Remote Monitoring Group Research Articles

Initial experience with a virtual atrial fibrillation clinic after pulmonary vein isolation

Abstract Introduction To detect recurrent atrial fibrillation (AF), a variety of methods are used, ranging from incidental electrocardiogram to rhythm monitoring with implantable loop recorders (ILRs). In clinical practice, routine use of ILRs is not feasible due to cost. Repeated (week)-Holters cause a considerable burden, both on patients and hospitals, and moreover are inadequate for detecting recurrent AF. Purpose To investigate whether remote monitoring (RM) is feasible in patients with AF after pulmonary vein isolation. Methods We set up a virtual AF clinic. Patients were equipped with a photopletysmography (PPG) application and asked to perform a recording when symptomatic. Recordings uploaded to the Hospital Electronic Patient Dossier and monitored by dedicated eNurses. The number of hospital contacts, hospital visits, electrocardiograms and Holter recordings were noted. Patient satisfaction and quality of life was measured by (validated) questionnaires. Comparisons were made with a historic control group from Jan-March 2019 with a traditional follow up of outpatient visits, electrocardiograms and Holters. Results 157 patients were studied, 78 in the RM group and 79 in the control group. Mean age was 63 ± 10 years, 64% male. AF was paroxysmal in 68% of patients. Follow-up was 1 year and completed in all patients. In the RM group, patients performed 16±29 recordings/year. AF was detected in 37 (47%) patients on RM. While more planned remote contacts were performed in the RM group, significantly less planned and unplanned outpatient clinic visits, AF-related hospital admissions, and Holters took place. Patients report a high satisfaction with this form of remote monitoring. Conclusions A virtual AF clinic is feasible. When asked to record when symptomatic, patients perform few measurements. Compared to patients with a traditional follow-up, patients on PPG-based RM need fewer hospital visits and admissions, and undergo fewer Holters. Patient satisfaction with RM is high.

Enhancing heart failure management: a comprehensive analysis of continuous remote monitoring vs. standard care in patients with cardiac implantable electronic devices

Abstract Background Utilizing remote monitoring (RM) in patients with heart failure (HF) who have cardiac implantable electronic devices (CIED) proves to be a dependable method for closely adhering to device-specific and heart failure-related parameters. While there is some favorable outcome data, the results remain incomplete. Aims We aimed to evaluate the advantages of continuous RM compared to the standard of care (SoC) in reducing all-cause mortality, cardiovascular-related death (CV), sudden cardiac death, and ICD shocks. Methods A systematic review and meta-analysis of randomized controlled trials (RCT) testing RM vs. SoC for the management of HF patients were performed. Endpoints were all-cause mortality, CV mortality, sudden cardiac death, ICD shocks. Odds ratios (ORs), Hazard ratios (HRs) and 95% confidence intervals (CI) were calculated. CENTRAL, EMBASE and MEDLINE were searched up, and only randomized controlled studies were included. Results Sixteen RCTs that enrolled a total of 11,140 patients were identified to evaluate all-cause mortality, resulting in an HR 0.83 (95% CI 0.72 to 0.96). When CV mortality was assessed, there was a significant difference between the RM group and SoC group, and the HR was 0.81 (95% CI 0.67 to 0.97) Moreover RM did not have an effect on the rate of sudden cardiac death and ICD shocks. Conclusions RM proved to be superior in reducing all-cause mortality and CV mortality compared to SoC despite of the heterogeneous study cohorts and unstandardized alert actions. However, the use of RM did not influence the occurrence of sudden cardiac death and ICD shocks.

