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Kratka A, Rotering TL, Raitt MH, Whooley MA, Dhruva SS. Informational letters or postcards to initiate remote monitoring among veterans with pacemakers and implantable cardioverter-defibrillators: A randomized, controlled trial. Pacing Clin Electrophysiol 2024; 47:642-649. [PMID: 38556540 DOI: 10.1111/pace.14912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/04/2023] [Accepted: 12/10/2023] [Indexed: 04/02/2024]
Abstract
BACKGROUND Remote monitoring (RM) of pacemakers and implantable cardioverter-defibrillators (ICDs) is a Class 1, Level of Evidence A recommendation because of its multitude of clinical benefits. However, RM adherence rates are suboptimal, precluding patients from achieving these benefits. There is a need for direct-to-patient efforts to improve adherence. METHODS In this national randomized, controlled trial conducted in the Veterans Health Administration (VHA), 2120 patients with a pacemaker or ICD who had not sent an RM transmission for ≥1 year (and usually ≥3 years) while under VHA care for their device were randomly assigned to be mailed a postcard (n = 1076) or a detailed letter (n = 1044). The postcard described what RM does and its key benefits (reduced mortality and fewer in-person visits). The letter provided a similar message but included more details about RM benefits and the process. The primary outcome was an RM transmission sent within 90 days of mailing, and a secondary outcome was an RM transmission sent within 365 days. RESULTS The primary outcome was achieved in 121 (11.3%) in the postcard and 96 patients (9.2%) in the letter group (p = .12). The secondary outcome was achieved in 266 (24.7%) and 239 (22.9%), respectively (p = .32). CONCLUSIONS This randomized trial showed no significant difference in the proportion of chronically non-adherent patients who sent an RM transmission after receiving a low-cost postcard or a detailed, higher-cost letter encouraging their participation in RM. However, as only a minority of patients responded to either, further work is needed to engage patients in the life-saving benefits of RM.
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Affiliation(s)
- Allison Kratka
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California, USA
| | - Thomas L Rotering
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco School of Medicine, San Francisco, United States
| | - Merritt H Raitt
- Veterans Affairs Portland Health Care System, Portland, Oregon, USA
- Knight Cardiovascular Institute, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Mary A Whooley
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco School of Medicine, San Francisco, United States
- Section of General Internal Medicine, Department of Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Sanket S Dhruva
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco School of Medicine, San Francisco, United States
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Badrish N, Sheifer S, Rosner CM. Systems of care for ambulatory management of decompensated heart failure. Front Cardiovasc Med 2024; 11:1350846. [PMID: 38455722 PMCID: PMC10918851 DOI: 10.3389/fcvm.2024.1350846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/25/2024] [Indexed: 03/09/2024] Open
Abstract
Heart failure (HF) represents a worldwide health burden and the annual per patient cost to treat HF in the US is estimated at $24,383, with most of this expense driven by HF related hospitalizations. Decompensated HF is a leading cause for hospital admissions and is associated with an increased risk of subsequent morbidity and mortality. Many hospital admissions for decompensated HF are considered preventable with timely recognition and effective intervention.Systems of care that include interventions to facilitate early recognition, timely and appropriate intervention, intensification of care, and optimization to prevent recurrence can help successfully manage decompensated HF in the ambulatory setting and avoid hospitalization.
