Early detection of adverse events with daily remote monitoring versus quarterly standard follow-up program in patients with CRT-D

Digital Transformation in Thoracic Surgery: a survey among the European Society of Thoracic Surgeons

OBJECTIVES

Digital transformation has drastically changed the surgical sector, but few is known about its impact on thoracic surgical practice. The aim of this paper is to report the European Society of Thoracic Surgeons (ESTS) survey results, assessing the impact of and the need for Digital Transformation in Thoracic Surgery.

METHODS

A 23-item survey was designed by the ESTS Digital Transformation Working Group to assess the impact of and the need for Digital Transformation in Thoracic Surgery. All ESTS members (1668) were invited to complete the survey between 13 March and 21 May 2022 anonymously. Data analysis was descriptive calculating frequencies and percentages. Group comparison was done using chi-square test.

RESULTS

The response rate was 6.3%. Surgeons from 26 European countries participated of which more than 80% were based in academic hospitals. The impact of digital transformation was rated very important (43.8%) and fundamental (22.7%) in more than two-thirds of the cases, regardless of surgeons' age. None of the participants felt that digital transformation was of no importance and more than 85% had implemented digital platforms in their direct patient care. Almost 90% of the surgeons, currently not using digital platforms for training and education, would consider introducing them. About 70% were at least 'somewhat satisfied' with their current engagement in Digital Transformation in Thoracic Surgery.

CONCLUSIONS

Digital transformation seems to play a major role across European Thoracic Surgery departments in direct patient care, professional networking and surgical training. However, overall satisfaction with the current status of Digital Transformation in Thoracic Surgery was rather reserved, implying the need to increase the implementation of digital solutions in the latter.

Telecardiology and its settings of application: An update

Among the wide range of medical specialties in which telemedicine has been successfully applied, cardiology can be considered as one of the most important fields of application. Through the transmission of clinical data and the electrocardiogram, telecardiology allows access to a real-time assessment (teleconsultation) without any need to travel for both patient and cardiologist. This review discusses the impact of telecardiology in different clinical settings of application. Pre-hospital telecardiology has proved to be useful either in the clinical management of remote patients with acute coronary syndrome or in supporting the decision-making process of general practitioners. In the setting of in-hospital telecardiology, most of the applications refer to real-time echocardiography transmissions between rural small hospitals and tertiary care centres, particularly for the diagnosis or exclusion of congenital heart disease in newborns. Finally, many trials show that post-hospital telecardiology improves outcomes and reduces re-admissions or outpatient contacts in patients with heart failure, arrhythmias or implantable devices.

Improving inflammatory arthritis management through tighter monitoring of patients and the use of innovative electronic tools

Treating to target by monitoring disease activity and adjusting therapy to attain remission or low disease activity has been shown to lead to improved outcomes in chronic rheumatic diseases such as rheumatoid arthritis and spondyloarthritis. Patient-reported outcomes, used in conjunction with clinical measures, add an important perspective of disease activity as perceived by the patient. Several validated PROs are available for inflammatory arthritis, and advances in electronic patient monitoring tools are helping patients with chronic diseases to self-monitor and assess their symptoms and health. Frequent patient monitoring could potentially lead to the early identification of disease flares or adverse events, early intervention for patients who may require treatment adaptation, and possibly reduced appointment frequency for those with stable disease. A literature search was conducted to evaluate the potential role of patient self-monitoring and innovative monitoring of tools in optimising disease control in inflammatory arthritis. Experience from the treatment of congestive heart failure, diabetes and hypertension shows improved outcomes with remote electronic self-monitoring by patients. In inflammatory arthritis, electronic self-monitoring has been shown to be feasible in patients despite manual disability and to be acceptable to older patients. Patients' self-assessment of disease activity using such methods correlates well with disease activity assessed by rheumatologists. This review also describes several remote monitoring tools that are being developed and used in inflammatory arthritis, offering the potential to improve disease management and reduce pressure on specialists.