The incidence of atrial fibrillation, new oral anticoagulation, stroke, and significant bleeds in patients receiving a new dual-chamber pacemaker

Background and objectivesAtrial fibrillation and flutter (AF/AFL) can be easily detected in patients who have a dual-chamber pacemaker (PM). This can result in a high detection rate of these arrhythmias especially if patients are monitored remotely and detection limits are sensitive. Materials and methodsA single-center retrospective registry analysis of 1,285 consecutive AF/AFL and anticoagulation naïve patients from a limited geographical area undergoing implantation of a new dual-chamber PM (between 2013 and 2019). Seven-year follow-up data for incident AF/AFL, initiation of new oral anticoagulation and for incident strokes and bleeds was obtained from an in-depth review of all relevant patient records including written medical records and death certificates detailing causes of death. ResultsDuring the follow-up, mortality reached 22.2 % and cumulative incidence of AF/AFL, new anticoagulation, strokes, and bleeds were 52.6 %, 40.4 %, 4.7 % and 10.4 %. In 92.6 % of the cases, AF/AFL was discovered by PM. Remote monitoring was initiated in 67 % (n = 856). Risk factor adjusted mortality in this group was significantly lower when compared to patients in regular out-patient clinic controls (HR 0.45, 95 % CI 0.35–0.57). Despite of their better overall prognosis, the AF/AFL was discovered, and oral anticoagulation was initiated more often in remote monitoring group (HR 1.58, 95 % CI 1.23–1.79 for AF/AFL and HR 1.67, 95 % CI 1.33–2.09 for anticoagulation). There was no significant difference in the incidence of strokes or bleeds. ConclusionsThe incidence of new AF/AFL is high in this population. Remote monitoring is associated with higher diagnostic yields of AF/AFL and initiated anticoagulation, but not with stroke and significant bleeds.

Long-term remote monitoring vs. in-office monitoring of pacemakers: a systematic review and meta-analysis

Abstract Background Remote monitoring (RM) is increasingly recognised as the standard of care for patients with cardiac implantable electronic devices (CIEDs) according to current practice guidelines, particularly in pacemaker usage which represents the majority of CIEDs. However, there is insufficient evidence to assess the long-term safety of RM compared to in-office (IO) monitoring of pacemakers over extended periods, as well as its effectiveness in reducing in-office visits for device reprogramming. Purpose We aimed to perform a meta-analysis to compare RM and IO monitoring of pacemakers with at least 12 months of follow-up. Methods We systematically systematic search EMBASE, PubMed/MEDLINE, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing remote monitoring (RM) and in-office (IO) monitoring of pacemakers, with a focus on outcomes related to (1) all-cause mortality, (2) stroke, and (3) hospitalizations due to cardiovascular and device-related adverse events. Heterogeneity was assessed using I² statistics, and outcomes with high heterogeneity were analysed using a random-effects model. Results Six RCTs with a total of 3,059 patients were included in the meta-analysis. Of these, 1,495 patients (48.87%) underwent RM. In-office number of follow-ups per year was not significantly different between groups (OR -0.71; 95% CI -1.45 - 0.03; p = 0.06; I² = 99%; Fig. 1a) but tended to favour the RM group. No significant differences were found between RM and IO monitoring in terms of all-cause mortality (OR 1.14; 95% CI 0.83 - 1.55; p = 0.42; I² = 0%; Fig. 1b), stroke (OR 0.82; 95% CI 0.37 - 2.19; p = 0.82; I² = 38%; Fig. 2a), or hospitalizations for cardiovascular or device-related adverse events (OR 0.96; 95% CI 0.72 - 1.28; p = 0.78; I² = 0%. Fig. 2b). Conclusion This is the first meta-analysis comparing RM and IO monitoring for long-term pacemaker usage. Our results suggest that the number of follow-ups tended to be fewer in the RM group, and both monitoring methods appear to be similar in terms of all-cause death, stroke, and hospitalizations for cardiovascular or device-related adverse events.

A Case Report on the Effectiveness of Virtual Monitoring of Postdischarge COVID-19 Positive Patients in a Rural Hospital Setting: A Retrospective Review.

