Costs Plunge, as Does Clinical Risk, in Remotely Monitored ICD, CRT Patients: Study

May 15, 2015

BOSTON, MA — Remote monitoring as a management strategy in patients with cardiac rhythm devices not only reduces the prevalence of hospitalizations, as has been previously demonstrated, it also substantially lowers their hospital payments, suggests an analysis of over 90,000 "real-world" patients with a variety of device types reported here at the Heart Rhythm Society (HRS) 2015 Scientific Sessions[1]. That points to a major opportunity for quality-of-care gains paired with lower costs in patients implanted with pacemakers, implantable cardioverter defibrillators (ICDs), and cardiac resynchronization therapy devices with (CRT-Ds) or without (CRT-Ps) defibrillators, given the deep shortfall in use of remote monitoring among US device patients, say researchers.

The study of US claims databases from 2008 to 2013 suggests that for every 100,000 patient-years of follow-up, the use of remote monitoring is associated with about 9800 fewer hospitalizations, a 119,000-day drop in hospitalization, and a $370,270,000 reduction in hospital payments, compared with a strategy of regular clinic visits without remote monitoring, reported Dr Jonathan P Piccini (Duke University Medical Center, Durham, NC).

The cost savings with remote monitoring apparently owed much to highly significant declines in rates of all-cause, heart-failure–related, and stroke-related hospitalizations, compared with standard follow-up without remote monitoring. For example, all-cause hospitalizations fell by 18% over a follow-up that averaged about 64 days. The significant reduction in all-cause hospitalization risk applied across all four device types individually and was particularly steep for patients with either ICDs or CRT-D implants, according to Piccini.

Prevalence of Remote Monitoring by Device Type

Device type n Remote monitoring, %
Pacemaker 54,520 29
ICD 27,816 49
CRT-D 9125 51
CRT-P 1105 27
CRT-D: cardiac resynchronization therapy with defibrillator
CRT-P: cardiac resynchronization therapy with pacing only
ICD: implantable cardioverter defibrillator

How often remote monitoring is used by device patients varies by study, Piccini told heartwire from Medscape; it was less than 50% of patients in the current US analysis, but in Europe it may be as high as 70%. The hope, he said, is that those numbers will climb now that just-released updated HRS guidelines that give a class Ia recommendation to remote monitoring of such devices, "combined with at least an annual [in-person evaluation] IPE over "a calendar-based schedule" of IPE[2].

The strategy "clearly is underutilized," noted Dr Michael R Gold (Medical University of South Carolina, Charleston). In its early days, he said for heartwire , it may not have been used as much as possible because physicians believed there were inadequate liability protections in place. But it hasn't helped that many remote monitoring systems have been incompatible with cellular phones.

"We're finding that more and more of our patients have cell phones only, so unless they have a landline, they can't use remote monitoring." That, Gold said, is "probably the single largest reason" utilization isn't what it could be. Third-party coverage has kept up with the times on this technology, so that doesn't seem to be a limiting factor, he said.

"In clinical practice, it's really helped us," he said. "For instance, we used to see our patients every 3 months to check out their devices. I see patients once a year now, unless there's some other clinical problem. But [if visits are only] for their device, we can reduce the number of visits to a hospital. It improves access to hospitals, and it improves patient compliance in most situations."

The current analysis included 92,566 patients with devices, of whom 34,259 were followed with both remote monitoring and scheduled clinic visits, and 58,307 had scheduled clinic visits only. They were followed for a primary end point of all-cause hospitalization that occurred later than 1 month after device implantation, plus secondary end points.

Piccini noted that patients with remote monitoring had significantly more heart failure and prior ventricular arrhythmias, and the group getting only in-person follow-up had significantly more prior atrial fibrillation and prior cerebrovascular disease.

Hazard Ratio (95% CI) for Hospitalization by Patient Type, Clinical Follow-up With vs Without Remote Monitoring, for All Devices

End points HR (95% CI) P
All-cause hospitalization (all devices) 0.82 (0.80–0.84) <0.001
HF hospitalization in patients with prior HF diagnosis 0.76 (0.71–0.81) <0.001
Stroke hospitalization in patients with known atrial fibrillation 0.78 (0.67–0.91) <0.001

Hospital costs overall for patients getting remote monitoring dropped significantly (P<0.001) compared with those getting clinic visits only: they were $8720 and $12,423 per patient-year, respectively. But the decreases were most pronounced in the two groups with defibrillating devices; costs for remote monitoring vs clinic visits only dropped by 31% for pacemakers, 43% for ICDs, 45% for CRT-D (P<0.001 for all three), and 35% for CRT-P (P=0.117).

Hazard Ratio (95% CI) for All-Cause Hospitalization, Clinical Follow-up With vs Without Remote Monitoring, By Device Type

Device type HR (95% CI) P
Pacemaker 0.83 (0.81–0.86) <0.001
ICD 0.74 (0.71–0.77) <0.001
CRT-D 0.72 (0.67–0.77) <0.001
CRT-P 0.84 (0.69–1.03) 0.089
CRT-D: cardiac resynchronization therapy with defibrillator
CRT-P: cardiac resynchronization therapy with pacing only
ICD: implantable cardioverter defibrillator

"These results are consistent with most other [studies] of remote monitoring," Dr John D Day (Intermountain Medical Center, Salt Lake City, UT), who wasn't involved in the study, told heartwire . "Every study shows if a patient uses remote monitoring, for whatever reason, they're going to live longer, they're going to do better, they're going to have less disease."

Day said that one way to explain how the studies all seem to show "dramatically improved survival" with remote monitoring is to look at what the strategy does for the patient both directly and indirectly. There are at least three such things, he said: "You're tethering the patient to the doctor, and that improves survival." Or the process may select out patients who are more motivated to adhere to therapy. Third, remote monitoring itself, with the at-home transmission equipment a continuing presence, may encourage favorable lifestyle adjustments that themselves help with outcomes.

But, he said, whichever mechanism is at work, "at the end of the day, maybe it doesn't matter."

Piccini said indirect effects may contribute to "some of the magnitude" of the strategy's benefits, but so do management adjustments based solely on changes picked up by the remote monitoring system. "I think the overall phenomenon is real," he said. "I think there's plenty of evidence here to motivate physicians, healthcare systems, and payers to reach out to the newly released HRS guidelines."

Piccini discloses receiving consulting fees or honoraria from Medtronic and research grants from Boston Scientific. Gold discloses receiving consulting fees or honoraria from Biotronik, St Jude Medical, Boston Scientific, and Medtronic. Day had no relevant financial relationships.

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