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.

Physicians' views on optimal use and payment system for telemedicine: a qualitative study

BACKGROUND

Telemedicine is already in use in daily practice, but appropriate reimbursement and physician payment is falling behind in many countries. One reason is the limited availability of research on the matter. This research therefore examined physicians' views on the optimal use and payment modalities for telemedicine.

METHODS

Sixty-one semi-structured interviews were conducted with physicians from 19 medical disciplines. Interviews were encoded using thematic analysis.

RESULTS

Telephone and video televisits tend not to be used as a first patient contact, except for triage of patients in urgency situations. Several minimum required modalities for the payment system of televisits and telemonitoring were identified. For televisits these were: (i) remuneration of both telephone- and videovisits to increase healthcare equity, (ii) little or no differentiation between videovisit and in-person visit fee to make videovisits financially attractive and sustainable for physicians, (iii) differentiation of televisit fee per medical discipline, and (iv) quality requirements such as mandatory reporting in the patient's medical file. The identified minimum required modalities for telemonitoring were: (i) an alternative payment scheme than fee-for-service, (ii) remunerating not only physicians but also other involved health professionals, (iii) designating and remunerating a coordinator, and (iv) distinguishing sporadic vs. continuously follow-up.

CONCLUSIONS

This research investigated the telemedicine usage behavior of physicians. Moreover, several minimum required modalities were identified for a physician-supported payment system of telemedicine, as these innovations necessitate challenging and innovation of the healthcare payment systems as well.

How to Pay for Telemedicine: A Comparison of Ten Health Systems

Telemedicine has the opportunity to improve clinical effectiveness, health care access, cost-savings, and patient care. However, payment systems may form important obstacles to optimally use telemedicine and enable its opportunities. Little is known about payment systems for telemedicine. Therefore, this research aims to increase knowledge on paying for telemedicine by comparing payment systems for telemedicine and identifying similarities and differences. Based on the countries' official physician fee schedules, listing all reimbursed medical services performed by physicians, a comparative analysis of telemedicine payment systems in ten countries was conducted. Findings show that many countries lacked tele-expertise and telemonitoring payment, with the exception for some specific payments such as for telemonitoring in patients with cardiac implantable electronic devices. Moreover, a wide variety of benefit specifications were implemented in all countries to specify which type of clinician contact should be used (remote versus physical) in which circumstances. Payment parity between video and in-person visits was established only in a few countries. Furthermore, fee-for-service was the dominant payment system, although two countries used a capitation-based or hybrid system. The results imply several potential payment challenges when implementing telemedicine: complex benefit specifications, payment parity discussions, and risk of overconsumption due to the dominant fee-for-service system. These challenges appear to be less present in capitation-based or hybrid systems. However, the latter needs to be further explored to harness the full potential of telemedicine.

The relationship of nursing home price and quality of life

Background

Knowledge about the relationship between the residents’ Quality of Life (QOL) and the nursing home price is currently lacking. Therefore, this study investigates the relationship between 11 dimensions of QOL and nursing homes price in Flemish nursing homes.

Methods

The data used in this cross-sectional study were collected by the Flemish government from years 2014 to 2017 and originates from 659 Flemish nursing homes. From 2014 to 2016, data on the QOL of 21,756 residents was assessed with the InterRAI instrument. This instrument contains 11 QOL dimensions. Multiple linear regression analyses were conducted to examine the research question.

Results

The multiple linear regressions indicated that a 10 euro increase in the daily nursing home price is associated with a significant decrease (P <  0.001) of 0.1 in 5 dimensions of QOL (access to services, comfort and environment, food and meals, respect, and safety and security). Hence, our results indicate that the association between price and QOL is very small. When conducting a subgroup analysis based on ownership type, the earlier found results remained only statistically significant for private nursing homes.

Conclusion

Our findings show that nursing home price is of limited importance with respect to resident QOL. Contrary to popular belief, our study demonstrates a limited negative effect of price on QOL. Further research that includes other indicators of QOL is needed to allow policymakers and nursing home managers to improve nursing home residents’ QOL.

Protection studies with a globin-enriched protein fraction of Ostertagia ostertagi

The protective capacity of an adult stage Ostertagia ostertagi globin antigen was tested in four vaccination experiments in cattle. In a preliminary experiment, calves were vaccinated three times intraperitoneally with 250 microg globin in Freund's adjuvant and challenged with a trickled infection of 25,000 infective larvae. In three subsequent field studies, calves were vaccinated twice or three times intramuscularly with 80-100 microg globin in Quil A and challenged with a natural gastrointestinal nematode infection on pasture. Higher globin-specific antibody levels were detected in the vaccinated calves than in the control animals in all vaccine trials. In the preliminary experiment, geometric mean cumulative egg counts in the globin group were reduced by 52% and total worm burdens were reduced by 28%, compared to the controls. In the first field trial cumulative faecal egg counts were reduced by 63% in the vaccinated calves. However, the reduction in faecal egg output in these two experiments was not statistically significant and no reduction in faecal egg counts was observed in the vaccinated animals in the two last field trials. In conclusion, vaccination of calves with O. ostertagi globin resulted in highly variable protection levels after challenge infection.