Objective: The pandemic has pushed hospital system to re-evaluate the ways they provide care. West Tennessee Healthcare (WTH) developed a remote patient monitoring (RPM) program to monitor positive COVID-19 patients after being discharged from the hospital for any worsening symptomatology and preemptively mitigate the potential of readmission. Methods: We sought to compare the readmission rates of individuals placed on our remote monitoring protocol with individuals not included in the program. We selected remotely monitored individuals discharged from WTH from October 2020 to December 2020 and compared these data points with a control group. Results: We analyzed 1,351 patients with 241 patients receiving no RPM intervention, 969 patients receiving standard monitoring, and 141 patients enrolled in our 24-h remote monitoring. Our lowest all cause readmission rate was 4.96% (p = 0.37) in our 24-h remote monitoring group. We also collected 641 surveys from the monitored patients with two statistically significant answers. Discussion: The low readmission rate noted in our 24-h remotely monitored cohort signifies a potential opportunity that a program of this nature can create for a health care system struggling during a resource-limited time to continue to provide quality care. Conclusion: The program allowed the allocation of hospital resources for individuals with more acute states and monitored less critical patients without using personal protective equipment. The novel program was able to offer an avenue to improve resource utilization and provide care for a health system in a rural area. Further investigation is needed; however, significant opportunities can be seen with data obtained during the study.

Smartphone-Based Remote Monitoring in Heart Failure With Reduced Ejection Fraction: Retrospective Cohort Study of Secondary Care Use and Costs.

Despite effective therapies, the economic burden of heart failure with reduced ejection fraction (HFrEF) is driven by frequent hospitalizations. Treatment optimization and admission avoidance rely on frequent symptom reviews and monitoring of vital signs. Remote monitoring (RM) aims to prevent admissions by facilitating early intervention, but the impact of noninvasive, smartphone-based RM of vital signs on secondary health care use and costs in the months after a new diagnosis of HFrEF is unknown. The purpose of this study is to conduct a secondary care health use and health-economic evaluation for patients with HFrEF using smartphone-based noninvasive RM and compare it with matched controls receiving usual care without RM. We conducted a retrospective study of 2 cohorts of newly diagnosed HFrEF patients, matched 1:1 for demographics, socioeconomic status, comorbidities, and HFrEF severity. They are (1) the RM group, with patients using the RM platform for >3 months and (2) the control group, with patients referred before RM was available who received usual heart failure care without RM. Emergency department (ED) attendance, hospital admissions, outpatient use, and the associated costs of this secondary care activity were extracted from the Discover data set for a 3-month period after diagnosis. Platform costs were added for the RM group. Secondary health care use and costs were analyzed using Kaplan-Meier event analysis and Cox proportional hazards modeling. A total of 146 patients (mean age 63 years; 42/146, 29% female) were included (73 in each group). The groups were well-matched for all baseline characteristics except hypertension (P=.03). RM was associated with a lower hazard of ED attendance (hazard ratio [HR] 0.43; P=.02) and unplanned admissions (HR 0.26; P=.02). There were no differences in elective admissions (HR 1.03, P=.96) or outpatient use (HR 1.40; P=.18) between the 2 groups. These differences were sustained by a univariate model controlling for hypertension. Over a 3-month period, secondary health care costs were approximately 4-fold lower in the RM group than the control group, despite the additional cost of RM itself (mean cost per patient GBP £465, US $581 vs GBP £1850, US $2313, respectively; P=.04). This retrospective cohort study shows that smartphone-based RM of vital signs is feasible for HFrEF. This type of RM was associated with an approximately 2-fold reduction in ED attendance and a 4-fold reduction in emergency admissions over just 3 months after a new diagnosis with HFrEF. Costs were significantly lower in the RM group without increasing outpatient demand. This type of RM could be adjunctive to standard care to reduce admissions, enabling other resources to help patients unable to use RM.

Economic analysis of remote monitoring in patients with implantable cardioverter defibrillators or cardiac resynchronization therapy defibrillators in the Trento area, Italy.

