Fiabilidad técnica y seguridad clínica de un sistema de monitorización remota de dispositivos cardiacos antiarrítmicos

Health-related quality of life on tele-monitoring for users with pacemakers 6 months after implant: the NORDLAND study, a randomized trial

BACKGROUND

With an ageing population and widening indications for pacemakers implantation, the number of persons carrying an implant is steadily increasing. The routine follow-up is thus a heavy burden for the respective NHS as well as for the patients and their relatives. Most of them of the studies have been performed in densely populated areas and nearby to the hospital. It is thus unknown whether these results could be applied also in rural areas such as Northern Norway with a more scattered population. The aim of this study was to assess the effectiveness of tele-monitoring (TM) in patients with pacemakers regarding reliability, safety and health-related quality of life, compared to traditional follow-up in outpatient clinic in a setting where geographical effects could possible influence the results.

METHODS

The NORDLAND study is a controlled, randomized, non-masked clinical trial in pacemaker patients, with data collection carried out during the pre-implant stage and after 6 months. Between August of 2014 and November of 2015, 50 patients were assigned to either a tele-monitoring group (n = 25) or a conventional hospital monitoring (HM) group (n = 25). The EuroQol-5D (EQ-5D) utilities and visual analogue scale (VAS) and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) were used to measure Health-Related Quality of Life. Baseline characteristics and number of hospital visits were also analyzed.

RESULTS

The baseline characteristics of the two study groups were similar for EQ-5D utilities (TM:0.81; HM:0.76; p = 0.47), EQ-5D VAS (TM: 64.00; HM:64.88; p = 0.86) and the MLHFQ (TM:20.20; HM:28.96; p = 0.07). At the 6 month follow-up, there were no significant differences between the groups in EQ-5D utilities (TM: 0.81; HM: 0.76; p = 0.54) and EQ-5D VAS scores (TM: 72.71; HM: 59.79; p = 0.08). The MLHFQ score was improved in both groups (TM: -4.40; HM: -15.13; p <  0.001). The number of in-office visits was similar in both groups (TM: 1.24 vs HM: 1.12; P = 0.30).

CONCLUSIONS

The NORDLAND trial shows that HRQoL is improved after implant in both groups. Without significant differences with regards to effectiveness and safety. In addition, provides a scientifically rigorous method to the field of HRQoL evaluations in patients with pacemakers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02237404 , September 11, 2014.

Effectiveness of pacemaker tele-monitoring on quality of life, functional capacity, event detection and workload: The PONIENTE trial

AIMS

The purpose of the present study was to assess the effectiveness of the remote monitoring (RM) of older adults with pacemakers on health-related quality of life, functional capacity, feasibility, reliability and safety.

METHODS

The PONIENTE study is a controlled, non-randomized, non-blinded clinical trial, with data collection carried out during the pre-implant stage and after 12 months. Between October of 2012 and November of 2013, 82 patients were assigned to either a remote monitoring group (n = 30) or a conventional hospital monitoring (HM) group (n = 52). The EuroQol-5D (EQ-5D) and the Duke Activity Status Index were used to measure health-related quality of life and functional capacity, respectively. Baseline characteristics and number of hospital visits were also analyzed.

RESULTS

The baseline characteristics of the two study groups were similar for both the EQ-5D (RM 0.74, HM 0.67; P = 0.404) and the Duke Activity Status Index (RM 21.42, HM 19.95; P = 0.272). At the 12-month follow up, the EQ-5D utility score was improved for both groups (RM 0.91, HM 0.81; P = 0.154), unlike the EQ-5D Visual Analog Scale (P = 0.043). The Duke Activity Status Index score was similar to the baseline score. The number of in-hospital visits was 27% lower (3 vs 4; P < 0.001) in the remote group as compared with the hospital group.

CONCLUSIONS

The PONIENTE trial suggests that the remote monitoring of pacemakers in older adults is an equivalent option to hospital monitoring, in terms of health-related quality of life and functional capacity. Furthermore, it allows for the early detection of clinical and pacemaker-related adverse events, and significantly reduces the number of in-hospital visits. Geriatr Gerontol Int 2016; 16: 1188-1195.