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Affiliation(s)
- Narotham Badrish
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
| | - Stuart Sheifer
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
- Department of Cardiology, Virginia Heart, Falls Church, VA, United States
| | - Carolyn M. Rosner
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
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McLaughlin MM, Raitt MH, Tarasovsky G, Whooley MA, Dhruva SS. Informational Postcards Increase Engagement with Remote Monitoring Among Veterans with Pacemakers and Implantable Cardioverter-Defibrillators: a Stepped-Wedge Randomized Controlled Trial. J Gen Intern Med 2024; 39:87-96. [PMID: 38252247 PMCID: PMC10937872 DOI: 10.1007/s11606-023-08478-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 10/12/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Remote monitoring (RM) of pacemakers and implantable cardioverter-defibrillators (ICDs) reduces morbidity and mortality. However, many patients are not adherent to RM. OBJECTIVE To test the effect of informational postcards on RM adherence. DESIGN/PATIENTS Stepped-wedge randomized controlled trial among Veterans with pacemakers and ICDs. INTERVENTION In wave 1, Veterans who had sent at least 1 transmission within the past 2 years but had become non-adherent were randomly assigned to receive a postcard or no postcard. Those receiving postcards were randomized to 1 of 2 messages: (1) a"warning" postcard describing risks of non-adherence or (2) an "encouraging" postcard describing benefits of adherence. In wave 2, Veterans who had either not received a postcard in wave 1 or had since become non-adherent were mailed a postcard (again, randomized to 1 of 2 messages). Patients who did not send an RM transmission within 1 month were mailed a second, identical postcard. MAIN MEASURES Transmission within 70 days. KEY RESULTS Overall, 6351 Veterans were included. In waves 1 and 2, postcards were mailed to 5657 Veterans (2821 "warning" messages and 2836 "encouraging" messages). Wave 1 included 2178 Veterans as controls (i.e., not mailed a postcard), some of whom received a postcard in wave 2 if they remained non-adherent. In wave 2, 3473 postcards were sent. Of the 5657 patients mailed a postcard, 2756 (48.7%) sent an RM transmission within 70 days, compared to 530 (24.3%) of 2178 controls (absolute difference 24.4%, 95% confidence interval [CI] 22.2%, 26.6%). Of those who sent a transmission, 71.8% did so after the first postcard. Transmission rates at 70 days did not significantly differ between "warning" and "encouraging" messages (odds ratio 1.04, 95% CI 0.92, 1.18). CONCLUSIONS Informational postcards led to a 24.4% absolute increase in adherence at 70 days among Veterans with pacemakers and ICDs who were non-adherent to RM.
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Affiliation(s)
- Megan M McLaughlin
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Merritt H Raitt
- Portland Veterans Affairs Health Care System, Portland, OR, USA
| | - Gary Tarasovsky
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Mary A Whooley
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Sanket S Dhruva
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA.
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Rotering TL, Hysong SJ, Williams KE, Raitt MH, Whooley MA, Dhruva SS. Strategies to enhance remote monitoring adherence among patients with cardiovascular implantable electronic devices. Heart Rhythm O2 2023; 4:794-804. [PMID: 38204458 PMCID: PMC10774668 DOI: 10.1016/j.hroo.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
Background Remote monitoring (RM) of patients with cardiovascular implantable electronic devices (CIEDs) (pacemakers and implantable cardioverter-defibrillators) has a Class 1, Level of Evidence A Heart Rhythm Society recommendation. Yet RM adherence varies widely across settings, and factors associated with variation are not understood. Objective The purpose of this study was to identify strategies for supporting RM across Veterans Health Administration (VHA) facilities. Methods In a national evaluation, we surveyed and interviewed 27 nurses, medical instrument technicians, and advanced practice providers across 26 VHA facilities (following approximately 15,000 CIED patients). Participants were selected based on overall patient adherence by facility, which ranged from 46%-96%. Questions covered RM adherence strategies, manufacturer resources, organizational characteristics, and workflows for optimizing adherence. Results All clinicians reported that RM adherence was extremely important (53.8%), very important (34.6%), or important (11.5%) for improving patient outcomes. High performing facilities prioritized consistent patient education about RM and evaluated nonadherence using dashboards and manufacturer web sites. High performing facilities instituted clear standard operating procedures that defined staff responsibilities and facilitated efficient contact with nonadherent patients and then family members by phone and then mail. Clinicians based at high performing facilities spent twice as many hours per week (9.1) on average managing RM adherence compared to other facilities (4.5). Effective communication (internally and with non-VHA care partners) and use of CIED manufacturer resources were essential. Facilities that were not high performing rarely used these strategies. Conclusion Clinicians can support high RM adherence by emphasizing patient education, regularly assessing and addressing nonadherence using staff protocols, and engaging CIED manufacturers.
