Telemonitoring and Quality of Life in Patients after 12 Months Following a Pacemaker Implant: the Nordland Study, a Randomised Trial
Abstract
:1. Introduction
2. Materials and Methods
2.1. Design and Participants
2.2. Ethics Approval and Consent for Participation
2.3. Instruments
2.4. Devices
2.5. Statistical Analysis
3. Results
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Ethical Approval
Conflicts of Interest
References
- Okamura, H. Remote monitoring of cardiovascular implantable electronic devices in Japan. J. Arrhythmia 2014, 30, 421–427. [Google Scholar] [CrossRef] [Green Version]
- Ellenbogen, K.A.; Freedman, R.A.; Gettes, L.S.; Gillinov, A.M.; Gregoratos, G.; Hayes, D.L.; Hlatky, M.A.; Newby, L.K.; Page, R.L.; Sweeney, M.O.; et al. 2012 ACCF/AHA/HRS Focused Update Incorporated Into the ACCF/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation 2012, 127, e283–e352. [Google Scholar]
- World Health Organization. Telemedicine: Opportunities and Developments in Member States: Report on the Second Global Survey on eHealth; WHO Publications: Geneva, Switzerland, 2010; Available online: http://www.who.int/goe/publications/goe_telemedicine_2010.pdf (accessed on 18 January 2018).
- Brumley, R.; Enguidanos, S.; Jamison, P.; Seitz, R.; Morgenstern, N.; Saito, S.; McIlwane, J.; Hillary, K.; Gonzalez, J. Increased Satisfaction with Care and Lower Costs: Results of a Randomized Trial of In-Home Palliative Care. J. Am. Geriatr. Soc. 2007, 55, 993–1000. [Google Scholar] [CrossRef] [PubMed]
- Inglis, S.C.; Clark, R.A.; McAlister, F.A.; Stewart, S.; Cleland, J.G. Which components of heart failure programmes are effective? A systematic review and meta-analysis of the outcomes of structured telephone support or telemonitoring as the primary component of chronic heart failure management in 8323 patients: Abridged Coc. Eur. J. Hear. Fail. 2011, 13, 1028–1040. [Google Scholar] [CrossRef] [Green Version]
- Kotb, A.; Cameron, C.; Hsieh, S.; Wells, G. Comparative Effectiveness of Different Forms of Telemedicine for Individuals with Heart Failure (HF): A Systematic Review and Network Meta-Analysis. PLoS ONE 2015, 10, e0118681. [Google Scholar] [CrossRef] [PubMed]
- Knox, L.; Rahman, R.J.; Beedie, C. Quality of life in patients receiving telemedicine enhanced chronic heart failure disease management: A meta-analysis. J. Telemed. Telecare 2017, 23, 639–649. [Google Scholar] [CrossRef] [PubMed]
- Villani, A.; Della Rosa, F.; Bellardita, L.; Branzi, G.; Malfatto, G.; Compare, A.; Molinari, E.; Parati, G. Clinical and psychological telemonitoring and telecare of high risk heart failure patients. J. Telemed. Telecare 2014, 20, 468–475. [Google Scholar] [CrossRef]
- Seto, E. Cost Comparison Between Telemonitoring and Usual Care of Heart Failure: A Systematic Review. Telemed. e-Health 2008, 14, 679–686. [Google Scholar] [CrossRef]
- Olen, M.M.; Dechert-Crooks, B. Implantable cardiac devices: The utility of remote monitoring in a paediatric and CHD population. Cardiol. Young 2017, 27, S143–S146. [Google Scholar] [CrossRef]
