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CardioSource WorldNews Interventions | Remote Monitoring: Getting It Here

The evolution of cardiac implantable electronic devices (CIEDs) has been rapid over the past few decades in a variety of ways. Indications for use have expanded, access has increased, technologies have improved, and the ability to monitor CIED patients remotely has grown. In the early days of remote monitoring, portions of a traditional device interrogation visit, such as remaining battery life, could be accomplished through transtelephonic monitoring (TTM). Since then, technical capabilities have evolved to allow for true remote monitoring in some cases, a paradigm that allows for 24/7 automatic monitoring.

Each major device manufacturer has its own remote monitoring system, and while these systems are all FDA cleared for remote monitoring and are evolving to become more similar, there are important differences that may make one a better fit for a particular patient. Therefore, thoughtful hardware selection at the time of implant includes consideration of the associated remote monitoring systems.

As the new era of remote monitoring has commenced, data demonstrating its many benefits has accumulated.1 It is no coincidence that this data accumulation has occurred in parallel with the era of “Big Data;” widespread remote monitoring results in an amassing of data by device manufacturers. The “Big Data” revolution has resulted in advances in computing power and statistical techniques that have made these massive data sources incredibly revealing. Indeed, some of the most compelling evidence for the clinical benefits of remote monitoring—including mortality—originate from these enormous data sets.2

Evidence of advantages of remote monitoring over the traditional model of device management continues to mount, including patient satisfaction and quality of life, healthcare utilization, disease management for heart failure and atrial fibrillation, reductions in inappropriate shocks from implantable defibrillators, cost effectiveness, and the special role of remote monitoring in the case of at-risk devices under advisory or recall. It is no wonder, then, that the Heart Rhythm Society has unequivocally recommended that all patients with a CIED be offered remote monitoring in a set of 2015 guidelines.3

Unlike most other interventions in medicine, remote monitoring of CIEDs requires a paradigm shift in the way health care is delivered. There is precedent for this “remote” model (e.g., heart failure management), but the growing pains for such a shift persist, and this is reflected in the suboptimal uptake of remote monitoring: less than half of eligible patients are enrolled, and only a subset of enrolled patients actually participate fully.2,4 This is particularly disappointing since it appears that earlier and more frequent remote monitoring is better than later and less frequent.2,5 No single group is to blame for the relatively poor uptake of remote monitoring. Barriers, both real and perceived, exist for all stakeholders. Some physicians fear the medicolegal consequences of transitioning to remote monitoring. Moreover, they may have insufficient support from office or health system personnel (vis-à-vis reimbursement, for example) to sustain a robust remote monitoring program. Health care systems and reimbursement structures are, at best, inconsistent with their support and facilitation of true remote monitoring systems; security issues—whether real or imagined—may prevent the full commitment of some physicians and health care systems.

Patients may be reluctant to give up face-to-face interaction with their physicians, they may be uncomfortable with the technical expertise required to set up and maintain a remote monitoring connection, or they may not have access to the necessary telecommunications infrastructure to facilitate such a connection. For example, while this is changing, voice over internet protocols (VoIP) and cable connections in place of traditional analog phone lines are incompatible with some remote monitoring systems. In light of the critical role that patients play in the success of a remote monitoring program, patient engagement is paramount and may be helped by interventions borrowed from colleagues with expertise in interventions to change health behaviors. For example, there may be benefit in the use of patient contracts to improve patient compliance with a remote monitoring program.

There is good news, though. The direct-to-consumer market for medical devices is booming, which may increase patients’ appetite for and tolerance of remote interaction with doctors. If, in parallel, barriers related to patient privacy and safety can be overcome, we may be able to more fully engage our patients in their healthcare through sharing of CIED data. Moreover, it may be possible to someday use remote monitoring platforms to facilitate a randomized controlled trial that tests truly disruptive interventions like remote programming.

Thus, while the realities of remote monitoring have not caught up to its promise, one need only follow the data to get there from here.

References:

  1. Zeitler EP, Piccini JP. Trends Cardiovasc Med. 2016;26(6):568-77.
  2. Varma N, Piccini JP, Snell J, Fischer A, Dalal N, Mittal S.
  3. J Am Coll Cardiol. 2015;65(24):2601-10.
  4. Slotwiner D, Varma N, Akar JG, Annas G, Beardsall M, Fogel RI, et al. Heart Rhythm. 2015;12(7):e69-100.
  5. Piccini JP, Mittal S, Snell J, Prillinger JB, Dalal N, Varma N. Heart Rhythm. 2016.
  6. Mittal S, Piccini JP, Snell J, Prillinger JB, Dalal N, Varma N. J Interv Card Electrophysiol. 2016;46(2):129-36.

Emily P. Zeitler, MD, MHS, is a Clinical Cardiac Electrophysiology Fellow at Duke University Hospital.

Read the full September/October issue of CardioSource WorldNews Interventions at ACC.org/CSWNI

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