Heart failure (HF) is the most common hospital discharge diagnosis in elderly patients . Between the age of 70 and 80 years the incidence of HF is 10 to 20%. HF is associated with high mortality and morbidity, readmission rates and costs . The readmission rates vary between 25% and 50% within 6 months after the first hospitalisation for HF, with a higher readmission rate within the first month after discharge[2, 3]. The costs related to HF contribute to 1-2% of all healthcare expenditures and are mainly the result of hospital stay [[4–6]]. Because of an increasing shortage of resources, HF is a major public health problem and therefore, a more effective and efficient organisation of care for HF patients needs to be reconsidered. A first step in organising treatment and care for patients with chronic HF more efficiently, was the implementation of specialised outpatient HF clinics. In the recent European Society of Cardiology (ESC) guidelines, HF management programmes are strongly recommended for all patients with HF  and HF clinics are considered as 'usual care' in several European countries . A widely used way to implement HF management is the use of specific disease management (DM) programs.
DM can be defined as an intervention, designed to manage a chronic disease and to reduce hospital readmissions, using a systematic approach to care and potentially employing multiple treatment modalities . Control and cost effectiveness are substantial components of a DM program. Randomised studies suggest that DM programs can reduce readmissions for HF or cardiovascular disease with 30% [[7, 9, 10]] and significantly decrease mortality rates . Yu et al  described that DM for HF patients, as recommended by the ESC guidelines,  are effective in reducing hospital readmissions and mortality rate . However, inconsistent findings for readmission and mortality rates have been found, probably due to the variety of components and practical applications of the DM programs.
We recently reported results of the COACH study, a study on the effect of a nurse led DM program on clinical outcome , in which the positive effects of a DM program on readmission were not confirmed, although there was a trend to a reduction of mortality in the intervention groups. The INH study  on the effect of DM in HF, showed that a DM program compared to usual care could reduce mortality but not hospitalisation rates. Important components of this program were patient education, optimisation of medical therapy, psychosocial support and an easy access to healthcare. An important aspect for the treatment of HF patients is the prescription of HF related medication at an optimal dose i.e. ACE-inhibitors, beta-blockers, and aldosteronantagonists. The up titration to optimal dosage is an aspect that often takes place at a HF outpatient clinic. However, data from the Euro Heart Failure Survey showed us that guideline adherence for HF medication although improving still is not optimal. In the IMPROVE study, dedicated HF clinics were associated with greater use of cardiac resynchronisation therapy and a better HF education, but not with better guideline adherence to medication . Health information technology, integrated into a DM program might facilitate adherence to guidelines of health professionals . With new information and communication technology (ICT), healthcare providers can be supported in the diagnosis, treatment and follow up of HF patients by expert computerised systems, based on guidelines and protocols . These systems can be used to optimise medication according to guidelines and provide structural support and education . We were the first to report promising findings on ICT guided DM in terms of higher doses of recommended HF medication and lower readmissions [21, 22]. Another promising ICT tool is telemonitoring. Telemonitoring is often used to monitor patients at home and guide patients to take action in case of deterioration, but it also can be used to up-titrate medication according to guidelines at distance . There is support that remote monitoring of patients with HF can reduce hospitalisation and mortality rates, [24, 25] however results on clinical outcome and efficacy are inconclusive and limited [[26–28]]. There are also recent study's that where not successful in their primary endpoints [29, 30]. Furthermore, cost-effectiveness of these systems has not been thoroughly evaluated. It can be concluded that the overall effects of telemonitoring are inconclusive. To summarise, due to a growing population of patients with HF and an expected shortage of healthcare providers in the near future, there is a need to seek to more cost effective and efficient ways of providing optimal care for HF patients, including a better adherence to guidelines. ICT guided DM tools in combination with telemonitoring could be of important value [31, 32]. At the same time there is substantional data that the adaptation and implementation of those systems is lacking . The experiences with such a system however are fragmented. User resistance is described as a major obstacle in the adoption of these computerised tools. More insight in user resistance and experienced barriers in using ICT guided DM tools is needed to successfully implementing such tools .
The IN TOUCH study will investigate the effect of telemonitoring in addition to an ICT guided DM system on the quality and efficiency of care for patients after worsening HF. This is the first study investigating a combination of two newly developed ICT interventions in a group of chronic HF patients on clinical outcome, adherence to guidelines, cost effectiveness and quality of life.
This study will add important information to other telemonitoring studies because of its strong commitment to ICT guided DM, the chosen composite endpoint, a strong focus on cost-effectiveness and the investigation of the influence of user aspects as resistance and barriers that accompany the use of modern healthcare related ICT tools.