Remote monitoring of implantable cardioverter-defibrillators (ICDs) and pacemakers shows marked improvement in patient outcomes, if only
patients and providers would use it.
Remote monitoring has progressed from requiring patients to call a center every few months to report on their pacing devices to timely streaming on device and patient conditions. Pacemakers and ICDs provide remote monitoring capabilities as a standard feature yet few patients implanted with these devices are being monitored.
Reasons range from lack of a landline and mobile phone costs to delays in delivery and hassles with checkups. Physicians and hospitals may resist based on concern about the potential loss of a physician-patient relationship, insufficient infrastructure for monitoring or increased workflow and staffing.
For those enrolled patients, the convenience of no longer embarking on multiple visits to ensure the device is still functional provides an incentive, especially in areas where the distance between patient and provider is great (Circulation 2013;128:2372-2383). In the Pacific Northwest and large portions of the Midwest, there is increased remote monitoring, while in southern California, New York, Chicago and other densely populated areas, fewer people enroll in remote monitoring.
“We need to educate patients and providers that the use of this technology is no longer just a luxury or convenience,” says Joseph G. Akar, MD, PhD, of Yale-New Haven Hospital in Connecticut. “Now we have evidence that use of this technology improves outcomes.”
Akar and colleagues found that 62 percent of patients in the Boston Scientific ALTITUDE program and American College of Cardiology’s National Cardiovascular Data Registry ICD registry with recently implanted devices had been enrolled for remote monitoring, and of that 76 percent activated the remote monitoring capabilities (Circulation 2013;128:2372-2383). This means that only 47 percent of remote monitoring-capable ICDs were actively transmitting data.
They also studied trends in outcomes for monitored and unmonitored ICDs. In patients who used the remote monitoring capabilities of their devices, rehospitalizations were reduced by 20 percent and the rates of mortality were reduced by 33 percent. The finding were presented at the Heart Rhythm Society 2014 scientific session.
Patients and providers may resist monitoring due to cost concerns, which may be unfounded. The cost for remote monitoring data transmission largely is built into the initial price for the device, and in the U.S., remote monitoring-capable devices are covered by Medicare. With the exception of the approximately $15 a month charge for some brands of devices to allow transmission across cellular services, there are no costs to the consumer.
Suneet Mittal, MD, director of Valley Hospital’s Electrophysiology Laboratory in Ridgewood, N.J., says this is “as close as you can get to a free lunch.”
In findings presented to the 2014 Heart Rhythm Society, Mittal and his colleagues reported highest rates of survival among patients implanted with St. Jude Medical devices using frequent remote monitoring, nearly double those of patients who did not (hazard ratio [HR] 2.23). Frequent monitoring also showed a survival advantage over less frequent monitoring (HR 1.49). Survival rates for patients who used remote monitoring, but used it less often, still had better outcomes than patients who didn’t. Irrespective of device, use of remote monitoring had a 1.81 hazard ratio over lack of monitoring.
His findings on patient outcomes in pacemaker and defibrillator use complement those of Akar's team.
He sees a future in remote monitoring with linkage to EHRs. Working with device manufacturers, Mittal, other physicians and their societies are trying to ensure that data coming across use a singular language, as opposed to proprietary codes, with a minimum amount of information to make it the most useful to the EHR and interpretation by physicians. With the data linked to EHRs and workflows improved, fewer barriers would stand in the way of greater utilization of remote monitoring technology (Cardiol Clin 2014;32:239-252).
Remote monitoring also represents a change in the practice of medicine for some physicians. “It’s a major paradigm shift to think of a patient encounter not as a transactional exercise but a continuous responsibility,” Mittal says. “It’s going to take some time to develop the optimal work flows and retailer practices to maximize efficiency. But, all around the country you’re seeing telehealth and mobile health initiatives. Remote monitoring [of implantable cardiac devices] has long been on the forefront of that trend.”
Mittal and Akar recognize opportunities to improve remote monitoring. First and most important: Improve patient and provider education about the usefulness of remote monitoring. Remote monitoring can help physicians catch transient atrial fibrillation and ischemic attacks sooner and more frequently than periodic visits, they say. When heart problems are detected earlier, clinicians can intervene before they escalate. Ultimately, this affects rates of mortality and hospitalization.
Second, remote monitoring can reduce costs, whether by avoiding financial charges if a patient’s status deteriorates or through loss of income. Mittal also encourages manufacturers to provide the remote monitoring device to the physician, who can then pass it along to the patient immediately following implantation with the directive to get monitoring started prior to the first wound check.
“Our hope is that studies such as ours can help inform guidelines and would serve as a motivation for physicians to strongly consider using this technology in patients,” Akar says. “For the first time, now we’re beginning to have concrete clinical outcomes that are favorable for the use of this technology. There’s a strong incentive for patient care if physicians start embracing this technology in all patients who are eligible."
Mittal agrees, emphasizing the mortality benefit. “I’m excited about the strength of data behind remote monitoring and hope that there will be a quick uptake as we educate patients and physicians about the true value of such novel technology.”