Conference Coverage
BOSTON – Remote monitoring of implanted cardiac devices, already known to save lives, also reduced all-cause hospitalizations and cut hospitalization costs substantially in a review of more than 92,000 U.S. patients followed for 5 years.
The analysis showed that for every 100,000 patient-years of remote monitoring of implanted pacemakers, implantable cardioverter defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices, there were 9,810 fewer all-cause hospitalizations, 119,000 fewer days spent hospitalized, and a savings of more than $370 million, compared with similar patients who did not undergo remote monitoring, Dr. Jonathan P. Piccini, Sr. said at the annual scientific sessions of the Heart Rhythm Society.
While these results are perhaps the first to document the impact of remote monitoring of implanted cardiac devices on health care use and cost, several previously reported study findings showed the positive impact of remote monitoring on clinical outcomes. For example, the IN-TIME (Influence of Home Monitoring on the Clinical Status of Heart Failure Patients With an Impaired Left Ventricular Function) trial randomized 664 patients with either ICDs or CRT devices to remote monitoring plus clinic visits or to monitoring by clinic visits only. After 1 year, patients on remote monitoring had a statistically significant 37% reduction in bad clinical outcomes, compared with the control patients (Lancet 2014;384:583-90). And findings from an observational study recently published by Dr. Piccini and his associates that involved 269,471 Americans with cardiac devices showed that 47% used remote monitoring, and the survival rate among users ran double that of patients with devices who did not undergo remote monitoring (J. Am. Coll. Cardiol. 2015 [doi:10.1016/j.jacc.2015.04.033]).
Despite this evidence for a substantial clinical benefit, remote monitoring has not become routine for U.S. patients with a pacemaker, ICD, or CRT device. During the period April 2008–March 2013 studied by Dr. Piccini and his associates using a health insurance claims database representative of the U.S. adult population, of 92,566 patients with an implanted device, 34,259 (37%) underwent remote monitoring.
“Remote monitoring has been underutilized,” commented Dr. Michael R. Gold, chief of cardiology and medical director of the Heart and Vascular Center at the Medical University of South Carolina in Charleston. One reason that patients don’t undergo remote monitoring today is that many remote monitoring systems require a land line telephone for data collection and transmittal, while many patients now just have a mobile phone, Dr. Gold said. Mobile phone adapters are available but the patient must buy one.
Remote monitoring can dramatically reduce the need for office visits by patients, Dr. Gold said. “Without remote monitoring we see patients with devices every 3 months; with remote monitoring I usually see then once a year,” he said.
Remote monitoring may now start increasing, driven by the compelling evidence of efficacy and cost saving and also by the statement released in mid-May by the an expert consensus panel of the Heart Rhythm Society that remote monitoring ”represents the new standard of care” for patients with cardiovascular implantable electronic devices (Heart Rhythm 2015 [doi.10.1016/j.hrthm.2015.05.008]).
To run their hospitalization analysis, Dr. Piccini and his associates retrospectively reviewed data from 92,566 U.S. patients with an implanted pacemaker, ICD, or CRT device during April 2008–March 2013 collected in the MarketScan database, which includes patients covered by private insurance or Medicare. During the period studied 58,307 (63%) patients were followed by clinic visits only while the others received both clinic visits and remote monitoring.
Most of the patients, 59%, carried a pacemaker, and 29% of the patients in this device subgroup had remote monitoring. In contrast, about half of the other patients had remote monitoring, both the 30% of patients who had an ICD, as well as the 11% with a CRT device.
The rate of all-cause hospitalization during follow-up, the analysis’s primary outcome, was 18% lower in the remote-monitoring patients, a statistically significant difference. In addition, when hospitalized the average hospital length of stay ran a third lower in the remotely monitored patients, a reduction of nearly 3 days in the hospital for each hospitalized patient and a cost savings of about 30% or $3,703 per hospitalized patient. Device type did not seem to matter, Dr. Piccini reported.
The analysis dug further to focus on rates for two common causes of hospitalization in device patients, and found a statistically significant 24% reduction in hospitalization for heart failure, and a significant 22% drop in the rate of stroke hospitalization. Remote monitoring can reduce heart failure hospitalizations in many ways, by keeping tabs on heart rate, arrhythmias, overall activity level, and chest-cavity fluid level measured by changes in myocardial impedance.