus 29.8%, p = 0.013). Of Exact matching on age would have decreased the sample size
those enrolled in the RM program during the study period, the median significantly. However, readmission and mortality results were similar
duration of participation was 82 days (mean = 71.0, SD = 54.5). Top with this slight age difference compared with exact matching on age, as
reasons for discontinuing the program included no longer meeting determined by our sensitivity analysis.

Table 2
All-cause readmissions at 30 and 90 days among the remote monitoring program (RM) users compared with the comparison patients.
n RM group Comparison group p-Value OR p-Value
n (%) n (%) [95% CI]

30-Day readmission outcomesa

Overall 1878 163 (24.0%) 229 (19.1%) 0.013 1.33 [1.06,1.67] 0.013
Low/med risk 1388 94 (19.1%) 149 (16.6%) 0.237 1.19 [0.89,1.58] 0.235
High risk 490 69 (36.5%) 80 (26.6%) 0.021 1.59 [1.07,2.35] 0.020
Black 210 17 (19.5%) 18 (14.6%) 0.350 1.42 [0.68,2.94] 0.349
White 1635 144 (24.6%) 210 (20.0%) 0.033 1.30 [1.02,1.66] 0.032
Female 974 94 (26.6%) 118 (19.0%) 0.007 1.54 [1.13,2.10] 0.006
Male 904 69 (21.2%) 111 (19.2%) 0.480 1.13 [0.81,1.58] 0.478

90-Day readmission outcomesa

Overall 1878 309 (45.4%) 419 (35.0%) <0.001 1.55 [1.28,1.88] <0.001
Low/med risk 1388 195 (39.7%) 282 (31.4%) 0.002 1.44 [1.14,1.81] 0.002
High risk 490 114 (60.3%) 137 (45.5%) 0.001 1.82 [1.26,2.63] 0.001
Black 210 40 (46.0%) 43 (35.0%) 0.108 1.58 [0.90,2.78] 0.109
White 1635 267 (45.6%) 373 (35.6%) <0.001 1.52 [1.23,1.86] <0.001
Female 974 169 (47.7%) 215 (34.7%) <0.001 1.72 [1.32,2.25] <0.001
Male 904 140 (42.9%) 204 (35.3%) 0.023 1.38 [1.05,1.82] 0.023
a
Inpatient and observation stay combined.

3
A.E. Johnson et al. American Heart Journal Plus: Cardiology Research and Practice 10 (2021) 100045

30-day
readmission
rate

90-day
readmission
rate

Fig. 1. Bar graphs with 30- and 90-day all-cause readmission rates for categories of patients in the remote monitoring and comparison groups.

Table 3
Mortality outcomes at 30 and 90 days among the remote monitoring program
(RM) users compared with the comparison patients.
n RM group Comparison p value
n (%) group
n (%)

30-day mortality 1878 6 (0.9%) 57 (4.8%) <0.001

Low/med readmission 1388 3 (0.6%) 37 (4.1%) <0.001
risk
High readmission risk 490 3 (1.6%) 20 (6.6%) 0.006
Black 210 0 (0.0%) 3 (2.4%) 0.072
White 1635 6 (1.0%) 54 (5.1%) <0.0001
Female 974 2 (0.6%) 19 (3.1%) 0.004
Male 904 4 (1.2%) 38 (6.6%) <0.001
90-day mortality 1878 38 (5.6%) 131 (10.9%) <0.001
Low/med readmission 1388 25 (5.1%) 96 (10.7%) <0.001
risk
High readmission risk 490 13 (6.9%) 35 (11.6%) 0.078
Black 210 1 (1.1%) 9 (7.3%) 0.024
White 1635 37 (6.3%) 121 (11.5%) <0.001 Fig. 2. Kaplan-Meier curves for mortality at 90 days among remote monitoring
Female 974 18 (5.1%) 65 (10.5%) 0.003 users and patients in comparison groups.
Male 904 20 (6.1%) 66 (11.4%) 0.007

tool was associated with improved survival in a group of patients with

4. Discussion
In this observational propensity-matched study, we showed that RM
was associated with increased readmissions and decreased mortality in a
high-risk cohort of patients with HF. Furthermore, though we matched
on a priori mortality risk, we found that patients receiving the RM
intervention were less likely to die from any cause. Having used the RM
HF.
This was a pragmatic approach to HF care given the involvement of
the patients' primary care physicians and primary cardiologists. Our
intervention did not solely rely on HF specialists to manage patients'
conditions, but instead facilitated patient self-management and as-
needed communication with staff from the Call Center. In repurposing
the existing Call Center's workflow to the HF RM program, we were able