Evolvement of left ventricular assist device: the implications on heart failure management

Heart failure (HF) is a potentially fatal disease that affects increasing number of people worldwide. Although heart transplant is the "gold standard" therapy for HF, due to the limited availability of organs, many patients died when waiting for the transplant. Left ventricular assist device (LVAD), as a mechanical circulatory support, has become a new light for patients with HF. With the technical advancements, LVADs work not only as a bridge to transplant, but also assist heart recovery and even as a destination therapy in long-term treatment. This observation paper reviewed the development of LVAD and its clinical roles. The challenges and possible solutions in nursing care for patients with LVAD at different stage of implantation were discussed. The healthcare professionals could obtain a better understanding about the LVAD treatment for HF patients.

The Influence of Remote Monitoring on Clinical Decision Making

The aim of this study was to examine the meaningful use of remote monitoring. In partnership with a home health care agency, we examined the degree to which the information obtained from remote monitoring influenced change in decisions that affect readmission rates among patients diagnosed with heart failure. Hospital utilization was highly associated with nurses’ clinical decisions to go to the hospital; the additional data provided by technology did not modify decisions. The role of nurses in heart failure management is critical to quality outcomes. Investments into remote monitoring technology should accompany strategies to enhance decision making and align clinical decision making with quality goals.

Innovations in telemedicine for cardiovascular care

Cardiovascular disease is one of the main fields of application for telemedicine, with benefits in almost all areas in the continuum of cardiovascular disease. The greatest impact has been shown in the early diagnosis of cardiovascular disease, in second consultation, between non-cardiologist and cardiologist and between cardiologists, and in follow-up and secondary prevention of cardiovascular disease. At present, the main area of implementation for telemedicine in cardiovascular disease is represented by pre-hospital triage, with telemedicine electrocardiogram in acute myocardial infarction. Significant results have also been achieved in the second opinion consultation of pediatric subjects with congenital cardiovascular disease, home-monitoring and the management of patients affected by chronic heart failure or with an implanted device. However, there is significant room for further improvement in delivering telemedicine assistance even in 'very-remote' populations, such as detainees, patients in developing countries or in underdeveloped areas of developed countries.

Large Controlled Observational Study on Remote Monitoring of Pacemakers and Implantable Cardiac Defibrillators: A Clinical, Economic, and Organizational Evaluation

Background

Patients with implantable devices such as pacemakers (PMs) and implantable cardiac defibrillators (ICDs) should be followed up every 3–12 months, which traditionally required in-clinic visits. Innovative devices allow data transmission and technical or medical alerts to be sent from the patient's home to the physician (remote monitoring). A number of studies have shown its effectiveness in timely detection and management of both clinical and technical events, and endorsed its adoption. Unfortunately, in daily practice, remote monitoring has been implemented in uncoordinated and rather fragmented ways, calling for a more strategic approach.

Objective

The objective of the study was to analyze the impact of remote monitoring for PM and ICD in a “real world” context compared with in-clinic follow-up. The evaluation focuses on how this service is carried out by Local Health Authorities, the impact on the cardiology unit and the health system, and organizational features promoting or hindering its effectiveness and efficiency.

Methods

A multi-center, multi-vendor, controlled, observational, prospective study was conducted to analyze the impact of remote monitoring implementation. A total of 2101 patients were enrolled in the study: 1871 patients were followed through remote monitoring of PM/ICD (I-group) and 230 through in-clinic visits (U-group). The follow-up period was 12 months.

Results

In-clinic device follow-ups and cardiac visits were significantly lower in the I-group compared with the U-group, respectively: PM, I-group = 0.43, U-group = 1.07, P<.001; ICD, I-group = 0.98, U-group = 2.14, P<.001. PM, I-group = 0.37, U-group = 0.85, P<.001; ICD, I-group = 1.58, U-group = 1.69, P=.01. Hospitalizations for any cause were significantly lower in the I-group for PM patients only (I-group = 0.37, U-group = 0.50, P=.005). There were no significant differences regarding use of the emergency department for both PM and ICD patients. In the I-group, 0.30 (PM) and 0.37 (ICD) real clinical events per patient per year were detected within a mean (SD) time of 1.18 (2.08) days. Mean time spent by physicians to treat a patient was lower in the I-group compared to the U-group (-4.1 minutes PM; -13.7 minutes ICD). Organizational analysis showed that remote monitoring implementation was rather haphazard and fragmented. From a health care system perspective, the economic analysis showed statistically significant gains (P<.001) for the I-group using PM.

