Assessment of a remote monitoring system for implantable cardioverter defibrillators

Investigating the Cost-Effectiveness of Telemonitoring Patients With Cardiac Implantable Electronic Devices: Systematic Review

BACKGROUND

Telemonitoring patients with cardiac implantable electronic devices (CIEDs) can improve their care management. However, the results of cost-effectiveness studies are heterogeneous. Therefore, it is still a matter of debate whether telemonitoring is worth the investment.

OBJECTIVE

This systematic review aims to investigate the cost-effectiveness of telemonitoring patients with CIEDs, focusing on its key drivers, and the impact of the varying perspectives.

METHODS

A systematic review was performed in PubMed, Web of Science, Embase, and EconLit. The search was completed on July 7, 2022. Studies were included if they fulfilled the following criteria: patients had a CIED, comparison with standard care, and inclusion of health economic evaluations (eg, cost-effectiveness analyses and cost-utility analyses). Only complete and peer-reviewed studies were included, and no year limits were applied. The exclusion criteria included studies with partial economic evaluations, systematic reviews or reports, and studies without standard care as a control group. Besides general study characteristics, the following outcome measures were extracted: impact on total cost or income, cost or income drivers, cost or income drivers per patient, cost or income drivers as a percentage of the total cost impact, incremental cost-effectiveness ratios, or cost-utility ratios. Quality was assessed using the Consensus Health Economic Criteria checklist.

RESULTS

Overall, 15 cost-effectiveness analyses were included. All studies were performed in Western countries, mainly Europe, and had primarily a male participant population. Of the 15 studies, 3 (20%) calculated the incremental cost-effectiveness ratio, 1 (7%) the cost-utility ratio, and 11 (73%) the health and cost impact of telemonitoring. In total, 73% (11/15) of the studies indicated that telemonitoring of patients with implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy ICDs was cost-effective and cost-saving, both from a health care and patient perspective. Cost-effectiveness results for telemonitoring of patients with pacemakers were inconclusive. The key drivers for cost reduction from a health care perspective were hospitalizations and scheduled in-office visits. Hospitalization costs were reduced by up to US $912 per patient per year. Scheduled in-office visits included up to 61% of the total cost reduction. Key drivers for cost reduction from a patient perspective were loss of income, cost for scheduled in-office visits and transport. Finally, of the 15 studies, 8 (52%) reported improved quality of life, with statistically significance in only 1 (13%) study (P=.03).

CONCLUSIONS

From a health care and patient perspective, telemonitoring of patients with an ICD or a cardiac resynchronization therapy ICD is a cost-effective and cost-saving alternative to standard care. Inconclusive results were found for patients with pacemakers. However, telemonitoring can lead to a decrease in providers' income, mainly due to a lack of reimbursement. Introducing appropriate reimbursement could make telemonitoring sustainable for providers while still being cost-effective from a health care payer perspective.

TRIAL REGISTRATION

PROSPERO CRD42022322334; https://tinyurl.com/puunapdr.

Cost-effectiveness of remote monitoring of implantable cardioverter-defibrillators in France: a meta-analysis and an integrated economic model derived from randomized controlled trials

Aims

Cost-effectiveness data on the remote monitoring (RM) of implantable cardioverter-defibrillators (ICDs) compared to the current standard of care (SC) remains limited. This meta-analysis was performed to assess the economic burden, and to develop an integrated economic model evaluating the efficiency of the RM strategy vs. SC in the context of French healthcare.

Methods and results

Randomized controlled trials, comparing RM to SC in patients implanted with ICDs with or without resynchronization therapy (±CRT-D), were identified through a systematic search of scientific literature databases dating from 2005. Seventeen trials (10 229 patients) reporting data on clinical outcomes, quality of life, cost, and/or utility, either as primary or secondary endpoints were identified. Compared to SC, RM resulted in significant reductions in annual costs per patient for direct healthcare costs (seven studies, difference in means −276.1, 95% standard error [SE]: 66.0, I2 = 76.3%) and for labour costs (two studies, difference in means −11.3, 95% SE: 1.4, I2 = 96.3%). A three-state Markov Model showed that RM resulted in cost-savings of €4142 per patient over a 5-year time horizon, with a quality-adjusted life year (QALY) gain of 0.29. The incremental cost-effectiveness ratio was −14 136 €/QALY, in favour of RM. Furthermore, probabilistic sensitivity analyses confirmed that the RM strategy was dominant over SC in 70% of cases.

Conclusion

Our economic model demonstrates that once implemented, RM of ICD ± CRT-D patients would result in increased effectiveness for lower costs over a 5-year period, compared to the current SC in France.

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.

