ACCEL | All stakeholders see potential benefits in remote monitoring of cardiac devices. Yet, while home monitoring has been available as a commercial product in Europe for more than 12 years, its adoption has been very slow. Both abroad and here in the United States, physicians and hospitals are unsure about the financial impact of remote monitoring and, thus, hesitant to adopt remote monitoring.

In the case of implantable cardioverter-defibrillators (ICD), remote follow-up allows for fewer in-office visits as well as earlier detection of relevant changes. It doesn’t help that a formal cost analysis from the provider viewpoint has never been performed. (Most previous trials have analyzed the cost impact from the healthcare payer’s perspective.) The results of an analysis from the provider’s perspective might influence willingness to change care models and make the necessary financial and personnel investments.

Hein Heidbuchel, MD, PhD, of Heart Center Hasselt, Belgium, led a randomized, prospective, multicenter, health economics trial to determine the total follow-up-related cost for providers, comparing home monitoring-facilitated follow-up (HM ON) compared to regular in-office follow-up (HM OFF) during the first two years post-ICD implantation. The results of the European Health Economic Trial on Home Monitoring in ICD Therapy (EuroEco) were recently published.¹

EUROECO

There were 312 patients randomized from 17 centers in six European Union countries, of which 303 were eligible for data analysis. Time expended was tracked for all contacts: in-office, calendar- or alert-triggered web-based review, discussions, or calls.

Resource use in the HM ON group was clearly different (see TABLE), with significantly fewer follow-up visits despite a small increase of unscheduled visits, more non-office-based contacts, more Internet sessions, and more in-clinic discussions, but with numerically (but not significantly) fewer hospitalizations and shorter length of stay.

However, based on this first financial assessment of the impact of home-monitored follow-up, the cost to physicians, hospitals, and insurance providers was not significantly different from traditional in-office monitoring. But the European Health Economic Trial on Home Monitoring in ICD Therapy (EuroEco) identified wide European variations in the financial burden that physicians and hospitals face in switching to this approach, due to national differences in insurance reimbursement.

The findings suggest that reimbursement for home monitoring may be one of the key determinants of which countries move to adopt the practice. In Belgium, Spain, and the Netherlands, home monitoring providers brought in less profit because of a lack of reimbursement, while in Germany and the UK where such reimbursement exists, home monitoring was associated with maintained or increased profit. Nevertheless, total payer costs did not increase in any country.

Dr. Heidbuchel, the study’s principal investigator, said, “Since our study shows that total insurance costs do not increase, and home monitoring actually reduces hospitalizations and length of stay, as seen in prior trials, we hope our results will allow informed discussions between payers, providers, and manufacturers to come to balanced reimbursement scenarios in order to stimulate reorganization towards remote monitoring-based care.”

There was a modest saving in physician time (73 vs. 64 min over 2 years; p=0.028) despite the fact that total physician time was higher than in other trials. The authors said this may be due to a learning curve, where physicians tended to do more of the home monitoring work in the early phase of adoption, while relying more to trained nurses in a later phase.

CONTRARY TO EXPECTATIONS

In the editorial accompanying the publication of the study results,2 Thorsten Lewalter, MD, and Turgut Brodherr, MD, both from the Isar Heart Center, Munich, Germany, wrote, “The study by Heidbuchel and colleagues provides evidence and substantial data to show—possibly contrary to expectations—that investment in remote monitoring and the associated reorganization does not increase costs to healthcare providers. Together with the demonstrated benefits to patients, such as reductions in inadequate shock delivery or reduced rehospitalization, the EuroEco trial should help the motivated physician to encourage hospital administrations, healthcare providers, and contributors—as well as less-motivated colleagues—to use remote monitoring as a cost-neutral tool to deliver optimal care to their patients.”

When the EuroEco data were presented at ESC.14, the trial discussant was Carina Blomstrom-Lundqvist, MD, PhD, of Uppsala, Sweden. She noted one potential methodological weakness in EuroEco: use of home monitoring was not optimized. Had a more lenient use of home monitoring been adopted, including the elimination of learning curves and mandatory in-office follow-ups for the home monitoring, she said the difference between the two groups might have been greater, more strongly favoring remote monitoring.

An observation that likely influenced the outcome, she said, was that the studied population was quite healthy with only moderately reduced LVEF and therefore likely less prone to recurrent arrhythmias, which require less interactions and follow-up visits.

According to Dr. Blomstrom-Lundqvist, “The ‘take home messages’—and supported by other (trials)—is that by using optimized home monitoring management routinely, in-office follow-ups can be replaced by home-monitoring follow-ups, leading to a total follow-up reduction, without increasing costs or effecting the quality of medical treatment.”

References

1. Heidbuchel H, Hindricks G, Broadhurst P, et al. Eur Heart J. 2015;36:158-69.
2. Lewalter T, Brodherr T. Eur Heart J. 2015;36:143-4.

Keywords: ACC Publications, CardioSource WorldNews Interventions, Arrhythmias, Cardiac, Belgium, Cost of Illness, Costs and Cost Analysis, Defibrillators, Implantable, Europe, European Union, Health Personnel

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