- Lim, P.C.Y.; Lee, A.S.Y.; Chua, K.C.M.; Lim, E.T.S.; Chong, D.T.T.; Tan, B.Y.; Ho, K.L.; Teo, W.S.; Ching, C.K. Remote monitoring of patients with cardiac implantable electronic devices: A Southeast Asian, single-centre pilot study. Singap. Med. J. 2016, 57, 372–377. [Google Scholar] [CrossRef]
- Mabo, P.; Victor, F.; Bazin, P.; Ahres, S.; Babuty, D.; Da Costa, A.; Binet, D.; Daubert, J.C. A randomized trial of long-term remote monitoring of pacemaker recipients (the COMPAS trial). Eur. Heart J. 2012, 33, 1105–1111. [Google Scholar] [CrossRef] [PubMed]
- López-Villegas, A.; Catalán-Matamoros, D.; Robles-Musso, E.; Peiró, S. Comparative effectiveness of remote monitoring of people with cardiac Pacemaker versus conventional: Quality of life at the six months. Rev. Esp. Salud Publica 2015, 89, 149–158. [Google Scholar] [CrossRef] [PubMed]
- López-Villegas, A.; Catalán-Matamoros, D.; Robles-Musso, E.; Peiro, S. Effectiveness of pacemaker tele-monitoring on quality of life, functional capacity, event detection and workload: The PONIENTE trial. Geriatr. Gerontol. Int. 2016, 16, 1188–1195. [Google Scholar] [CrossRef] [PubMed]
- Hole, T.; Grundtvig, M.; Gullestad, L.; Flønaes, B.; Westheim, A.; Flønæs, B. Improved quality of life in Norwegian heart failure patients after follow-up in outpatient heart failure clinics: Results from the Norwegian heart failure registry. Eur. J. Hear. Fail. 2010, 12, 1247–1252. [Google Scholar] [CrossRef] [PubMed]
- Dar, O.; Riley, J.; Chapman, C.; Dubrey, S.W.; Morris, S.; Rosen, S.D.; Roughton, M.; Cowie, M.R. A randomized trial of home telemonitoring in a typical elderly heart failure population in North West London: Results of the Home-HF study. Eur. J. Hear. Fail. 2009, 11, 319–325. [Google Scholar] [CrossRef] [PubMed]
- Ong, M.K.; Romano, P.S.; Edgington, S.; Aronow, H.U.; Auerbach, A.D.; Black, J.T.; De Marco, T.; Escarce, J.J.; Evangelista, L.S.; Hanna, B.; et al. Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients with Heart Failure: The Better Effectiveness After Transition–Heart Failure (BEAT-HF) Randomized Clinical Trial. JAMA Intern. Med. 2016, 176, 310–318. [Google Scholar] [CrossRef] [PubMed]
- Lopez-Villegas, A.; Catalan-Matamoros, D.; Lopez-Liria, R.; Enebakk, T.; Thunhaug, H.; Lappegård, K.T. Health-related quality of life on tele-monitoring for users with pacemakers 6 months after implant: The NORDLAND study, a randomized trial. BMC Geriatr. 2018, 18, 223. [Google Scholar] [CrossRef]
- EuroQol Group. EuroQol A new facility for the measurement of health-related quality of life. Health Policy 1990, 16, 199–208. [Google Scholar] [CrossRef]
- Rector, T.S.; Kubo, S.H.; Cohn, J.N. Patients self-assessment of their congestive heart failure: Content, reliability and validity of a new measure, The Minnesota Living with Heart Failure questionnaire. Heart Failure 1987, 3, 198–209. [Google Scholar]