Remote monitoring (RM) technologies have the potential to improve patient care by increasing compliance, providing early indications of heart failure (HF), and potentially allowing for therapy optimization to prevent HF admissions. The aim of this retrospective study was to assess the clinical and economic consequences of RM vs. standard monitoring (SM) through in-office cardiology visits, in patients carrying a cardiac implantable electronic device (CIED). Clinical and resource consumption data were extracted from the Electrophysiology Registry of the Trento Cardiology Unit, which has been systemically collecting patient information from January 2011 to February 2022. From a clinical standpoint, survival analysis was conducted, and incidence of cardiovascular (CV) related hospitalizations was measured. From an economic standpoint, direct costs of RM and SM were collected to compare the cost per treated patient over a 2-year time horizon. Propensity score matching (PSM) was used to reduce the effect of confounding biases and the unbalance of patient characteristics at baseline. In the enrollment period, N = 402 CIED patients met the inclusion criteria and were included in the analysis (N = 189 patients followed through SM; N = 213 patients followed through RM). After PSM, comparison was limited to N = 191 patients in each arm. After 2-years follow-up since CIED implantation, mortality rate for any cause was 1.6% in the RM group and 19.9% in the SM group (log-rank test, p < 0.0001). Also, a lower proportion of patients in the RM group (25.1%) were hospitalized for CV-related reasons, compared to the SM group (51.3%; p < 0.0001, two-sample test for proportions). Overall, the implementation of the RM program in the Trento territory was cost-saving in both payer and hospital perspectives. The investment required to fund RM (a fee for service in the payer perspective, and staffing costs for hospitals), was more than offset by the lower rate of hospitalizations for CV-related disease. RM adoption generated savings of -€4,771 and -€6,752 per patient in 2 years, in the payer and hospital perspective, respectively. RM of patients carrying CIED improves short-term (2-years) morbidity and mortality risks, compared to SM and reduces direct management costs for both hospitals and healthcare services.

Association of a Remote Blood Pressure Monitoring Program With Postpartum Adverse Outcomes.

To use administrative claims data to evaluate the association of a remote blood pressure monitoring program with adverse postpartum clinical outcomes in patients with a hypertensive disorder of pregnancy. This was a retrospective cohort study of Independence Blue Cross members with a hypertensive disorder of pregnancy diagnosis across three obstetric hospitals from 2017 to 2021. Patients who were enrolled in twice-daily text-based blood pressure monitoring for 10 days postpartum were compared with two propensity-score matched cohorts of patients who met the program criteria: an asynchronous cohort (cohort A), consisting of patients at any of the three participating hospitals before remote monitoring program implementation, and a contemporaneous cohort (cohort C), consisting of patients at other hospitals during the same time period as clinical use of the program. Patients with less than 16 months of continuous insurance enrollment before delivery were excluded. Claims for adverse clinical outcomes after delivery discharge were evaluated. Health care service utilization and total medical costs were evaluated. The 1,700 patients in remote blood pressure monitoring program were matched to 1,021 patients in cohort A and 1,276 in cohort C. Within the first 6 months after delivery, patients enrolled in remote monitoring were less likely to have the composite adverse outcome than those in cohort A (2.9% vs 4.7%; OR 0.61, 95% CI 0.40-0.98). There was no statistically significant difference relative to cohort C (3.2% vs 4.5%; OR 0.71, 95% CI 0.47-1.07). The remote monitoring group had more cardiology visits and fewer postnatal emergency department (ED) visits and readmissions compared with both comparison cohorts. Reductions in ED visits and readmissions drove overall lower total medical costs for the program cohort. Patients enrolled in a remote blood pressure monitoring program were less likely to experience an adverse outcome in the first 6 months after delivery. Reductions in ED visits and readmissions resulted in lower postpartum total medical costs compared with both control cohorts. Broad implementation of evidence-based remote monitoring programs may reduce postpartum adverse outcomes, thereby reducing morbidity and mortality in populations such as the one studied here.

Telemonitoring heart failure in a remote region: data from cardiac implantable electronic devices

