Costs of remote monitoring versus ambulatory follow-up of implanted cardioverter defibrillators in the randomized ECOST study

Abstract

Background: The randomized ECOST study demonstrated the safety and effectiveness of long-term remote monitoring (RM) of implantable cardioverter defibrillators (ICD). Beside these obvious benefits, it was necessary to question the economic aspects of RM. We compared the long term costs of RM with those of ambulatory follow-up. Methods: ECOST randomly assigned 433 patients to RM (Biotronik Home Monitoring®) (active group) vs. ambulatory follow-ups (control group). Patients assigned to active group were seen once a year unless the RM system reported an ICD dysfunction or a clinical event mandating an ambulatory visit, while patients assigned to control group underwent ambulatory visits every 6 months. The economic analysis included 310 patients. The individual costs associated with each follow-up strategy were compared using the actual billing documents issued by the French national health insurance system, including 1) costs of cardiovascular hospitalizations and 2) non-hospital costs related to device management (ICD-related ambulatory visits and associated transports), cardiovascular procedures, drugs and other ambulatory visits. The ICD and RM system costs were evaluated based on the remaining longevity of the device at the end of study. Results: The characteristics of the study groups were similar. Over a follow-up of 27 months, the hospitalization costs per patient-year were not different (€2,829±6,382 in the active vs. €3,549±9,714 in the control group, p=0.46). The non-hospital costs were respectively €1,695±1,131 vs. €1,952±1,023 per patient-year, a €257 cost-saving in the active group (p=0.04), difference mainly due to the device management. Adding the ICD costs to non-hospital costs, the cost-saving in the active group was €494 per patient-year (p=0.005) or €315 if the Home Monitoring® system costs are included (p=0.05). Conclusion: RM generates, from the perspective of health insurance, savings on the budget post of care which includes ambulatory care and devices, without affecting the cost of hospital care. This analysis did not take into account the remuneration of physicians for the acts of telemedicine, which is not yet supported in France. After having proven its safety and its clinical efficacy, the remote monitoring of ICDs has proven its cost efficiency.