- Bharmal, M.; Thomas, J.; Bharmal, D.M. Comparing the EQ-5D and the SF-6D Descriptive Systems to Assess Their Ceiling Effects in the US General Population. Value Heal. 2006, 9, 262–271. [Google Scholar] [CrossRef] [Green Version]
- Balestroni, G.; Bertolotti, G. EuroQol-5D (EQ-5D): An instrument for measuring quality of life. Monaldi Arch. Chest Dis. 2012, 78, 155–159. [Google Scholar] [CrossRef] [PubMed]
- Savoia, E.; Fantini, M.P.; Pandolfi, P.P.; Dallolio, L.; Collina, N. Assessing the construct validity of the Italian version of the EQ-5D: Preliminary results from a cross-sectional study in North Italy. Heal. Qual. Life Outcomes 2006, 4, 47. [Google Scholar] [CrossRef] [PubMed]
- Morgan, K.; McGee, H.; Shelley, E. Quality of life assessment in heart failure interventions: A 10-year (1996–2005) review. Eur. J. Cardiovasc. Prev. Rehabil. 2007, 14, 589–607. [Google Scholar] [CrossRef] [PubMed]
- Ricci, R.P.; Vicentini, A.; D’Onofrio, A.; Sagone, A.; Rovaris, G.; Padeletti, L.; Morichelli, L.; Fusco, A.; De Vivo, S.; Lombardi, L.; et al. Economic analysis of remote monitoring of cardiac implantable electronic devices: Results of the Health Economics Evaluation Registry for Remote Follow-up (TARIFF) study. Hear. Rhythm. 2017, 14, 50–57. [Google Scholar] [CrossRef] [PubMed]
- Comoretto, R.I.; Facchin, D.; Ghidina, M.; Proclemer, A.; Gregori, D. Remote control improves quality of life in elderly pacemaker patients versus standard ambulatory-based follow-up. J. Eval. Clin. Pract. 2017, 23, 681–689. [Google Scholar] [CrossRef] [PubMed]
- Antonicelli, R.; Testarmata, P.; Spazzafumo, L.; Gagliardi, C.; Valentini, M.; Olivieri, F.; Bilo, G.; Parati, G. Impact of telemonitoring at home on the management of elderly patients with congestive heart failure. J. Telemed. Telecare 2008, 14, 300–305. [Google Scholar] [CrossRef] [PubMed]
- Klersy, C.; De Silvestri, A.; Gabutti, G.; Regoli, F.; Auricchio, A. A Meta-Analysis of Remote Monitoring of Heart Failure Patients. J. Am. Coll. Cardiol. 2009, 54, 1683–1694. [Google Scholar] [CrossRef] [Green Version]
- López-Villegas, A.; Catalán-Matamoros, D.; Martín-Saborido, C.; Villegas-Tripiana, I.; Robles-Musso, E. A Systematic Review of Economic Evaluations of Pacemaker Telemonitoring Systems. Rev. Esp. Cardiol. 2016, 69, 125–133. [Google Scholar] [CrossRef]
- Slotwiner, D.; Varma, N.; Akar, J.G.; Annas, G.; Beardsall, M.; Fogel, R.I.; Galizio, N.O.; Glotzer, T.V.; Leahy, R.A.; Love, C.J.; et al. HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable electronic devices. Hear. Rhythm. 2015, 12, e69–e100. [Google Scholar] [CrossRef]
- López-Villegas, A.; Catalán-Matamoros, D.; Robles-Musso, E.; Peiró, S. Workload, time and costs of the informal cares in patients with tele-monitoring of pacemakers: The PONIENTE study. Clin. Res. Cardiol. 2016, 105, 307–313. [Google Scholar] [CrossRef]
- Madigan, E.; Schmotzer, B.J.; Struk, C.J.; Dicarlo, C.M.; Kikano, G.; Piña, I.L.; Boxer, R.S. Home Health Care with Telemonitoring Improves Health Status for Older Adults with Heart Failure. Home Health Care Serv. Q. 2013, 32, 57–74. [Google Scholar] [CrossRef] [PubMed]