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Heart failure (HF) represents an important burden to the medical system attending to its high prevalence and high risk of hospital admissions by decompensations. Remote monitoring (RM) systems using invasive and non-invasive parameters were developed to anticipate clinical deterioration in patients with cardiac implantable electronic devices (CIEDs). Objective To characterize a cohort of patients with HF and CIEDs in an outermost region. We aimed to accessed data from monitoring device algorithms and to analyze the real impact in clinical decompensations, hospital admissions and all-cause mortality. Methods Retrospectively multicenter cohort study included 211 patients with HFrEF and CIEDs, between 2010 and 2020. This study population was divided into two specific groups: Group A including patients with RM data and Group B including patients who receive usual care at regular hospital consultations. RM technology applied used different parameters to access the risk of worsening HF and stablishing an alert threshold. Results Out of 211 patients enrolled, 75% were male and 44.8% were in NYHA functional class II at the time of device implantation. One-hundred and twenty (56.9%) received in-home monitoring system (89% Latitude® and 10.8% Carelink®), corresponding to the Group A. The remaining 91 patients (43.1%) were included in Group B. Forty-nine patients (40.8%) had transvenous implantable cardioverter defibrillator (ICD), 13 (10.8%) had a subcutaneous ICD, 54 (45%) a cardiac resynchronization therapy (CRT) defibrillator and 4 (3.3%) a CRT pacemaker. Group A patients did not have coronary artery disease (p 0.047) and were younger than patients in Group B (median age 66 years, IQR 55 – 73; median age 70 years, IQR 63 – 77). No other statistically differences in main comorbidities were detected between groups. The number of atrial fibrillation (AF) episodes and AF burden was higher in Group A during the follow-up (p 0.006) as well as non-sustained ventricular tachycardia episodes (p 0.016). However, no differences were accessed in emergency department (ED) admissions or heart failure hospitalizations (HFH) by decompensation for patients in group A who received alerts versus patients who not received (p 0.178 and p 0.748, respectively) nor between group A and B (p 0.921 and p 0.213, respectively). Patients in group A had a lower all-cause mortality rate (p &amp;lt; 0.001) and cardiovascular mortality (p 0.002), but no difference in life-threatening ventricular events occurred. Conclusion In our cohort of HF patients, remote monitoring allowed the premature detection and the correct quantification of arrhythmic events but did not reflect any difference in ED nor HFH by decompensation. Instead, RM system demonstrates ability to reduce global mortality when compared to conventional care. More data about the application of this system and the ideal tracking algorithms are necessary.

Meta-Analysis Comparing Outcomes of Remote Hemodynamic Assessment Versus Standard Care in Patients With Heart Failure

In patients with congestive heart failure (CHF), remote hemodynamic monitoring can reduce heart failure exacerbation and mortality. In this study, we compared the effectiveness of remote hemodynamic monitoring with that of standard care in the management of patients with CHF. The remote monitoring group included 7,733 patients, and the control group included 7,567 patients. Chi-square test and I-square statistics were used to assess heterogeneity. Risk ratios (RRs) were calculated using fixed-effects and random-effects methods to determine the risk of all-cause hospitalization and CHF-related hospitalization (primary outcomes) and all-cause mortality and device outcomes (secondary outcomes). Pooled findings indicated a 7% lower risk of all-cause hospitalization in the remote monitoring group than that in the control group (RR 0.93, 95% confidence interval [CI] 0.89 to 0.98, p=0.004). The results also revealed a 32% lower risk of CHF-related hospitalization in the remote monitoring group than that in the control group (RR 0.68, 95% CI 0.65 to 0.71, p <0.001). No statistically significant differences were noted between the groups in terms of all-cause mortality (RR 0.97, 95% CI 0.87 to 1.07, p=0.53) and device outcomes (RR 1.23 95% CI 0.92 to 1.65, p=0.16). These results provided evidence regarding the comparable effectiveness of remote CHF monitoring and routine care. The current evidence is insufficient to introduce remote hemodynamic CHF monitoring; however, our results suggest that the integration of telemonitoring systems with routine medical management may improve heart failure care.

Smartphone-based remote monitoring (RM) in chronic heart failure reduces emergency hospital attendances, unplanned admissions and secondary care costs: a retrospective cohort study