Conclusions

This study contributes to build solid evidence regarding the usefulness of RM in detecting and managing clinical and technical events with limited use of manpower and other health care resources. To fully gain the benefits of RM of PM/ICD, it is vital that organizational processes be streamlined and standardized within an overarching strategy.

Comparison of partners-heart failure algorithm vs care alert in remote heart failure management

AIM: To compare the utility of the partners-heart failure (HF) algorithm with the care alert strategy for remote monitoring, in guiding clinical actions oriented to treat impending HF.

METHODS: Consecutive cardiac resynchronization-defibrillator recipients were followed with biweekly automatic transmissions. After every transmission, patients received a phone contact in order to check their health status, eventually followed by clinical actions, classified as “no-action”, “non-active” and “active”. Active clinical actions were oriented to treat impending HF. The sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of the partners-HF algorithm vs care alert in determining active clinical actions oriented to treat pre-HF status and to prevent an acute decompensation, were also calculated.

RESULTS: The study population included 70 patients with moderate to advanced systolic HF and QRS duration longer than 120 ms. During a mean follow-up of 8 ± 2 mo, 665 transmissions were collected. No deaths or HF hospitalizations occurred. The sensitivity and specificity of the partners-HF algorithm for active clinical actions oriented to treat impending HF were 96.9% (95%CI: 0.96-0.98) and 92.5% (95%CI: 0.90-0.94) respectively. The positive and negative predictive values were 84.6% (95%CI: 0.82-0.87) and 98.6% (95%CI: 0.98-0.99) respectively. The partners-HF algorithm had an accuracy of 93.8% (95%CI: 0.92-0.96) in determining active clinical actions. With regard to active clinical actions, care alert had a sensitivity and specificity of 11.05% (95%CI: 0.09-0.13) and 93.6% respectively (95%CI: 0.92-0.95). The positive predictive value was 42.3% (95%CI: 0.38-0.46); the negative predictive value was 71.1% (95%CI: 0.68-0.74). Care alert had an accuracy of 68.9% (95%CI: 0.65-0.72) in determining active clinical actions.

CONCLUSION: The partners-HF algorithm proved higher accuracy and sensitivity than care alert in determining active clinical actions oriented to treat impending HF. Future studies in larger populations should evaluate partners-HF ability to improve HF-related clinical outcomes.

Telemedicine for cardiovascular disease continuum: A position paper from the Italian Society of Cardiology Working Group on Telecardiology and Informatics

Telemedicine is the provision of health care services, through the use of information and communication technology, in situations where the health care professional and the patient, or 2 health care professionals, are not in the same location. It involves the secure transmission of medical data and information, through text, sound, images, or other forms needed for the prevention, diagnosis, treatment, and follow-up of a patient. First data on implementation of telemedicine for the diagnosis and treatment of acute myocardial infarction date from more than 10 years ago. Telemedicine has a potential broad application to the cardiovascular disease continuum and in many branches of cardiology, at least including heart failure, ischemic heart disease and arrhythmias. Telemedicine might have an important role as part of a strategy for the delivery of effective health care for patients with cardiovascular disease. In this document the Working Group on Telecardiology and Informatics of the Italian Society of Cardiology intends to remark some key-points regarding potential benefit achievable with the implementation of telemedicine support in the continuum of cardiovascular disease.