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Affiliation(s)
- Thomas L. Rotering
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Section of Cardiology, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California
| | - Sylvia J. Hysong
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Katherine E. Williams
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California
| | - Merritt H. Raitt
- Portland Veterans Affairs Health Care System, Portland, Oregon
- Knight Cardiovascular Institute, Oregon Health and Sciences University, Portland, Oregon
| | - Mary A. Whooley
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California
| | - Sanket S. Dhruva
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Section of Cardiology, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California
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Dhruva SS, Raitt MH, Munson S, Moore HJ, Steele P, Rosman L, Whooley MA. Barriers and Facilitators Associated With Remote Monitoring Adherence Among Veterans With Pacemakers and Implantable Cardioverter-Defibrillators: Qualitative Cross-Sectional Study. JMIR Cardio 2023; 7:e50973. [PMID: 37988153 DOI: 10.2196/50973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/07/2023] [Accepted: 10/12/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND The Heart Rhythm Society strongly recommends remote monitoring (RM) of cardiovascular implantable electronic devices (CIEDs) because of the clinical outcome benefits to patients. However, many patients do not adhere to RM and, thus, do not achieve these benefits. There has been limited study of patient-level barriers and facilitators to RM adherence; understanding patient perspectives is essential to developing solutions to improve adherence. OBJECTIVE We sought to identify barriers and facilitators associated with adherence to RM among veterans with CIEDs followed by the Veterans Health Administration. METHODS We interviewed 40 veterans with CIEDs regarding their experiences with RM. Veterans were stratified into 3 groups based on their adherence to scheduled RM transmissions over the past 2 years: 6 fully adherent (≥95%), 25 partially adherent (≥65% but <95%), and 9 nonadherent (<65%). As the focus was to understand challenges with RM adherence, partially adherent and nonadherent veterans were preferentially weighted for selection. Veterans were mailed a letter stating they would be called to understand their experiences and perspectives of RM and possible barriers, and then contacted beginning 1 week after the letter was mailed. Interviews were structured (some questions allowing for open-ended responses to dive deeper into themes) and focused on 4 predetermined domains: knowledge of RM, satisfaction with RM, reasons for nonadherence, and preferences for health care engagement. RESULTS Of the 44 veterans contacted, 40 (91%) agreed to participate. The mean veteran age was 75.3 (SD 7.6) years, and 98% (39/40) were men. Veterans had been implanted with their current CIED for an average of 4.4 (SD 2.8) years. A total of 58% (23/40) of veterans recalled a discussion of home monitoring, and 45% (18/40) reported a good understanding of RM; however, when asked to describe RM, their understanding was sometimes incomplete or not correct. Among the 31 fully or partially adherent veterans, nearly all were satisfied with RM. Approximately one-third recalled ever being told the results of a remote transmission. Among partially or nonadherent veterans, only one-fourth reported being contacted by a Department of Veterans Affairs health care professional regarding not having sent a remote transmission; among those who had troubleshooted to ensure they could send remote transmissions, they often relied on the CIED manufacturer for help (this experience was nearly always positive). Most nonadherent veterans felt more comfortable engaging in RM if they received more information or education. Most veterans were interested in being notified of a successful remote transmission and learning the results of their remote transmissions. CONCLUSIONS Veterans with CIEDs often had limited knowledge about RM and did not recall being contacted about nonadherence. When they were contacted and troubleshooted, the experience was positive. These findings provide opportunities to optimize strategies for educating and engaging patients in RM.
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Affiliation(s)
- Sanket S Dhruva
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Merritt H Raitt
- Division of Cardiology, Department of Specialty Care, Portland Veterans Affairs Health Care System, Portland, OR, United States
| | - Scott Munson
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Hans J Moore
- Cardiology Section, Medical Service, Washington DC Veterans Affairs Medical Center, Washington, DC, United States
| | - Pamela Steele
- Cardiology Section, Medical Service, Washington DC Veterans Affairs Medical Center, Washington, DC, United States
| | - Lindsey Rosman
- Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Mary A Whooley
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
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Sane M, Annukka M, Toni J, Elina P, Charlotte A, Eeva T, Leena K, Pekka R, Jarkko K. Real-life data on the workload of cardiac implantable electronic device remote monitoring in a large tertiary center. Pacing Clin Electrophysiol 2023; 46:1109-1115. [PMID: 37486912 DOI: 10.1111/pace.14792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/23/2023] [Accepted: 07/09/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Cardiac implantable electronic devices (CIED) and implantable loop recorders (ILR) are increasingly monitored by systems allowing remote transmission of data from the patient to the hospital. Remote monitoring (RM) has been shown to increase patient satisfaction and safety. However, real-life data on the number and causes of the RM transmissions, and actions initiated by them are scarce. METHODS A total of 3446 patients with CIED and 92 patients with ILR were included in the study. Data on the number of alerts, scheduled and patient-initiated transmissions as well as the causes and actions initiated by the transmissions were systematically collected from March 1 to December 30, 2022. The data was subdivided by the device type. RESULTS During the study period 7087 remote CIED and 1212 ILR transmissions were generated, (0.2 and 1.3 per patient per month), respectively. Of these transmissions 49% (4084) were automatic alerts, and 29% (2434) and 22% (1781) were scheduled and patient initiated, respectively. Most of the CIED alerts (73%) and the scheduled transmissions (90%) were nonactionable, and only 7% and 5% led to in-office follow-up, respectively. Off all ILR alerts (1011) PM implantation was scheduled to 11 patients. CONCLUSIONS RM transmissions were common, but most of them were nonactionable. These real-life findings indicate that detailed analysis of the causes of the RM transmissions is important for optimization of the remote follow-up workload.