A Systematic Review of Economic Evaluations of Pacemaker Telemonitoring Systems

INTRODUCTION AND OBJECTIVES

Over the last decade, telemedicine applied to pacemaker monitoring has undergone extraordinary growth. It is not known if telemonitoring is more or less efficient than conventional monitoring. The aim of this study was to carry out a systematic review analyzing the available evidence on resource use and health outcomes in both follow-up modalities.

METHODS

We searched 11 databases and included studies published up until November 2014. The inclusion criteria were: a) experimental or observational design; b) studies based on complete economic evaluations; c) patients with pacemakers, and d) telemonitoring compared with conventional hospital monitoring.

RESULTS

Seven studies met the inclusion criteria, providing information on 2852 patients, with a mean age of 81 years. The main indication for device implantation was atrioventricular block. With telemonitoring, cardiovascular events were detected and treated 2 months earlier than with conventional monitoring, thus reducing length of hospital stay by 34% and reducing routine and emergency hospital visits as well. There were no significant intergroup differences in perceived quality of life or number of adverse events. The cost of telemonitoring was 60% lower than that of conventional hospital monitoring.

CONCLUSIONS

Compared with conventional monitoring, cardiovascular events were detected earlier and the number or hospitalizations and hospital visits was reduced with pacemaker telemonitoring. In addition, the costs associated with follow-up were lower with telemonitoring.

Workload, time and costs of the informal cares in patients with tele-monitoring of pacemakers: the PONIENTE study

OBJECTIVES

The purpose of this study was to assess the burden borne by and the costs to informal caregivers of patients with remotely monitored (RM) pacemakers.

METHODS

The PONIENTE study was a controlled, non-randomised clinical trial, with data collected from informal caregivers, 12 months after implantation of pacemakers. The survey on disabilities, personal autonomy, and dependency situations was used to gather information on demographic and social characteristics, levels of professionalism, time and types of care, difficulties in providing care, health status, professional aspects, economic and family or leisure impacts due to informal caregiving for patients with pacemakers.

RESULTS

During 14 months, 76 caregivers were enrolled in the PONIENTE trial. Of which, 26 were included in the RM group and 50 in the hospital-monitored group (HM). The mean ages were 58.62 ± 16.51 and 61.10 ± 12.67 years, respectively (p = 0.56) in the groups, and 69.7 % were females. The majority (96.1 %) of the caregivers declared that they had to provide their services between 6 and 7 days per week (88.5 % in RM group versus 100 % in HM group; p = 0.037). The costs related to care provided by the informal caregivers were 21.38 % lower in the RM group than in the HM group (p = 0.033).

CONCLUSIONS

The PONIENTE study shows a significant impact of informal care on relatives and friends of patients with pacemakers in terms of their well-being and costs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02234245.

Remote monitoring of cardiac implantable electronic devices in Europe: results of the European Heart Rhythm Association survey

The aim of this European Heart Rhythm Association survey was to provide an insight into the current use of remote monitoring for cardiac implantable electronic devices in Europe. The following topics were explored: use of remote monitoring, infrastructure and organization, patient selection and benefits. Centres using remote monitoring reported performing face-to-face visits less frequently. In many centres (56.9%), a nurse reviews all the data and forwards them to the responsible physician. The majority of the centres (91.4%) stated that remote monitoring is best used in patients with implantable cardioverter-defibrillators and those live far from the hospital (76.6% top benefit). Supraventricular and ventricular arrhythmias were reported to be the major events detected earlier by remote monitoring. Remote monitoring will have a significant impact on device management.

Work burden with remote monitoring of implantable cardioverter defibrillator: is it time for reimbursement policies?

AIMS

The efficacy and accuracy, as well as patients' satisfaction, of device remote monitoring are well demonstrated. However, the workload of remote monitoring management has not been estimated and reimbursement schemes are currently unavailable in most European countries. This study evaluates the workload associated with remote monitoring systems.

METHODS

A total of 154 consecutive implantable cardioverter defibrillator patients (age 66±12 years; 86.5% men) with a remote monitoring system were enrolled. Data on the clinician's workload required for the management of the patients were analyzed.

