Stefan Sack, chair and director, Department of Cardiology, Pneumology and Intensive Care Medicine, Academic General Hospital Munich, Germany, speaks to Cardiac Rhythm News about what current data for remote monitoring shows and what studies on remote monitoring are currently investigating.
On the whole, what do we know about remote monitoring of cardiac devices compared with standard in-hospital follow-up?
There is fundamental evidence that remote monitoring can reduce follow-up burden and costs and that it can improve patient outcomes. For example, the REFORM study (Hindricks G et al, Dtsch Ärztebl 2008: 105:156-9) and the TRUST study (Varma et al, Circulation 2010; 122:325-32) demonstrated a decline in patient adherence with standard in-hospital follow-up and a reduction in costs.
Both the ECOST and EVATEL studies, which were presented at the European Society of Cardiology 2011 annual meeting, showed that remote monitoring reduced the number of inappropriate shocks. What are the reasons behind this and what are the implications of this result?
In the ECOST trial, my understanding is that the early detection capabilities of remote monitoring (Biotronik Home Monitoring) allowed early identification of changes in the clinical condition such that an intervention, like a modification of medication, could occur before the patient’s condition worsens to the point that a shock occurs. The implications for this are increased battery longevity of the implant, which is an economic benefit because the patient gets more treatment days out of one device. Furthermore, there is an improvement of care due to reducing inappropriate and potentially painful shock delivery.
We are still waiting for data for the cost-effectiveness of remote monitoring. Do you think remote monitoring will be shown to be cost effective and how important is it to the future of remote monitoring that it is found to be cost-effective?
Convincing health economic data, although not necessarily cost-effectiveness data in a methodological sense, will remain crucial to allow payers to assess whether remote monitoring provides value for money compared with alternative investments. Economic data are available that show remote monitoring to have potential to be either cost neutral or cost-effective, depending on the healthcare system that uses it.
In addition, for hospitals, economic and quality of care considerations become more and more important as hospitals face an increasing demand for their services (due to an ageing population and an increasing adoption of device therapy), significant cost pressure (eg. in the form of fixed case payments in some diagnosis-related group systems), and quality demands from payers (eg. the “payment by results” initiative in the UK, although devices are not part of this initiative).
Randomised controlled trials and observational evidence have shown that by using remote monitoring, hospitals can tailor their service provision to patients that have an actual medical need for in-hospital follow-up visits. Considering that between 71% and 93% of all calendar-based in-hospital follow-up visits do not need further action, there is an enormous potential for streamlining hospital services and increasing efficiency at no compromise to patient safety.
On the whole, do you think that patients/doctors trust remote monitoring? (ie, if using remote monitoring, do they also use standard in-hospital follow-up just in case?) and how can doctors/patients be encouraged to trust remote monitoring?
Remote monitoring is a tool that can be seen as an extension in-patient care from the physician’s point of view. Outside of office hours, the patient is under surveillance. Clinical events are monitored at 24 hours a day, seven days a week; the doctor can be informed right away of an event or at scheduled intervals. The patient’s primary care physician must be sent the information provided by the device and this information must be analysed by the referring hospital or cardiologist. Scepticism about the benefits of remote monitoring is high but once the patient has seen the benefits of remote monitoring, I do not think they will miss an in-hospital follow-up.
Shaunmugam et al (Europace 2011; Epub) recently showed that device-detected atrial high-rate events were associated with an increased incidence of thromboembolic events. What are the implications of this?
Atrial fibrillation is silent and undetected in 30% of cases. Almost one third of episodes can be detected by a remote monitoring device. This has implications for using device therapy with anticoagulants and/or antiarrhythmic therapy.
Are there any data or any current studies that show whether the detection of atrial high-rate events with remote monitoring can reduce the risk of stroke or other adverse outcomes?
Currently there are a number of studies in the pipeline on this issue, such as EchoCRt and Home PAT.
There are reports given that detection of atrial fibrillation and subsequent therapeutic consequences might improve mortality and morbidity. The COMPAS study (European Heart Journal 2011 Epub) demonstrated that remote monitoring (Home Monitoring, Biotronik) allows earlier intervention for pacemaker patients and showed a 66% reduction in hospitalisation for atrial arrhythmia and related strokes. Another study, IMPACT, is comparing anticoagulation by atrial tachycardia episodes detected by remote monitoring with conventional physician-directed anticoagulation criteria. The composite endpoint is stroke, systemic embolism, and major bleeding.
What are the advantages of remote monitoring for the patient’s quality of life? Are there any disadvantages?
Based on the available evidence so far, the quality of life in patients who are monitored remotely is maintained. This has been confirmed in several studies, using different tools. The hypothesis that patients who receive remote monitoring would be concerned that they are not being properly cared for has not been realised.
By using remote monitoring technology, patients can be relieved from having to attend unnecessary in clinic visits and spared the burden of travelling. Unfortunately, quite often, such real benefits for patients are left out when payers make decisions about funding.
Do you think there will ever be a point where all cardiac devices are monitored remotely?
The adoption of remote monitoring technology of devices is hampered by the widespread lack of reimbursement for either the transmitter device or the remote physician service or for the ongoing data transmission costs, or all three of them.