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Affiliation(s)
- Markus Sane
- Heart and Lung Center Helsinki University Hospital, Helsinki, Finland
- Helsinki University, Helsinki, Finland
| | - Marjamaa Annukka
- Heart and Lung Center Helsinki University Hospital, Helsinki, Finland
- Helsinki University, Helsinki, Finland
| | - Jäntti Toni
- Heart and Lung Center Helsinki University Hospital, Helsinki, Finland
- Helsinki University, Helsinki, Finland
| | - Pennanen Elina
- Heart and Lung Center Helsinki University Hospital, Helsinki, Finland
| | - Aura Charlotte
- Heart and Lung Center Helsinki University Hospital, Helsinki, Finland
| | - Torvinen Eeva
- Heart and Lung Center Helsinki University Hospital, Helsinki, Finland
| | - Karjalainen Leena
- Heart and Lung Center Helsinki University Hospital, Helsinki, Finland
| | - Raatikainen Pekka
- Heart and Lung Center Helsinki University Hospital, Helsinki, Finland
| | - Karvonen Jarkko
- Heart and Lung Center Helsinki University Hospital, Helsinki, Finland
- Helsinki University, Helsinki, Finland
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Bawa D, Kabra R, Ahmed A, Bansal S, Darden D, Pothineni NVK, Gopinathannair R, Lakkireddy D. Data deluge from remote monitoring of cardiac implantable electronic devices and importance of clinical stratification. Heart Rhythm O2 2023; 4:374-381. [PMID: 37361614 PMCID: PMC10288027 DOI: 10.1016/j.hroo.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Background Remote monitoring (RM) has been accepted as a standard of care for follow-up of patients with cardiac implantable electronic devices (CIEDs). However, the resulting data deluge poses major challenge to device clinics. Objective This study aimed to quantify the data deluge from CIED and stratify these data based on clinical relevance. Methods The study included patients from 67 device clinics across the United States being remotely monitored by Octagos Health. The CIEDs included implantable loop recorders, pacemakers, implantable cardioverter-defibrillators, cardiac resynchronization therapy defibrillators, and cardiac resynchronization therapy pacemakers. Transmissions were either dismissed before reaching the clinical practice if they were repetitive or redundant or were forwarded if they were either clinically relevant or actionable transmission (alert). The alerts were further classified as level 1, 2, or 3 based on clinical urgency. Results A total of 32,721 patients with CIEDs were included. There were 14,465 (44.2%) patients with pacemakers, 8381 (25.6%) with implantable loop recorders, 5351 (16.4%) with implantable cardioverter-defibrillators, 3531 (10.8%) with cardiac resynchronization therapy defibrillators, and 993 (3%) with cardiac resynchronization therapy pacemakers. Over a period of 2 years of RM, 384,796 transmissions were received. Of these, 220,049 (57%) transmissions were dismissed, as they were either redundant or repetitive. Only 164,747 (43%) transmissions were transmitted to the clinicians, of which only 13% (n = 50,440) had clinical alerts, while 30.6% (n = 114,307) were routine transmissions. Conclusion Our study shows that data deluge from RM of CIEDs can be streamlined by utilization of appropriate screening strategies that will enhance efficiency of device clinics and provide better patient care.