4
A.E. Johnson et al.
to focus existing resources on the high-yield care of an at-risk patient
population. There was a clear escalation protocol for management of
program alerts in which the Call Center nurses provided feedback to
patients and involved the ordering physician as needed. The program
also emphasized the important elements of patient self-care and edu­
cation with online content using the provided tablet. Importantly, the
hospital-issued tablet ensured that patients were not required to use
their own technology, thus removing a potential barrier from partici­
pation in telehealth. [21]
We used a previously validated readmission risk score for this anal­
ysis. [16] At baseline, the mean a priori all-cause readmission prediction
score was 0.2 higher in the RM group and there was no difference in the
categorical version of the score between the two groups. Our analysis
showed that the 30- and 90-day all-cause readmission rates were
significantly higher in the RM group, both overall and among each of the
subgroups analyzed. It is therefore doubtful that a negligible baseline
difference in risk score would drive the large difference in readmissions
found in our results. Notably, our overall all-cause readmission rate was
comparable to the recent national average of about 30% at 60 days. [1]
The current findings build on earlier work analyzing RM for HF but
differ in important ways. A large systematic review conducted in 2015
found that RM (including telephone support and non-invasive tele­
monitoring) reduced all-cause mortality but was less effective at
reducing readmissions. [22] A 2015 Cochrane review of telemedicine
for HF care found no significant mortality benefit at six months. Read­
missions ranged from decreased by 64% to increased by 60%. [14] Our
work did not confirm the findings of prior work suggesting higher rates
of readmission among Black patients. [23,24]
Regarding mortality, the latest trends suggest that HF deaths are on
the rise and are disproportionately higher among Black men and
women. [25,26] For our analysis, the APR-DRG risk of mortality score
[18] was added to the matching algorithm to correct for any imbalance.
Despite correcting for mortality risk, our analysis showed a reduction in
30-, 60-, and 90-day mortality. In addition, we showed that the RM
intervention improved survival at one year. Our findings have important
implications for HF care among Black patients. In our study, Black RM
users had higher odds of all-cause readmission at each time interval than
did White RM users, but these findings did not meet statistical signifi­
cance. We have shown that RM use among Black patients is associated
with a survival benefit. This will be important moving forward as policy
makers seek ways to address the growing racial differences in HF out­
comes. [27]
Readmissions may present an opportunity to provide additional care
needed to keep patients alive. [28] RM enhances the ability for clinicians
to make therapeutic decisions about their patients and to consider novel
interventions such as same-day infusion centers to administer intrave­
nous diuretics for patients with volume overload. [29,30] In our current
practice environment, we have become accustomed to using HF read­
missions as a marker of poor hospital performance. Our findings suggest
a need for improved measures of hospital quality. [31]
Policies to reduce HF readmissions have shown mixed results
including variable associations with mortality. After the Hospital
Readmission Reduction Program (HRRP) was implemented in 2010,
there was an observed increase in mortality in an analysis of the Get
With the Guidelines Heart Failure registry linked with Medicare data
[32] An interrupted time series analysis showed a reduction in the all-
cause readmission rate and a concomitant increase in all-cause mortal­
ity. [32] Similarly, a propensity weighted analysis of Medicare re­
cipients determined an increase in mortality for patients with
comparable case mix after HRRP. [33] A separate analysis of Medicare
data found that the trends of increasing HF mortality began prior to the
implementation of the HRRP and did not increase relative to the rate of
decreased readmissions. [34] Overall, given limitations in retrospective
analyses, any observed increase in mortality among HF patients in the
post HRRP period cannot be definitively linked to a reduction in read­
missions. Nevertheless, our findings support the need for closer
5
American Heart Journal Plus: Cardiology Research and Practice 10 (2021) 100045
monitoring of high-risk HF patients during the post-discharge period.
Some have proposed that all-cause readmissions are a fixed entity
reflective of patient aspects that are not easily modifiable, such as so­
cioeconomic factors. [1,35] During the COVID-19 pandemic, the
threshold for HF admissions has likely increased due to patients' desire
to stay at home and the shift of inpatient hospital care to focus on
COVID-related illness. [36] Healthcare systems have therefore incor­
porated RM as an important adjunct to HF care. Importantly, the
acceptance of telehealth among older and chronically ill patients is on
the rise. According to the National Poll on Healthy Aging, older adults
are using telehealth technology at unprecedented rates. [37] RM and
telehealth technologies may better allow clinicians to keep patients with
HF safely in their homes and minimize the need for in-person hospital or
clinic visits.
Our analysis had several strengths. Beyond simple observational
analyses, we performed robust propensity matching to better determine
the effect of RM on the outcome. Our assessment of a regional healthcare
system includes patients living in different states and in urban and
exurban locations. This work shows the benefit of a system-wide
application of an RM tool, an example of how hospital systems can
leverage the size of their networks to provide far-reaching patient care.
Our findings should be reviewed in light of study limitations. First,
our large hospital system includes hospitals that vary in size and case-
mix indices. We did not match based upon hospital of initial treatment
and readmission rates might vary in tertiary care hospitals compared
with others. Second, in an attempt to include patients who were being
discharged to home, we limited the study sample to those who were
likely to die within 6 months based upon the available clinical data. As a
result, we may have introduced selection bias in our screening process.
However, the matched sample did not differ from RM users regarding
post-acute care settings. Furthermore, the sample included patients
going home with home health, which could provide additional resources
to this HF cohort, a factor which would have biased our findings toward
the null. Third, this observational analysis was potentially affected by
unobserved confounding. Sensitivity analyses aim to assess how strong
an unobserved confounder would have to be to change the study con­
clusions. Sensitivity to unobserved confounders can be reduced by uti­
lizing a large set of observed confounders in the analysis and by
including more than one match per patient, as we have done. Fourth, use
of data from the medical record such as the social security death index,
while convenient, may be imprecise. Lastly, our program was dependent
on hospital resources including a nurse-based call center, which may
limit generalizability to settings without such resources. However,
others have done similar work for HF management and found the pro­
grams to be cost-effective. [38,39]
In conclusion we have shown that a kit-based RM program that re­
sponds to biometric data and encourages patient self-care can be used in
a large hospital system to monitor high risk patients and is associated
with decreased all-cause mortality. Our findings suggest that, irre­
spective of race or gender subgroups, investments in RM technology may
help to improve HF care and save lives. Future research directions
should include the association of RM and other telemedicine tools on HF
outcomes, the implementation of these strategies, and their cost
effectiveness.
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.ahjo.2021.100045.
Disclaimers
None.
Source of funding
This work was supported by the National Institutes of Health [T32
T32HL129964-1A1].
A.E. Johnson et al.
Disclosures
All authors have nothing relevant to disclose.
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgments
We thank collaborators from UPMC and Vivify for making this work
possible.
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