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 implantable cardioverter-defibrillators. Problems and implications using a telemonitoring system

The rising number of implantable devices has led to an increase in device-related workload, e.g., regular interrogation follow-up visits. Telemonitoring systems for implantable cardioverter-defibrillators (ICDs) seem to be a promising tool for reducing workload and costs, and they have the potential of optimizing patient care. However, issues such as practical functionality of ICD telemonitoring in daily routine may affect its broad implementation. The objective of this study was to evaluate potential problems during the implementation of a telemonitoring system, Medtronic CareLink™ (CL™) with respect to the installation and data transmission process. A total of 159 patients with ICDs who were equipped with the CL™ system were evaluated and followed up for 16 months regarding the success rate of the first data transmission via the telemonitoring system. In this cohort, a high rate of nontransmission of 23.9 % was observed after the 16-month follow-up. A detailed interview of these patients (no transmission) revealed that the main reasons for failed transmissions were due to the patients' loss of interest in the concept (approximately 50 %) as well as technical problems (approximately 25 %) with setting up the system. These results indicate that telemonitoring systems bear potential problems and that the evaluation of patient motivation and technical support options seems to play an important role in establishing the functionality of these systems.

Costs of remote monitoring vs. ambulatory follow-ups of implanted cardioverter defibrillators in the randomized ECOST study

AIMS

The Effectiveness and Cost of ICD follow-up Schedule with Telecardiology (ECOST) trial evaluated prospectively the economic impact of long-term remote monitoring (RM) of implantable cardioverter defibrillators (ICDs).

METHODS AND RESULTS

The analysis included 310 patients randomly assigned to RM (active group) vs. ambulatory follow-ups (control group). Patients in the active group were seen once a year unless the system reported an event mandating an ambulatory visit, while patients in the control group were seen in the ambulatory department every 6 months. The costs of each follow-up strategy were compared, using the actual billing documents issued by the French health insurance system, including costs of (i) (a) ICD-related ambulatory visits and transportation, (b) other ambulatory visits, (c) cardiovascular treatments and procedures, and (ii) hospitalizations for the management of cardiovascular events. The ICD and RM system costs were calculated on the basis of the device remaining longevity at the end of the study. The characteristics of the study groups were similar. Over a follow-up of 27 months, the mean non-hospital costs per patient-year were €1695 ± 1131 in the active, vs. €1952 ± 1023 in the control group (P = 0.04), a €257 difference mainly due to device management. The hospitalization costs per patient-year were €2829 ± 6382 and €3549 ± 9714 in the active and control groups, respectively (P = 0.46). Adding the ICD to the non-hospital costs, the savings were €494 (P = 0.005) or, when the monitoring system was included, €315 (P = 0.05) per patient-year.

CONCLUSION

From the French health insurance perspective, the remote management of ICD patients is cost saving.

CLINICAL TRIALS REGISTRATION

NCT00989417, www.clinicaltrials.gov.

[Remote monitoring for follow-up of patients with implantable cardiac devices]

With a widening of indications for cardiac devices, especially in view of the clinical benefits of implantable cardioverter-defibrillators and cardiac resynchronization therapy, the number of patients with such devices is growing steadily. However, the resources required, and the need for long-term regular interrogation in dedicated clinics, represent a significant burden for already overstretched electrophysiology teams and hospital services. Remote telemonitoring is increasingly used for such follow-up, as it is a safe and effective alternative to conventional follow-up programs in outpatient clinics. This technology has been shown to be technically reliable, enabling early identification of device malfunction, arrhythmic events and heart failure decompensation, while reducing the risk of under-reporting, the number of outpatient clinic visits and hospitalizations due to cardiac events, and healthcare costs. Further studies are needed to determine how best to implement this new technology in a cost-effective manner, and what new legislation governing the use of remote monitoring in clinical practice may be required. In this article, we describe current systems, review the technical and clinical evidence in the literature regarding remote monitoring of implantable cardiac devices, and expand on outstanding questions.

Workload and usefulness of daily, centralized home monitoring for patients treated with CIEDs: results of the MoniC (Model Project Monitor Centre) prospective multicentre study

AIM

Automated, daily Home Monitoring (HM) of pacemaker and implantable cardioverter-defibrillator (ICD) patients can improve patient care. Yet, HM introduction to routine clinical practice is challenged by resource allocation for regular HM data review. We tested the feasibility, safety, workload, and clinical usefulness of a centralized HM model consisting of one monitor centre and nine satellite clinics.

METHODS AND RESULTS

Having no knowledge about patients' clinical data, a telemonitoring nurse (TN) and a supporting physician at the monitor centre screened and filtered HM data in 62 pacemaker and 59 ICD patients from nine satellite clinics for over 1 year. Basic screening of arrhythmic and technical events required 25.7 min (TN) and 0.7 min (physician) per working day, normalized for 100 patients monitored. Communication of relevant events to satellite clinics per email or phone required additional 4.3 min (TN) and 0.4 min (physician). Telemonitoring nurse also screened for abnormal developments in longitudinal data trends weekly for 3 months after implantation, and then monthly; one patient session lasted 4.0 ± 2.9 min. To handle transmission-gap notifications, TN needed additional 2.8 min daily. Satellite clinics received 231.3 observations from the monitor centre per 100 patients/year, which prompted 86.3 patient contacts or intensive HM screening periods by the satellite clinic itself (37.3% response rate), 51.7 extra follow-up controls (22.3%), and 30.1 clinical interventions (13.0%).