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Affiliation(s)
- Danish Bawa
- Department of Electrophysiology, Kansas City Heart Rhythm Institute, Overland Park, Kansas
| | - Rajesh Kabra
- Department of Electrophysiology, Kansas City Heart Rhythm Institute, Overland Park, Kansas
| | - Adnan Ahmed
- Department of Electrophysiology, Kansas City Heart Rhythm Institute, Overland Park, Kansas
| | - Shanti Bansal
- Department of Electrophysiology, Houston Heart Rhythm and Octagos Health, Houston, Texas
| | - Douglas Darden
- Department of Electrophysiology, Kansas City Heart Rhythm Institute, Overland Park, Kansas
| | | | - Rakesh Gopinathannair
- Department of Electrophysiology, Kansas City Heart Rhythm Institute, Overland Park, Kansas
| | - Dhanunjaya Lakkireddy
- Department of Electrophysiology, Kansas City Heart Rhythm Institute, Overland Park, Kansas
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Vandenberk B, Raj SR. Remote Patient Monitoring: What Have We Learned and Where Are We Going? CURRENT CARDIOVASCULAR RISK REPORTS 2023; 17:103-115. [PMID: 37305214 PMCID: PMC10122094 DOI: 10.1007/s12170-023-00720-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 06/13/2023]
Abstract
Purpose of Review Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) is an important part of patient follow-up. The increasing number of patients with CIEDs and the recent pandemic pose several challenges for already limited device clinic resources. This review focuses on recent evolutions in RM and identifies future needs to improve RM. Recent Findings RM has been associated with multiple clinical benefits, including improved survival, early detection of actionable events, reduction in inappropriate shocks, longer battery lives, and more efficient healthcare utilization. The survival benefit was driven by studies using alert-based continuous RM with daily transmissions and fast reaction times. Patients report a high satisfaction rate without significant differences in quality of life between RM and in-office follow-up.The increasing workload, due to the increasing number of CIEDs implanted with daily remote transmissions, results in several challenges for the future of RM. RM requires appropriate reimbursement for RM device clinics to optimize patient/staff ratios, including sufficient non-clinical and administrative support. Universal alert programming and data processing may minimize inter-manufacturer differences, improve the signal-to-noise ratio, and allow the development of standard operating protocols and workflows. In the future, programming by remote control and true remote programming may further improve remote CIED management, patient quality of life, and device clinic workflows. Summary RM should be considered standard of care in management of patients with CIEDs. The clinical benefits of RM can be maximized by an alert-based continuous RM model. Adapted healthcare policies are required to keep RM manageable for the future.
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Affiliation(s)
- Bert Vandenberk
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Satish R. Raj
- Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, GAC70 HRIC Building, 3280 Hospital Dr NW, Calgary, AB T2N 4Z6 Canada
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN USA
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Chew DS, Piccini JP, Au F, Frazier-Mills CG, Michalski J, Varma N. Alert-driven vs scheduled remote monitoring of implantable cardiac defibrillators: A cost-consequence analysis from the TRUST trial. Heart Rhythm 2023; 20:440-447. [PMID: 36503177 PMCID: PMC11103640 DOI: 10.1016/j.hrthm.2022.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/22/2022] [Accepted: 12/04/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Alert-driven remote patient monitoring (RPM) or fully virtual care without routine evaluations may reduce clinic workload and promote more efficient resource allocation, principally by diminishing nonactionable patient encounters. OBJECTIVE The purpose of this study was to conduct a cost-consequence analysis to compare 3 postimplant implantable cardioverter-defibrillator (ICD) follow-up strategies: (1) in-person evaluation (IPE) only; (2) RPM-conventional (hybrid of IPE and RPM); and (3) RPM-alert (alert-based ICD follow-up). METHODS We constructed a decision-analytic Markov model to estimate the costs and benefits of the 3 strategies over a 2-year time horizon from the perspective of the US Medicare payer. Aggregate and patient-level data from the TRUST (Lumos-T Safely RedUceS RouTine Office Device Follow-up) randomized clinical trial informed clinical effectiveness model inputs. TRUST randomized 1339 patients 2:1 to conventional RPM or IPE alone, and found that RPM was safe and reduced the number of nonactionable encounters. Cost data were obtained from the published literature. The primary outcome was incremental cost. RESULTS Mean cumulative follow-up costs per patient were $12,688 in the IPE group, $12,001 in the RPM-conventional group, and $11,011 in the RPM-alert group. Compared to the IPE group, both the RPM-conventional and RPM-alert groups were associated with lower incremental costs of -$687 (95% confidence interval [CI] -$2138 to +$638) and -$1,677 (95% CI -$3134 to -$304), respectively. Therefore, the RPM-alert strategy was most cost-effective, with an estimated cost-savings in 99% of simulations. CONCLUSIONS Alert-driven RPM was economically attractive and, if patient outcomes and safety are comparable to those of conventional RPM, may be the preferred strategy for ICD follow-up.