- Varma, N.; Michalski, J.; Stambler, B.; Pavri, B.B. TRUST Investigators Superiority of automatic remote monitoring compared with in-person evaluation for scheduled ICD follow-up in the TRUST trial-testing execution of the recommendations. Eur. Hear. J. 2014, 35, 1345–1352. [Google Scholar] [CrossRef] [PubMed]
- Spleen, A.M.; Lengerich, E.J.; Camacho, F.T.; Vanderpool, R.C. Health care avoidance among rural populations: Results from a nationally representative survey. J. Rural Health 2014, 30, 79–88. [Google Scholar] [CrossRef] [PubMed]
- Field, K.S.; Briggs, D.J. Socio-economic and locational determinants of accessibility and utilization of primary health-care. Health Soc. Care Community 2001, 9, 294–308. [Google Scholar] [CrossRef] [PubMed]
- Leahy, R.A.; Davenport, E.E. Home Monitoring for Cardiovascular Implantable Electronic Devices: Benefits to Patients and to Their Follow-up Clinic. AACN Adv. Crit Care 2015, 26, 343–355. [Google Scholar] [CrossRef] [PubMed]
EQ-5D Utilities | Month 0 | Month 12 | |||||||
---|---|---|---|---|---|---|---|---|---|
TM n (%) | HM n (%) | Total | p | TM n (%) | HM n (%) | Total | p | ||
MOBILITY | No problems | 15 (60.0) | 12 (48.0) | 27 (54.0) | 0.29 | 16 (69.6) | 11 (47.8) | 27 (58.7) | 0.12 |
Some problems | 10 (40.0) | 13 (52.0) | 23 (46.0) | 7 (30.4) | 12 (52.2) | 19 (41.3) | |||
Extreme problems | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | |||
SELF-CARE | No problems | 22 (88.0) | 22 (88.0) | 44 (88.0) | 0.67 | 23 (100.0) | 22 (95.7) | 45 (97.8) | 0.50 |
Some problems | 22 (88.0) | 22 (88.0) | 6 (12.0) | 0 (0.0) | 1 (4.3) | 1 (2.2) | |||
Extreme problems | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | |||
USUAL ACTIVITIES | No problems | 16 (64.0) | 14 (56.0) | 30 (60.0) | 0.84 | 14 (60.9) | 13 (56.5) | 27 (58.7) | 0.50 |
Some problems | 8 (32.0) | 10 (40.0) | 18 (36.0) | 9 (9.1) | 10 (43.5) | 19 (41.3) | |||
Extreme problems | 1 (4.0) | 1 (4.0) | 2 (4.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | |||
PAIN/DISCOMFORT | No problems | 11 (44.0) | 14 (56.0) | 25(50.0) | 0.08 | 9 (39.1) | 12 (52.2) | 21 (45.7) | 0.48 |
Some problems | 14 (56.0) | 8 (32.0) | 22 (44.0) | 11 (47.8) | 10 (43.5) | 21 (45.7) | |||
Extreme problems | 0 (0.0) | 3 (12.0) | 3 (6.0) | 3 (13.0) | 1 (4.3) | 4 (8.7) | |||
ANXIETY/DEPRESSION | No problems | 16 (64.0) | 16 (64.0) | 32 (64.0) | 0.62 | 20 (87.0) | 21 (91.3) | 41 (89.1) | 0.50 |
Some problems | 9 (36.0) | 9 (36.0) | 18 (36.0) | 3 (13.0) | 2 (8.7) | 5 (10.9) | |||
Extreme problems | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | |||
EQ-5D Utilities | TOTAL (95CI) | 0.81 (0.74;0.87) | 0.76 (0.64;0.88) | 0.78 (0.72;0.85) | 0.47 | 0.73 (0.68;0.91) | 0.78 (0.74;0.91) | 0.76 (0.71;0.88) | 0.53 |
EQ-5D VAS | TOTAL (95CI) | 64.00 (55.77;72.23) | 64.88 (51.69;74.07) | 64.83 (56.74;70.14) | 0.86 | 71.52 (63.47;79.57) | 68.65 (59.91;77.40) | 70.09 (64.36;75.81) | 0.65 |
MLHF Items | Month 0 | Month 12 | ||||
---|---|---|---|---|---|---|