RESULTS

A total of 1744 transmissions were received during a mean follow-up of 15.3±12.4 months. Median number of transmissions per patient was 11.3. There were 993 event-free transmissions, whereas 638 transmissions regarded one or more events (113 missed transmissions, 141 atrial events, 132 ventricular episodes, 299 heart failure-related transmissions, 14 transmissions regarding lead malfunction and 164 transmissions related to other events). In 402 cases telephonic contact was necessary, whereas in 68 cases an in-clinic visit was necessary and in 23 of them an in-clinic visit was prompted by the manufacturer due to technical issues of the transmitter. During follow-up, 316 work hours were required to manage the enrolled patients. Each month, a total of 14.9 h were spent on the remote monitoring of 154 patients (9.7 h for 100 patients monthly) with approximately 1.1±0.15 h per year for each patient.

CONCLUSION

The clinician's work burden is high in patients with remote monitoring. In order to expand remote monitoring in all patients, reimbursement policies should be considered.

Metrics for assessing the reliability of a telemedicine remote monitoring system

OBJECTIVE

The goal of this study was to assess using new metrics the reliability of a real-time health monitoring system in homes of older adults.

MATERIALS AND METHODS

The "MobileCare Monitor" system was installed into the homes of nine older adults >75 years of age for a 2-week period. The system consisted of a wireless wristwatch-based monitoring system containing sensors for location, temperature, and impacts and a "panic" button that was connected through a mesh network to third-party wireless devices (blood pressure cuff, pulse oximeter, weight scale, and a survey-administering device). To assess system reliability, daily phone calls instructed participants to conduct system tests and reminded them to fill out surveys and daily diaries. Phone reports and participant diary entries were checked against data received at a secure server.

RESULTS

Reliability metrics assessed overall system reliability, data concurrence, study effectiveness, and system usability. Except for the pulse oximeter, system reliability metrics varied between 73% and 92%. Data concurrence for proximal and distal readings exceeded 88%. System usability following the pulse oximeter firmware update varied between 82% and 97%. An estimate of watch-wearing adherence within the home was quite high, about 80%, although given the inability to assess watch-wearing when a participant left the house, adherence likely exceeded the 10 h/day requested time. In total, 3,436 of 3,906 potential measurements were obtained, indicating a study effectiveness of 88%.

CONCLUSIONS

The system was quite effective in providing accurate remote health data. The different system reliability measures identify important error sources in remote monitoring systems.

Innovations in heart rhythm disturbances: cardiac electrophysiology, arrhythmias, and cardiac pacing

This article reviews the most relevant articles published in 2012 in the field of arrhythmias, on subjects that include clinical arrhythmology, ablation, cardiac pacing, and the genetics of sudden cardiac death.

[Advances in cardiac pacing]

This article contains a review of the current status of remote monitoring and follow-up involving cardiac pacing devices and of the latest developments in cardiac resynchronization therapy. In addition, the most important articles published in the last year are discussed.

Can information technology improve the performance of remote monitoring systems?

Despite some clinical, economic, and other qualitative advantages associated with remote cardiac device monitoring systems, one of the main challenges concerns the management of the out-of-hospital data. Manual updating of hospital databases with the data stored in the manufacturers' servers increases time requirements and may introduce mistakes in the entries. The use of communication standards such as Health Level 7 for data interchange could provide a safe and easy way to access patient and device information. The present study of 38 patients was carried out with the Carelink® remote monitoring technology. A formal process for remote cardiac device monitoring was established, including some features in the Arrhythmias Information System: mobile phone and e-mail were included for communication between patients and hospital, with a new gateway for automatic message sending. Device reports generated through the manufacturer's application were attached to the patient's record. Once the information concerning the transmission session was reviewed, the physician made a medical report, which was sent via post and e-mail to the patient. A new interface was created for Health Level 7 communication with the manufacturers' applications, so that the Arrhythmias Information System could automatically interchange information concerning the device and/or the patient when this kind of communication system is available. The volume of data generated by system warning alerts and transmission sessions makes it very difficult to meet the hospital database updating requirements. Standard-based communication between hospital and manufacturers' applications is fundamental to automatic and reliable update of data.

[Progress in cardiac pacing]

This review discusses the utility and current status of remote monitoring in patients with cardiac devices in Spain, the different anticoagulation strategies used during device implantation, the surgical replacement and maintenance of pacemakers and defibrillators, and the present and future importance of impedance sensors in cardiac pacing and heart failure management. Finally, there is a summary of the most relevant scientific articles published in the last year.