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Affiliation(s)
- Derek S Chew
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Duke University, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Flora Au
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Camille G Frazier-Mills
- Duke Clinical Research Institute, Duke University, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | | | - Niraj Varma
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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Rodrigues G, Adragão P. Cardiac device remote monitoring in 2022: Are digital and remote monitoring synonymous with ease and improvement? Rev Port Cardiol 2022; 41:999-1000. [PMID: 36228666 DOI: 10.1016/j.repc.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Gustavo Rodrigues
- Serviço de Cardiologia, Hospital de Santa Cruz, CHLO, Carnaxide, Portugal
| | - Pedro Adragão
- Serviço de Cardiologia, Hospital de Santa Cruz, CHLO, Carnaxide, Portugal.
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Stolen C, Rosman J, Manyam H, Kwan B, Kelly J, Perschbacher D, Garner J, Richards M. Preliminary results from the LUX-Dx insertable cardiac monitor remote programming and performance (LUX-Dx PERFORM) study. Clin Cardiol 2022; 46:100-107. [PMID: 36208096 PMCID: PMC9849434 DOI: 10.1002/clc.23930] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 01/26/2023] Open
Abstract
Despite the wide adoption of insertable cardiac monitors (ICMs), high false-positive rates, suboptimal signal quality, limited ability to detect atrial flutter, and lack of remote programming remain challenging. The LUX-Dx PERFORM study was designed to evaluate novel technologies engineered to address these issues. Here, we present preliminary results from the trial focusing on the safety of ICM insertion, remote monitoring rates, and the feasibility of remote programming. LUX-Dx PERFORM is a multicenter, prospective, single-arm, post-market, observational study with planned enrollment of up to 827 patients from 35 sites in North America. A preliminary cohort consisting of the first 369 patients who were enrolled between March and October 2021 was selected for analysis. Three hundred sixty-three (363) patients had ICM insertions across inpatient and outpatient settings. The mean time followed was 103.4 ± 61.8 days per patient. The total infection rate was 0.8% (3/363). Interim results show high levels of remote monitoring with a median 94% of days with data transmission (interquartile range: 82-99). Thirteen (13) in-clinic and 24 remote programming sessions were reported in 34 subjects. Reprogramming examples are presented to highlight signal quality, the ability to detect atrial flutter, and the positive impact of remote programming on patient management. Interim results from LUX-Dx PERFORM study demonstrate the safety of insertion, high data transmission rates, the ability to detect atrial flutter, and the feasibility of remote programming to optimize arrhythmia detection and improve clinical workflow. Future results from LUX-Dx PERFORM will further characterize improvements in signal quality and arrhythmia detection.
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Affiliation(s)
- Craig Stolen
- Cardiac Rythm ManagementBoston ScientificSt PaulMinnesotaUSA
| | - Jonathan Rosman
- Cardiac Arrhythmia ServiceFlorida Atlantic University CESCOMBoca RatonFloridaUSA
| | - Harish Manyam
- Department of Cardiology, Erlanger HospitalUniversity of TennesseeKnoxvilleTennesseeUSA
| | - Brian Kwan
- Cardiac Rythm ManagementBoston ScientificSt PaulMinnesotaUSA
| | - Jonathan Kelly
- Cardiac Rythm ManagementBoston ScientificSt PaulMinnesotaUSA
| | | | - John Garner
- Department of Clinical MedicineUniversity of Missouri School of MedicineColumbiaMissouriUSA
| | - Mark Richards
- Yakima Heart Lung & Vascular ClinicYakima Valley MemorialYakimaWashingtonUSA
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Latif I, Patil V. To the Editor — Remote monitoring devices and the unseen challenges. Heart Rhythm O2 2022; 3:455. [PMID: 36097462 PMCID: PMC9463704 DOI: 10.1016/j.hroo.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Idrees Latif
- Blizard Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom
| | - Vinod Patil
- Department of Anaesthesia, Barking Havering and Redbridge University Hospitals NHS Trust, Romford, United Kingdom
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