CHICAGO—Calculating the cost-benefit ratio of remote monitoring patients who have implantable cardioverter-defibrillators (ICDs) depends on many variables, and the answer hinges on who pays and who benefits, said Mark H. Schoenfeld, MD, of Yale University School of Medicine in New Haven, Conn., in a March 24 presentation at the 61st annual American College of Cardiology (ACC) scientific session.
“When you talk about cost-benefit, you have to ask to whom is the cost and to whom is the benefit, and you have to acknowledge there are many individual players,” said Schoenfeld, who has served on guideline committees and expert consensus panels looking at cardiac device monitoring. “There is the individual patient, the healthcare provider, society, taxpayers, third-party payors, government and, of course, industry.”
Schoenfeld emphasized that remote follow-up was distinct from remote monitoring, with follow-up replacing periodic in-person device checks and monitoring providing daily surveillance to assess device integrity, functionality and other factors.
Benefits optimize healthcare and may lead to lower costs, he explained. He added that much of the cost-benefit literature derives from Europe with analyses of transportation costs.
Monitoring offers many benefits, though, including the ability to monitor device integrity, arrhythmia progression and patterns of arrhythmia onset. “Just because we can identify that there is a problem with system integrity, even with diagnostics that are capable of remote monitoring, it doesn’t really tell you what the associated problem is,” he pointed out.
But monitoring provides clear potential benefits to patients, he said. For example, monitoring helped identify a patient with ventricular tachycardia who was not aware he was being shocked, as well as tracked episodes of atrial fibrillation in a “holiday heart” patient who was prone to alcoholic binges. “We can learn a lot about our patients if we take the time and have the time,” Schoenfeld said.
Gauging benefits against costs is a function of the players, he reiterated. For patients, the cost-benefit ratio may include better access to care, better quality of life and less travel time, which may be viewed as more efficiency and lower personal costs. For doctors, nurses and other caregivers, the formula may include better quality of care, an option to increase follow-ups, fewer no-show office visits and perhaps less administrative work.
Hospitals, on the other hand, may pick up the cost of transmitters and patient education but potentially benefit from reputational gains and shorter hospital stays. He noted that there is a learning curve for staff as well as they master the monitoring process.
Industry benefits from centralized data may lead to better quality control, he pointed out, but there may be costs in providing products and database services. Payors get data and better and more efficient managed healthcare.
Schoenfeld reviewed literature that assessed costs and benefits, noting that there was a paucity of data. The CONNECT trial, which compared ICD remote wireless monitoring and physician alerts with standard care, found that physicians in the remote group responded quicker to atrial tachycardia and atrial fibrillation events, at a median of three days vs. 24 days. Hospital stays were shorter in the remote patient group for a cost saving of $1,793 per hospitalization (J Am Coll Card 2011;57:1181-1189).
“Is it because the remote monitoring afforded faster clinical decision making?” Schoenfeld asked. “It is hard to know. The important thing was a cost savings of $1,793 in the remote arm. “
His own calculations suggested that remote monitoring could save about $100 per patient per year. But he added, “Monitoring does not equal follow-up. We can’t, for example, reprogram remotely.” And he argued there still was an important role for inpatient visits to assess symptoms and interrogate the device.
“The irony is that reimbursement for remote monitoring was allowed in the U.S. in 2006, even though there was no demonstration of cost savings,” he concluded. “We don’t know how this cost effectiveness will work out.”
Panelist Niraj Varma, MD, PhD, of the cardiovascular medicine department at the Cleveland Clinic, followed up with a comment that many countries do not reimburse the costs of remote monitoring of ICD patients. “That lack of reimbursement is a disincentive,” he said.
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