TM n = 25 | HM n = 25 | p | TM n = 23 | HM n = 23 | p | |
Swelling in ankles, legs | 0.84 | 1.00 | 0.62 | 0.29 | 0.71 | 0.25 |
Resting during the day | 1.28 | 2.08 | 0.22 | 0.81 | 1.48 | 0.09 |
Walking and climbing stairs | 0.96 | 1.92 | 0.28 | 0.38 | 0.48 | 0.79 |
Working around the house | 1.20 | 2.36 | 0.33 | 0.52 | 0.95 | 0.31 |
Going away from home | 0.28 | 1.44 | 0.90 | 0.62 | 0.24 | 0.29 |
Sleeping | 0.84 | 1.32 | 0.37 | 0.38 | 0.43 | 0.89 |
Doing things with friends or family | 0.88 | 1.96 | 0.70 | 0.62 | 0.86 | 0.61 |
Working to earn a living | 0.40 | 0.72 | 0.73 | 0.05 | 0.05 | 1.00 |
Recreational pastimes | 1.24 | 1.76 | 0.08 | 0.38 | 0.95 | 0.16 |
Sexual activities | 0.32 | 0.68 | 0.95 | 0.14 | 0.19 | 0.83 |
Eating less of the food liked | 0.60 | 1.00 | 0.21 | 0.29 | 0.29 | 1.00 |
Shortness of breath | 2.44 | 2.48 | 0.87 | 1.10 | 1.76 | 0.22 |
Fatigue, tiredness, low on energy | 2.36 | 3.20 | 0.78 | 0.86 | 1.57 | 0.19 |
Staying in the hospital | 1.48 | 1.76 | 0.95 | 0.14 | 0.00 | 0.33 |
Costing money for medical care | 0.60 | 0.80 | 0.21 | 0.19 | 0.10 | 0.61 |
Side effects from medication | 0.44 | 0.68 | 0.67 | 0.43 | 0.05 | 0.07 |
Feeling burdensome | 0.32 | 0.76 | 0.57 | 0.00 | 0.00 | 1.00 |
Feeling a loss of self-control | 0.80 | 0.76 | 0.22 | 0.19 | 0.48 | 0.36 |
Worrying | 1.00 | 0.88 | 0.83 | 0.38 | 0.24 | 0.63 |
Difficulty remembering & concentrating | 1.16 | 0.96 | 0.70 | 0.48 | 0.33 | 0.67 |
Feeling depressed | 0.44 | 0.76 | 0.96 | 0.29 | 0.19 | 0.72 |
TOTAL (95%CI) | 20.20 (14.48; 25.92) | 28.96 (19.97;37.95) | 0.07 | 9.17 (4.05;14.29) | 10.78 (5.52;16.05) | 0.45 |
Questionnaires | All | Telemonitoring | Hospital Monitoring | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Health-Related Quality of Life–Specific | ||||||||||||
Baseline | Month 12 | Differences | p | Baseline | Month 12 | Differences | p | Baseline | Month 12 | Differences | p | |
MLHF (95CI) | 24.58 (19.30;29.86) | 9.96 (6.42;13.49) | 14.17 (8.24; 20.10) | <0.001 | 20.20 (14.48;25.92) | 9.17 (4.05;14.29) | 10.67 (4.98;16.36) | 0.001 | 28.96 (19.97–37.95) | 10.78 (5.52–16.05) | 16.57 (7.54;25.60) | 0.001 |
Health-Related Quality of Life–General | ||||||||||||
EQ5D VAS (95CI) | 64.83 (56.74;70.14) | 70.09 (64.36;75.81) | 5.26 (2.44;12.96) | 0.18 | 64.00 (55.77;72.23) | 71.52 (63.47;79.57) | 6.52 (3.16;16.20) | 0.18 | 64.88 (51.69;74.07) | 68.65 (59.91;77.40) | 3.77 (0.45;8.26) | 0.66 |
EQ-5D utilities (95CI) | 0.78 (0.72;0.85) | 0.76 (0.71;0.88) | 0.02 (−0.11;0.07) | 0.62 | 0.81 (0.74;0.87) | 0.73 (0.68;0.91) | 0.08 (−0.12;0.10) | 0.84 | 0.76 (0.64;0.88) | 0.78 (0.74;0.91) | 0.02 (−0.12;0.07) | 0.53 |
Variables | n (%) | TM n = 23 | HM n = 23 | p-Value |
---|---|---|---|---|
In-clinic visits | ||||
0 | 1 (2.0) | 0 (0.0) | 1 (4.0) | 0.297 |
1 | 41 (82.0) | 21 (84.0%) | 20 (80.0) | |
2 | 6 (12.0) | 2 (8.0) | 4 (16.0) | |
3 | 2 (4.0) | 2 (8.0) | 0 (.0) | |
Transmissions from patients’ home | ||||
0 | 30 (60.0) | 5 (20.0) | 25 (100.0) | <0.001 |
3–5 | 15 (30.0) | 15 (60.0) | 0 (0.0) | |