CONCLUSION

Centralized HM was feasible, reliable, safe, and clinically useful. Basic screening and communication of relevant arrhythmic and technical events required a total of 30 min (TN) and 1.1 min (physician) daily per 100 patients monitored.

Innovation in health care technology: is it part of the problem or part of the solution? eHealth gives the answer

There is no doubt that the contribution of the Health Care Technologies to the tremendous evolution on Medicine since mid XX century has been one of its most important pillars. At the same time the innovation has been sometimes accused of been the root of the increase in the Health Care expenditure to support the Health of the society. Actually, when the Health Care Systems are focusing not only on the critical processes but on the continuum of the disease, the application of innovation to the chronic diseases and, more specifically, in the Cardiovascular ones (specially the Cardiac Insufficiency), represents a great challenge for care givers, patients and the Health Care Systems as their treatment requires continuous medical care and patient self management. The key for establishing this continuity of care in an efficient way is based in the concept of "Anticipation". This is the only way to avoid the burden of the continuous re-hospitalizations of this kind of patients. The engagement of patients in the adoption of healthy lifestyles with a positive impact in the progression of their diseases is fundamental to avoid the appearance of chronic complications or co-morbidities. Only with these assumptions the Innovation on Health Care Technologies will become part of the solution of the sustainability of the Health Care expenditure for the society. This paper present the keys for making the innovation efficient understanding the transversal of the Health Care processes.

A review on remote monitoring technology applied to implantable electronic cardiovascular devices

Implantable electronic cardiovascular devices (IECD) include a broad spectrum of devices that have the ability to maintain rhythm, provide cardiac resynchronization therapy, and/or prevent sudden cardiac death. The incidence of bradyarrhythmias and other cardiac problems led to a broader use of IECD, which turned traditional follow-up into an extremely heavy burden for healthcare systems to support. Our aim was to assess the impact of remote monitoring on the follow-up of patients with IECD. We performed a review through PubMed using a specific query. The paper selection process included a three-step approach in which title, abstract, and cross-references were analyzed. Studies were then selected using previously defined inclusion criteria and analyzed according to the country of origin of the study, year, and journal of publication; type of study; and main issues covered. Twenty articles were included in this review. Eighty percent of the selected papers addressed clinical issues, from which 94% referred clinical events identification, clinical stability, time savings, or physician satisfaction as advantages, whereas 38% referred disadvantages that included both legal and technical issues. Forty-five percent of the papers referred patient issues, from which 89% presented advantages, focusing on patient acceptance/satisfaction, and patient time-savings. The main downsides were technical issues but patient privacy was also addressed. All the papers dealing with economic issues (20%) referred both advantages and disadvantages equally. Remote monitoring is presently a safe technology, widely accepted by patients and physicians, for its convenience, reassurance, and diagnostic potential. This review summarizes the principles of remote IECD monitoring presenting the current state-of-the-art. Patient safety and device interaction, applicability of current technology, and limitations of remote IECD monitoring are also addressed. The use of remote monitor should consider the selection of patients, the type of disease, and centers' availability to receive, interpret and respond to device alerts. Before remote IECD monitoring can be routinely used, technical, procedure, and ethical/legal issues should be addressed.

Health technology assessment review: remote monitoring of vital signs--current status and future challenges

Recent developments in communications technologies and associated computing and digital electronics now permit patient data, including routine vital signs, to be surveyed at a distance. Remote monitoring, or telemonitoring, can be regarded as a subdivision of telemedicine - the use of electronic and telecommunications technologies to provide and support health care when distance separates the participants. Depending on environment and purpose, the patient and the carer/system surveying, analysing or interpreting the data could be separated by as little as a few feet or be on different continents. Most telemonitoring systems will incorporate five components: data acquisition using an appropriate sensor; transmission of data from patient to clinician; integration of data with other data describing the state of the patient; synthesis of an appropriate action, or response or escalation in the care of the patient, and associated decision support; and storage of data. Telemonitoring is currently being used in community-based healthcare, at the scene of medical emergencies, by ambulance services and in hospitals. Current challenges in telemonitoring include: the lack of a full range of appropriate sensors, the bulk weight and size of the whole system or its components, battery life, available bandwidth, network coverage, and the costs of data transmission via public networks. Telemonitoring also has the ability to produce a mass of data - but this requires interpretation to be of clinical use and much necessary research work remains to be done.

Remote monitoring and follow-up of pacemakers and implantable cardioverter defibrillators

In the era of communication technology, new options are now available for following-up patients implanted with pacemakers (PMs) and defibrillators (ICDs). Most major companies offer devices with wireless capabilities that communicate automatically with home transmitters, which then relay data to the physician, thereby allowing remote patient follow-up and monitoring. These systems are being widely used in the USA for remote follow-up, and have been more recently introduced in Europe, where their adoption is increasing. In this article, we describe the currently existing systems, review the available evidence in the literature regarding remote follow-up and monitoring of PMs and ICDs, and finally discuss some unresolved issues.