Adherence to Remote Monitoring and Survival | Journal Scan

Study Questions:

Is there a relationship between the level of adherence to automatic wireless remote monitoring (RM) and survival in patients with implantable pacemakers and defibrillators?

Methods:

This was a retrospective, national, observational study of consecutive patients receiving new implants of pacemakers, implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy devices (CRTs) between 2008 and 2011. All of the devices had wireless RM capability. The authors analyzed weekly utilization and all-cause survival for each device type by percentage exposure to remote monitoring (percentage of time in remote monitoring [%TRM]) stratified by age. Eight US Census variables were used to assess socioeconomic influences on %TRM.

Results:

The cohort was comprised of 269,471 patients with the following types of devices: 115,076 pacemakers, 85,014 ICDs, 61,475 CRT-Ds, and 7,906 CRT-Ps. When considered together, 47% patients used RM (RM Any). Among RM users, 67,920 (53%) patients had ≥75%TRM (High%TRM) and 59,786 (47%) <75%TRM (Low%TRM). RM utilization was not affected by age or sex, but demonstrated wide geographic and socioeconomic variability. Survival was better in High%TRM versus RM None (hazard ratio [HR], 2.10; p < 0.001), in High%TRM versus Low%TRM (HR, 1.32; p < 0.001), and also in Low%TRM versus RM None (HR, 1.58; p < 0.001). The same relationship was observed when assessed by individual device type.

Conclusions:

RM is associated with improved survival, irrespective of device type (even inpatients with pacemakers). There is a positive graded relationship with the level of adherence and survival.

Perspective:

Remote home monitoring has evolved over the course of several decades, from a simple transtelephonic monitoring using a magnet rate to predict battery depletion, to daily wireless transmission of comprehensive device data, which does not require active patient involvement (the transceiver is in the bedroom and it automatically transmits data to the server when alerts are triggered). RM captured interest in the early and mid 2000s following the publication of primary prevention studies expanding the indications for ICD therapy and amid a series of Food and Drug Administration advisories, all of which were expected to overwhelm device clinic capacity. Given that about 90% of in-person device clinic appointments are not actionable encounters (i.e., there is no need to reprogram the device in response to the observed interrogation data), RM has become an efficient way to monitor a large number of patients with devices. The RM system in the present study is an older version, which relied on weekly patient activation. While causal relationship between frequent monitoring and survival cannot be inferred from the current observational study, the findings are consistent with other studies in this field, with some notable exceptions of small randomized studies, which may have been underpowered to demonstrate survival benefit. The most notable finding, however, is the fact that even patients with pacemakers, who are at a lower risk of adverse events than ICD or CRT-D patients, still appear to derive survival benefit from the monitoring. It is possible that early identification of device malfunction, the onset of asymptomatic atrial fibrillation, and new or increasing burden of ventricular arrhythmias may be responsible for this benefit. Due to relatively favorable reimbursement rates for RM, there is a growing cohort of device patients followed by general cardiologists rather than electrophysiologists, regardless of who has implanted the device. It would be interesting to explore whether there is a relationship between the primary specialty of the physician responsible for RM, adherence to RM, and patient survival.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Cardiac Resynchronization Therapy Devices, Censuses, Cost of Illness, Defibrillators, Implantable, Heart Conduction System, Heart Failure, Inpatients, Magnets, Monitoring, Physiologic, Pacemaker, Artificial, Patient Participation, Primary Prevention, Retrospective Studies, Survival


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