Chicago, IL—Remote disease management is effective and more efficient for patients, their caregivers, and for physicians. Although there are few data on its cost-effectiveness, the value for the patient and for guiding treatment is high, by reducing hospitalizations and improving management of arrhythmias. The value and benefits of remote disease management and its effect on improving clinical outcomes were the focus of a clinical session at the 2012 American College of Cardiology (ACC) meeting.
Remote Monitoring for Arrhythmias
Remote monitoring of arrhythmias is defined as daily and continuous surveillance through a device that allows assessment of arrhythmia burden, patient status, and device integrity. Remote follow-up refers to contact with a patient that replaces a clinic visit.
“Remote device monitoring can identify arrhythmia and atrial fibrillation earlier,” said George H. Crossley, III, MD, President of Mid-State Cardiology, St. Thomas Heart, Nashville, TN. A 45% reduction in office visits over a 15-month follow-up period was shown in the 2010 Lumos-T Safely Reduces Routine Office Device Follow-Up (TRUST) study of automatic remote monitoring of implantable cardioverterdefibrillators (ICDs). Dr Crossley said this shows a “huge amount of the efficiency value” of monitoring.
Event detection was faster in the TRUST study, “showing the effectiveness of monitoring,” Dr Crossley noted. Clinically relevant asymptomatic events were detected 41 days sooner with wireless remote monitoring compared with traditional in-office follow-up. All arrhythmia events were detected 35 days sooner. Adherence to the follow-up schedule was significantly improved with remote monitoring compared with traditional monitoring (94% vs 88%, respectively).
An informal study in Dr Crossley’s office showed that remote follow-up saves time and requires approximately 7 minutes, including the call to the patient, compared with approximately 20 minutes for an in-office visit. Remote follow-up can also be used for taking a patient’s history, which can contribute to shorter office visits, and for the nurse to report data to the patient.
The Clinical Evaluation of Remote Notification to Reduce Time to Clinical Decision (CONNECT) study showed a significant reduction in the time to create a treatment plan (approximately 4 days vs 22 days in the control group) after a clinically actionable event was identified in patients with an ICD (Crossley GH, et al. J Am Coll Cardiol. 2011;57:1181-1189).
Healthcare utilization was also reduced with remote monitoring in the CONNECT study, including hospitalization and emergency department visits. Length of hospitalization was significantly reduced in patients with an ICD and with a cardiac resynchronization therapy defibrillator; the costsavings in the remote monitoring arm was $1793 per patient.
In patients with a pacemaker, the 2009 PREFER study showed that remote pacemaker follow-up was more effective in identifying clinically actionable events over 12 months than transtelephonic monitoring (TTM). In the CareLink arm, 45% of patients had an event, of which 66% were detected remotely. In the TTM arm, 38% had an event, of which only 2% was detected via TTM. TTM requires the patient to manually send the data via the telephone, whereas remote monitoring using the CareLink device automatically sent the data.
Remote Monitoring of Atrial Fibrillation
More devices are capable of storing electrograms and event counter diagnostics, which can be retrieved remotely through a modem connected to the internet. These diagnostics are reviewed by a remote monitoring center and can be directly retrieved by the physician’s office. The availability of newer devices with this capability makes it more feasible to conduct prospective studies to evaluate their benefits and costs in patients with atrial fibrillation, said Paul A. Levine, MD, Professor of Medicine, Loma Linda University School of Medicine, University of California, Los Angeles.
“A wealth of information is obtained from continuous rhythm monitoring,” said Dr Levine. This includes details about the onset of sustained arrhythmias, arrhythmia burden, correlation of symptoms with arrhythmias, improved understanding of the rhythms, and timely intervention and the response to the intervention.
Yet, there are a number of limitations and cautions that clinicians must consider, Dr Levine pointed out. As the devices and their uses mature, many of these will be addressed. The large volume of data obtained requires sorting out what is a clinically actionable event in a timely fashion.
There is marked variation in the recordings, and the clinician must determine when intervention is warranted. Device diagnostics presume that the diagnosis is correct, but independent validation is needed. For example, was a recorded episode truly brief, or was it a result of signal dropout during transmission? What is the role of the cumulative burden or the duration of individual episodes recorded in evaluating the data and determining treatment? In terms of physicians using the data accumulated from remote device monitoring, how does it impact the work flow in the office or clinic? Is there a legal liability if the physician doesn’t use the data?
There are currently no data regarding the impact of continuous monitoring and early notification on long-term outcomes.
What Is the Cost-Benefit Ratio and for Whom?
“There is a paucity of cost data,” said Mark H. Schoenfeld, MD, Clinical Professor of Medicine, Yale University School of Medicine, and Director of the Cardiac Electrophysiology and Pacemaker Laboratory, Hospital of Saint Raphael, New Haven, CT.
Although remote monitoring has been reimbursed in the United States since 2006, this was done without demonstrating a cost-savings, and most studies so far relate to transportation costs. For example, one study showed patients saved approximately $1377 to $4113 over 5 years through avoiding transportation costs for office visits.
An informal analysis by Dr Schoenfeld found a $100 annual cost-savings per patient by using remote monitoring to reduce the annual clinic visits from 2 to 1. The calculation did not include other costs, such as transportation or cost to payers, and it was limited to Medicare data for Connecticut.
For monitoring of a dual-chamber pacemaker with device interrogations every 3 months with 1 annual clinic visit, the cost was $354.11 using TTM and $378.80 with remote monitoring in that analysis. This cost was increased to $486.28 for device interrogations every 6 months and 2 annual clinic visits. For remote monitoring of a dual-chamber ICD with device interrogations every 3 months plus 1 annual office visit, the cost was $504.85. The cost was $606.62 for device interrogations every 6 months plus 2 annual office visits.
Yet, the cost-benefit ratio depends on the perspective, said Dr Schoenfeld. This differs for the individual patient, the provider, society and taxpayers, payers, the government, and industry. For each of these parties, the cost and benefit regarding access to care, quality, efficiency, costs, and financial incentives differ.
For the clinician, remote monitoring provides more patient data and can help to provide better care, with faster follow-up and without any increased costs. For the hospital, there are more networked data, perhaps some influence on a better reputation, greater efficiency, and savings from shorter hospital stays that can offset the costs of transmitters, data analysis, and patient education. For the government and insurers, this approach provides more healthcare data, which can contribute to better care, increased efficiency, and cost control.
Whether the cost-benefit ratio is viewed from the perspective of the patient or of another party is an ongoing issue, said Dr Schoenfeld. Also, office visits are not eliminated completely, because devices cannot be reprogrammed remotely, and some patients prefer to see the doctor and opt out of remote monitoring. Remote device monitoring via mobile phones is more challenging, and many patients no longer have landline phones. Advances in technology and economic changes may limit the ability to make satisfactory financial projections, Dr Schoenfeld said.