Inverse expression of peroxisomes and connexin-43 in the granulosa cells of the quail follicle

Studying the regulation of peroxisome (Px) expression could improve our understanding of human peroxisomal disorders. The granulosa of the largest preovulatory quail follicles proved to be a relevant model because (a) Px expression changes according to the follicular maturation stage and (b) Px expression varies regionally according to the distance of the granulosa relative to the germinal disc region containing the female gamete (oocyte). The question was asked whether Px expression is related to the extent of metabolic cell coupling and whether zonal Px variation is causally related to oocytal factors. This was evaluated by the presence of catalase and Cx-43 (marker proteins for peroxisomes and gap junctions, respectively) and by in vitro experiments with granulosa explants. The data obtained show that the expression of Cx-43 and Px is inversely correlated both temporally and spatially. Uncoupling of gap junctions results in an upregulation of alpha-catalase immunofluorescence. This is in agreement with reports that gap junctions are often negatively affected by Px proliferators. The zonal gradient in Px expression appears to be imposed by the oocyte, as is the case for steroidogenesis and proliferative capacity in the granulosa epithelium. (J Histochem Cytochem 48:167-177, 2000)

Pathophysiological aspects of Mecistocirrus digitatus (Nematoda: Trichostrongylidae) infection in calves

Three groups of four calves were experimentally infected with infectious larvae of Mecistocirrus digitatus. One group received a trickle infection of 5000 L3 per day for 8 days, the other two groups received a single infection of 5000 and 40,000 L3, respectively. All animals were necropsied 120 days after infection. Prepatent periods varied between 61 and 79 days, and maximal faecal egg output was reached between 80 and 100 days after infection. Repeated infections were not additive and worm counts at 120 days after infection varied between 100 and 440 in the first two groups and between 120 and 1700 in the last group. There was no significant difference in worm counts between the different infection regimes. However, there was a significant positive relationship between worm burden and faecal egg counts. In addition, there were significant negative relationships between worm burden and packed cell volume, and weight gain. The relative decreases in packed cell volume and weight gain emerged 70-80 days after infection. Serum pepsinogen levels were significantly elevated by the end of the trial, but the observed positive relationship between worm burden and pepsinogen was not significant. An enzyme immunoassay based on crude adult antigen was able to detect M. digitatus infection at 90 and 100 days after infection, but again there was no significant association between worm burden and antibody levels. Therefore, anaemia and a reduction in weight gain caused by the haematophagous activity of adult stages seem to be the most important pathogenic effects of M. digitatus infection in calves.

Evaluation of an enzyme-linked immunosorbent assay (ELISA) for the serological diagnosis of sarcoptic mange in swine

An enzyme-linked immunosorbent assay (ELISA) using an extract from Sarcoptes scabiei var. culpes as antigen was evaluated for its usefulness in monitoring antibodies to S. scabiei var. suis in naturally infected pigs. Five hundred and fifty-eight serum samples from certified Sarcoptes-free pigs (120 from weaned piglets, 218 from fatteners and 220 from adult sows) and 94 samples from certified Sarcoptes-infected pigs (35 from weaned piglets, 45 from fatteners and 14 from adult sows) were examined. The cut-off optical density (OD) values, considered to reflect the presence of antibodies to S. scabiei var. suis, were determined to be 0.059, 0.213 and 0.374 for weaners, fatteners and sows, respectively. The specificity of the ELISA was high (> or = 98%) for all age groups. Sensitivity was highest in the piglets (80%), followed by fatteners (78%) and sows (50%). These results indicate that an ELISA may be a simple and valuable alternative to monitor S. seabiei var. suis infections in naturally infected weaners and fatteners.

Isolation, characterization and immunolocalization of a globin-like antigen from Ostertagia ostertagi adults

Western blot analysis using an anti-globin rabbit serum Rb94 revealed a major band of 17 kDa in extracts of Ostertagia ostertagi adults and 4th-stage larvae. The adult stage globin-like antigen (OoAdGlb) was purified from total worm extracts by liquid chromatography. The protein has an estimated molecular mass of 36 kDa under non-reducing conditions, suggesting a dimeric structure containing 2 non-covalently linked 17 kDa monomers. Tryptic peptides were sequenced and showed strong similarities with the globins of free-living and parasitic nematodes. Immunolocalization revealed the presence of this globin-like antigen in the body wall musculature and/or the cuticle of O. ostertagi adults. An enzyme-linked immunosorbent assay based on the purified OoAdGlb showed no differences in response between calves infected by O. ostertagi and/or Cooperia oncophora and the negative controls.