6–8 | 5 (10.0) | 5 (20.0) | 0 (0.0) | |
Cardiovascular adverse events | ||||
None | 47 (94.0) | 23 (92.0) | 24 (96.0) | 0.388 |
PCI | 1 (2.0) | 1 (4.0) | 0 (0.0) | |
Angina | 1 (2.0) | 0 (0.0) | 1 (4.0) | |
Lead dislodgement x 2 | 1 (2.0) | 1 (4.0) | 0 (0.0) | |
Calls/letters sent to the patients | ||||
0 | 28 (56.0) | 4 (16.0) | 24 (96.0) | <0.001 |
1 | 21 (42.0) | 20 (80.0) | 1 (4.0) | |
3 | 1 (2.0) | 1 (4.0) | 0 (0.0) | |
Changes of medication | ||||
0 | 34 (68.0) | 17 (68.0) | 17 (68.0) | 0.107 |
1 | 7 (14.0) | 5 (20.0) | 2 (8.0) | |
2 | 3 (6.0) | 1 (4.0) | 2 (8.0) | |
3 | 4 (8.0) | 0 (0.0) | 4 (16.0) | |
4 | 2 (4.0) | 2 (8.0) | 0 (0.0) | |
Changes of PM reprogramming | ||||
0 | 35 (70.0) | 16 (64.0) | 19 (76.0) | 0.311 |
1 | 13 (26.0) | 7 (28.0) | 6 (24.0) | |
2 | 2 (4.0) | 2 (8.0) | 0 (0.0) | |
Hospitalisation number after implant | ||||
0 | 30 (60.0) | 14 (56.0) | 16 (64.0) | 0.532 |
1 | 15 (30.0) | 7 (28.0) | 8 (32.0) | |
2 | 4 (8.0) | 3 (12.0) | 1 (4.0) | |
5 | 1 (2.0) | 1 (4.0) | 0 (0.0) | |
Days spent hospitalised | ||||
0 | 30 (60.0) | 14 (56.0) | 16 (64.0) | 0.535 |
1–5 | 12 (24.0) | 6 (24.0) | 6 (24.0) | |
6–10 | 5 (10.0) | 2 (8.0) | 3 (12.0) | |
+11 | 3 (6.0) | 3 (12.0) | 0 (0.0) | |
Reasons for hospitalisation | ||||
None | 30 (60.0) | 14 (56.0) | 16 (64.0) | 0.333 |
Other | 6 (12.0) | 3 (12.0) | 3 (12.0) | |
Cancer | 1 (2.0) | 1 (4.0) | 0 (0.0) | |
Coronary problems | 10 (20.0) | 4 (16.0) | 6 (24.0) | |
PM disfunction | 3 (6.0) | 3 (12.0) | 0 (0.0) |
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López-Liria, R.; López-Villegas, A.; Enebakk, T.; Thunhaug, H.; Lappegård, K.T.; Catalán-Matamoros, D. Telemonitoring and Quality of Life in Patients after 12 Months Following a Pacemaker Implant: the Nordland Study, a Randomised Trial. Int. J. Environ. Res. Public Health 2019, 16, 2001. https://doi.org/10.3390/ijerph16112001
López-Liria R, López-Villegas A, Enebakk T, Thunhaug H, Lappegård KT, Catalán-Matamoros D. Telemonitoring and Quality of Life in Patients after 12 Months Following a Pacemaker Implant: the Nordland Study, a Randomised Trial. International Journal of Environmental Research and Public Health. 2019; 16(11):2001. https://doi.org/10.3390/ijerph16112001
Chicago/Turabian StyleLópez-Liria, Remedios, Antonio López-Villegas, Terje Enebakk, Hilde Thunhaug, Knut Tore Lappegård, and Daniel Catalán-Matamoros. 2019. "Telemonitoring and Quality of Life in Patients after 12 Months Following a Pacemaker Implant: the Nordland Study, a Randomised Trial" International Journal of Environmental Research and Public Health 16, no. 11: 2001. https://doi.org/10.3390/ijerph16112001
APA StyleLópez-Liria, R., López-Villegas, A., Enebakk, T., Thunhaug, H., Lappegård, K. T., & Catalán-Matamoros, D. (2019). Telemonitoring and Quality of Life in Patients after 12 Months Following a Pacemaker Implant: the Nordland Study, a Randomised Trial. International Journal of Environmental Research and Public Health, 16(11), 2001. https://doi.org/10.3390/ijerph16112001