Remote HF Monitoring: Implantable Devices Take Charge

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 - Heart Rate
Several implantable cardiac devices hold potential for treating heart failure patients. Newer remote monitoring systems also help to detect and proactively prevent events that could lead to worsening health. But to effectively take advantage of these capabilities, administrators need to ensure that physicians and nurses have the resources available and appropriate training for collecting, interpreting and acting on this information in a timely fashion.

Heart failure (HF) accounts for approximately one million hospitalizations every year and was linked to one in nine deaths in 2007 (Circulation 2011;123:e18-e209). Healthcare costs for elderly HF patients—the vast majority of all HF patients—totaled $30.2 billion in 2007, with much of that expense due to hospitalizations (Pharmacoeconomics 2008;26[6]:447-462). Remote monitoring offers an opportunity to identify complications early, before they balloon into more serious conditions that require hospitalization, potentially improving care and saving downstream costs.

While designed to provide a therapeutic benefit, devices such as implantable cardioverter-defibrillators (ICDs) and pacemakers now can do double-duty as remote monitors for tracking symptoms, says Gregg C. Fonarow, MD, director of the Ahmanson-University of California, Los Angeles (UCLA) Cardiomyopathy Center in Los Angeles.

"More and more, patients are able to transmit personal health data from home to the provider without having to come in for a visit specifically for interrogating the device," Fonarow says. "This remote monitoring capability, with data being transmitted in a secure fashion [over the internet], is reassuring for patients and can provide high-value and efficient management of these patients."

Pacemakers are designed to support the stability of heart rate, but also perform diagnostics to assess the integrity of the device, such as the pacing system or battery life. But today's models also can detect atrial arrhythmias and other clinical events as well as transmit those data to clinicians responsible for managing the patient. In a study comparing remote pacemaker interrogation with standard care using trans-telephonic monitoring and routine office visits, remote monitoring bested standard care by identifying 66 percent of clinically actionable events vs. 2 percent for standard care. Mean time to the first diagnosis was two months earlier in the remote group (J Am Coll Card 2009;54:2012-2029).

The CONNECT trial, which compared remote wireless monitoring and physician alerts with standard care using ICDs, found that clinicians in the remote group responded quicker to atrial tachycardia and atrial fibrillation events, at a median of three days vs. 24 days. Hospital stays, when required, were shorter in the remote patient group for a cost saving of $1,793 per hospitalization (J Am Coll Card 2011;57:1181-1189).

Workflow woes

Implementing a remote monitoring program that allows timely intervention is challenging, advocates admit. It requires staffing, training, communication and alert systems that provide pertinent data. Depending on the facility, some if not most of the burden falls on the nurses, who may not be experienced with the data side of pacemakers and ICDs.

"Most facilities underestimate the amount of time needed to become proficient," says Robin J. Trupp, PhD, RN, of the College of Nursing at Ohio State University in Columbus. "There is a huge learning curve associated with an implanted device, especially with differences from one manufacturer to another."

While the type of information may be similar in each device, the programming and interfaces may differ device to device, she says. Report generation may vary, and simply knowing where to look requires hands-on experience.

"Once the nurse gets over that hump, he or she can review data on many patients more quickly," Trupp says. "But we typically don't allow the time for that learning curve to take place."

The infrastructure for interrogating an ICD already is in place in many centers, says Fonarow, paving the way for the next step of acquiring and interpreting data about the status of the device as well as the patient. Patients are familiar with the transmission process and remote monitoring already is reimbursed, removing what could be significant obstacles to adoption. In the electrophysiology setting, physicians and other staff are used to collecting and interpreting the data.

But the next step—coordinating communications to ensure that cardiologists, primary care physicians, nurses and others involved in the patient's care get that information—is not consistently practiced as well as it might be. "We need to do a better job of having these departments work together," Trupp says. "It is no longer just the electrophysiologist looking at the device for critical functions and me looking at the patient with heart failure. We have to evaluate the continuum of care for that patient."

Fonarow agrees, calling it "a shared responsibility." He observes that the use of EHRs can facilitate information exchange, if the data interrogation device is interoperable with the EHR. But he adds nurses also play a key role in helping to ensure the communication processes function efficiently.

"At UCLA, our advanced nurse practitioners [APNs] are essential in helping as part of the care team, knowing that the device is interrogated or transmitted, tracking down that information and making sure it is available to clinicians," he says. If a patient is not feeling well, it is the APN who digs through information in the device transmissions for a possible explanation and guidance for the appropriate next step.

Nurses generally are enthused about opportunities to provide better patient care using pacemaker and ICD data as a resource, according to Trupp. But she cautions that these added tasks can become a source of frustration if nurses are rushed in the process. "They want to do it right, and they want the time to understand it," she argues. "But if that isn't given to them, then it quickly becomes just another thing they have to do."

Information overload also can undermine the effectiveness of remote monitoring, Fonarow says. Building a smart alert system that can discriminate information to determine what is critical, what is useful but not urgent and what is unimportant noise will help relieve the burden for overworked nurses and physicians. "This makes the care more efficient," he says. "With the same fixed amount of time, we are able to care for a greater proportion of patients at a higher quality."

Trupp sees the clinical information gained through remote monitoring as an opportunity to bring physicians and nurses together in a team with the common goal of optimizing care for their HF patient. "One person alone can't manage heart failure because it is so complex," she says. "A multidisciplinary approach works better. If we expand that concept out to a patient with heart failure who has an implanted device, then it will tell us what specialists we need on the heart team as well."