Feasibility and efficacy of a remote real-time wireless ECG monitoring and stimulation system for management of ventricular arrhythmia in rabbits with myocardial infarction

The purpose of this study was to explore the feasibility of continuous remote monitoring, and the induction and termination of malignant ventricular arrhythmias (VAs) by a novel implantable electronic cardiovascular device (IECD) system in rabbits with myocardial infarction (MI). The IECD was implanted and MI was induced by ligation of the left anterior descending coronary artery in 20 adult rabbits. Internet-based remote electrocardiogram (ECG) monitoring and ventricular stimulation were conducted in remote locations with internet access. The voltage amplitudes of the stimulation signals were recorded synchronously by remote and surface ECG. Programmed stimulation with regular stimuli and regular stimuli with an added extra stimulus were performed prior to and following the MI surgery to induce and terminate VAs. IECD implantation and MI surgery, as well as qualified remote and bidirectional signal communications between the implanted IECD and extracorporeal system, were successfully achieved in 18 rabbits. The voltage of the stimulation signals recorded by the remote and surface ECGs showed a good correlation with the stimulation current (remote ECG, r=0.972 and surface ECG, r=0.988; P<0.001). Sustained ventricular tachycardia (VT) was induced in five rabbits (5/20, 25%) prior to MI induction and in 12 rabbits (12/16, 75%) following MI induction. Of the 17 induced VTs, 16 were successfully terminated by remote ventricular stimulation. The novel IECD system provides qualified remote wireless ECG monitoring and possesses the potential to induce and terminate VAs by remote ventricular pacing in this rabbit model of MI. Thus, this model of MI may be used to test the efficacy of novel drugs and devices for the management of VAs.

Continuous monitoring of atrial fibrillation in heart failure

In patients with atrial fibrillation (AF) undergoing cardiac resynchronization therapy (CRT) for heart failure, continuous monitoring of the percentage of biventricular BiV% pacing has shown that the greatest improvement and reduction in mortality occur with a BiV pacing greater than 98%. Continuous monitoring of BiV pacing has improved the CRT management of patients with AF. Continuous monitoring has generated important new questions about anticoagulant therapy, which require randomized trials. Anticoagulant therapy should probably be considered in patients who have a high risk of thromboembolism according to standard scoring systems.

Economic impact of remote monitoring on ordinary follow-up of implantable cardioverter defibrillators as compared with conventional in-hospital visits. A single-center prospective and randomized study

INTRODUCTION

Few data are available on actual follow-up costs of remote monitoring (RM) of implantable defibrillators (ICD). Our study aimed at assessing current direct costs of 1-year ICD follow-up based on RM compared with conventional quarterly in-hospital follow-ups.

METHODS AND RESULTS

Patients (N = 233) with indications for ICD were consecutively recruited and randomized at implant to be followed up for 1 year with standard quarterly in-hospital visits or by RM with one in-hospital visit at 12 months, unless additional in-hospital visits were required due to specific patient conditions or RM alarms. Costs were calculated distinguishing between provider and patient costs, excluding RM device and service cost. The frequency of scheduled in-hospital visits was lower in the RM group than in the control arm. Follow-up required 47 min per patient/year in the RM arm versus 86 min in the control arm (p = 0.03) for involved physicians, generating cost estimates for the provider of USD 45 and USD 83 per patient/year, respectively. Costs for nurses were comparable. Overall, the costs associated with RM and standard follow-up were USD 103 ± 27 and 154 ± 21 per patient/year, respectively (p = 0.01). RM was cost-saving for the patients: USD 97 ± 121 per patient/year in the RM group versus 287 ± 160 per patient/year (p = 0.0001).

CONCLUSION

The time spent by the hospital staff was significantly reduced in the RM group. If the costs for the device and service are not charged to patients or the provider, patients could save about USD 190 per patient/year while the hospital could save USD 51 per patient/year.

Use of remote monitoring in the management of system-related complications in implantable defibrillator patients

Remote monitoring of implantable defibrillators (ICDs) is designed to minimise regular follow-up visits and to facilitate early detection of adverse events. With the increased rate of ICD implantations in today's clinical setting and multiple device advisories, which pose management challenges, this approach becomes very attractive. The aim of this article is to present the role of remote monitoring in the detection of system-related complications, its potential benefits and its barriers in the outpatient management of ICD patients.

[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.