Abstract Background Despite effective therapies, the economic burden of heart failure with reduced ejection fraction (HFrEF) is driven by frequent hospital attendances [1]. Treatment optimisation and admission avoidance relies on frequent symptom review and monitoring of vital signs [2]. RM programmes aim to prevent admissions and improve system efficiency by enabling self-management [3]. Few studies evaluate the economic impact of RM in HFrEF, compared to real-world matched controls [4]. We compare hospital attendances and costs between patients using Luscii, a novel smartphone-based RM platform, and matched controls receiving usual care for 3 months. Purpose To assess the impact of RM on emergency department (ED) attendances, unplanned admissions and associated healthcare costs over 3 months. Methods A retrospective cohort study of new HFrEF referrals to our service was undertaken using the Discover dataset [5] for two cohorts (i) “RM group”: patients who used the RM platform for at least 3 months and (ii) “control group”: consecutive patients referred before the RM platform was available. The groups were matched 1:1 for age, sex, ethnicity, New York Heart Association grade and left ventricular ejection fraction. Medical co-morbidities, ED attendances, unplanned admissions and costs were extracted over 3 months from platform onboarding (RM group) or accepted referral (control group). Platform costs were added for the RM group. Differences between outcomes were analysed using t-tests, Kaplan-Meier event analysis and Cox's proportional hazard modelling. Results 146 patients (mean age 63 years; 23% female) were included in the analyses (73 “RM group”; 73 “Control group”). The groups were well-matched for all baseline characteristics except hypertension (p=0.03). Compared to the control group, after 3 months follow-up the RM group had significantly fewer ED attendances (p&amp;lt;0.01) and unplanned admissions (p&amp;lt;0.01). Accounting for RM platform costs, there was no difference between ED costs (p=0.42), but significantly lower unplanned admissions costs in the RM group (p=0.02) (Table 1). RM was protective against ED attendances (HR=0.43, p=0.02) and unplanned admissions (HR=0.26, p=0.02), which was sustained after controlling for hypertension (Table 1). Kaplan-Meier analyses found significantly lower probability of ED attendances (p=0.02) and unplanned admissions (p=0.01) in the RM group (Figure 1). Conclusions HFrEF patients with RM were half as likely to attend ED and approximately four times less likely to need short-term unplanned admissions. The economic benefit of RM is driven by lower unplanned admission costs; the cost benefit is equivocal at the ED stage. Participants were younger than the typical HFrEF cohort. RM use could free up valuable resources to enhance standard care for older patients who decline or are unable to use RM. Further evaluation is required of the long-term impact of RM and its effect on outpatient encounters and costs. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Discover data extraction and analyst time were funded by Astra Zeneca. Astra Zeneca did not have any input to study design, analyses or reporting.

Assessment of heart failure parameters by telemonitoring patients with an implantable cardioverter defibrillator

Abstract Introduction Different heart failure (HF) parameters have been evaluated in patients with an implantable cardioverter defibrillator (ICD). Recently, a multi-parameters HF index available in some ICDs has been proposed for patients monitoring in order to prevent hospitalizations for HF. We sought to analyze this index in our patients, based on the occurrence of hospitalizations for HF and/or all-cause mortality. As a second endpoint, the level of NT-pro-BNP, the treatment of HF and the Minnesota score (quality of life) were as well evaluated. Method This was on an open, single-center, case-control study. Inclusions started on March 2017 to end up in November 2020 with the main criteria of HF with left ventricular ejection fraction (LVEF) &amp;lt;35%, DDD or CRT-D implanted in primary prevention. A control group was composed of patients receiving telemonitoring and a control group composed of patients receiving standard monitoring. A 1/1 pairing was carried out, based on 3 criteria: age, sex and the date of ICD implantation. Data collection was carried out in August 2021. Results 74 patients were included in the study; none was lost to follow-up. The occurrence of hospitalization for HF and/or death from any cause was found at the end of the study in 7 of 37 patients in the remote monitoring group versus 22 events of 37 in patients receiving standard monitoring (p=0.011). The number of deaths from any cause was 4 in the study group vs 8 in the control group (NS, p=0.21). The average length of hospital stay is 6.27 days (± 23.6) for patients receiving remote monitoring compared to 9.14 days (± 22.1) p=0.64. NT-pro-BNP was found with a median level of 553 pg/mL [146; 1541] in the remotely monitored group against 498 pg/mL [211; 1400] in controls (p=0.77). The assessment of quality of life by the Minnesota score shows a similar result (p=0.7). Analysis of the treatment of HF shows a significantly (p&amp;lt;0.01) greater presence of anti-aldosterone in patients receiving remote monitoring. Conclusion Our study demonstrates the benefit of the telemonitoring protocol on the occurrence of hospitalizations for heart failure and/or all-cause mortality in heart failure patients with an ICD. We observe a significantly higher percentage of anti-aldosterone treatment in monitored patients, suggesting a more optimized medical treatment. Funding Acknowledgement Type of funding sources: None.

