JACC in a Flash | Remote monitoring may improve the outcomes of patients with implantable devices, according to two studies recently published in JACC.

In the first study, researchers analyzed data from nine randomized controlled trials to compare clinical outcomes in patients with implantable cardioverter-defibrillators (ICDs) who underwent remote monitoring to ICD patients who received conventional in-office follow-up. Specifically, they sought to evaluate the impact of remote monitoring on mortality, hospitalization, unscheduled clinic visits, device shocks, atrial arrhythmia detection, and the time taken to clinical decision or clinical event detection.

A total of 6,469 patients were included in the analysis, 3,496 of whom underwent remote monitoring and 2,973 who had in-office follow-ups. The data showed similar outcomes between the two groups for all-cause and cardiovascular mortality, as well as hospitalizations. However, remote monitoring patients who received a daily verification of transmission experienced reduced all-cause mortality. Additionally, while the odds of receiving an ICD shock were similar in both groups, the odds of receiving an inappropriate shock were reduced in remote monitoring patients.

While remote monitoring has been increasingly integrated into the care of ICD patients, as many as 50% of eligible patients in North America are not receiving it, even though the practice is reimbursed. The authors argue that possible reasons for low adoption rates may be a lack of familiarity with the technology, concerns about data management and legal liability, and cost.

The second study found that while remote monitoring is associated with improved survival rates, a lack of adherence may be influenced by geographic and socioeconomic factors.

The study evaluated 269,471 patients receiving new implants of pacemakers, implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) with pacing/defibrillation capability (CRT-P/CRT-D). Fifty-three percent of patients never used remote monitoring and 70.6% of those who did used it less than 50% of the time. Only 25.2% of remote monitoring capable patients utilized the technology at least 75% of the time, indicating that many recipients do not utilize the full capabilities of their devices.

In all implantable device groups, survival was greater in patients who used remote monitoring compared with those who did not. Those who spent more time in remote monitoring had lower mortality than those with less time. The researchers highlight the important finding that this association extended to patients with pacemakers. The patients at a lower risk for cardiac events than patients with other devices, but still benefited from remote monitoring. Finally, researchers examined ZIP code-associated data for patients and found geographic and socioeconomic factors to be a significant predictor of remote monitoring use.

“The current results illustrate the critical impact of adherence,” said the authors, led by Niraj Varma, MD, PhD, from Cleveland Clinic. “In order to benefit from remote monitoring, patients (and providers) must use it.” The researchers also state that a “healthy-user effect” may be the cause of the association, meaning that patients who use remote monitoring are less sick and more compliant, or they may have a physician who is more up-to-date with recommended treatment.

In an editorial accompanying both studies, James V. Freeman, MD, MPH, and Leslie Saxon, MD, said the findings showing “that remote monitoring utilization remains poor in clinical practice suggests that efforts to change treatment patterns through more aggressive use of guideline recommendations and continuing medical education should be undertaken at this point. Additionally, research must be conducted to better understand patient- and physician-level impediments to adopting remote monitoring and methods to address these barriers.”

“These studies show that remote monitoring can positively impact the care of patients with implantable devices,” added Jodie L. Hurwitz, MD, chair of the ACC’s Electrophysiology Section Leadership Council. “Remote monitoring can facilitate better patient care by replacing the need for in-office visits and, as these findings show, improve the outcomes of the patients as well. It is important to expand training and development of this technology in order for physicians and their staff to utilize it fully.”

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References

1. Parthiban N, Esterman A, Mahajan R, et al. J Am Coll Cardiol. 2015;doi:10.1016/j.jacc.2015.04.031.
2. Varma N, Piccini JP, Snell J, Fischer A, Dalal N, Mittal S. J Am Coll Cardiol. 2015;doi:10.1016/j.jacc.2015.04.033.

Keywords: CardioSource WorldNews, ACC Publications, Defibrillators, Implantable

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