Economic evaluation of remote monitoring of patients with an implantable cardiac defibrillator (REMOTE-CIED study)

Introduction Remote patient monitoring (RPM) of heart failure patients has the potential to reduce healthcare resource use and costs, but current evidence has been inconclusive. This study aims assess the impact of RPM of heart failure patients with an implantable cardioverter defibrillator on medical resource use, direct medical costs, quality-adjusted life years (QALYs), and travel time of patients, and to estimate its commercial headroom in the Netherlands and Germany. Methods Data from the REMOTE-CIED randomized controlled trial were used to calculate differences in length of hospital stay, outpatient clinic visits, telephone consults, emergency room visits, and travel time between patients on in-clinic follow-up and RPM in the Netherlands, Germany, and France. Incremental cardiac-related healthcare costs and QALYs were calculated and used to calculate the commercial headroom of RPM in the Netherlands and Germany. The impact of imputation, parameter, and case-mix uncertainty on these outcomes was explored using probabilistic analysis. Results Length of hospitalization, number of unscheduled admissions, and number of outpatient visits were lower in the remote monitoring group in all three countries. Number of hospital admissions was higher, and number of calls was lower in the Netherlands and Germany but not in France. Costs were lower in both the Netherlands (−€1041, 95% confidence interval (CI): −€3308, €1005) and Germany (−€2865, 95% CI: −€7619, €1105), while incremental effectiveness differed: −0.003 (95% CI: −0.114, 0.107) QALY in the Netherlands and +0.086 (95% CI: −0.083, 0.256) in Germany. Commercial headroom was estimated at €881 (95% CI: −€5430, €7208) in the Netherlands and €5005 (95% CI: −€1339, €11,960) in Germany. Discussion RPM was found to result in reduced medical resource use and travel time. Whether it is cost saving or cost effective strongly depends on the costs of remote monitoring. Trial registration number and trial register ClinicalTrials.gov: NCT01691586.

Smartphone-based remote monitoring (RM) in chronic heart failure reduces emergency hospital attendances, unplanned admissions and secondary care costs: a retrospective cohort study

Abstract Background Despite effective therapies, the economic burden of heart failure with reduced ejection fraction (HFrEF) is driven by frequent hospital attendances [1]. Treatment optimisation and admission avoidance relies on frequent symptom review and monitoring of vital signs [2]. RM programmes aim to prevent admissions and improve system efficiency by enabling self-management [3]. Few studies evaluate the economic impact of RM in HFrEF, compared to real-world matched controls [4]. We compare hospital attendances and costs between patients using Luscii, a novel smartphone-based RM platform, and matched controls receiving usual care for 3 months. Purpose To assess the impact of RM on emergency department (ED) attendances, unplanned admissions and associated healthcare costs over 3 months. Methods A retrospective cohort study of new HFrEF referrals to our service was undertaken using the Discover dataset [5] for two cohorts (i) “RM group”: patients who used the RM platform for at least 3 months and (ii) “control group”: consecutive patients referred before the RM platform was available. The groups were matched 1:1 for age, sex, ethnicity, New York Heart Association grade and left ventricular ejection fraction. Medical co-morbidities, ED attendances, unplanned admissions and costs were extracted over 3 months from platform onboarding (RM group) or accepted referral (control group). Platform costs were added for the RM group. Differences between outcomes were analysed using t-tests, Kaplan-Meier event analysis and Cox's proportional hazard modelling. Results 146 patients (mean age 63 years; 23% female) were included in the analyses (73 “RM group”; 73 “Control group”). The groups were well-matched for all baseline characteristics except hypertension (p=0.03). Compared to the control group, after 3 months follow-up the RM group had significantly fewer ED attendances (p&amp;lt;0.01) and unplanned admissions (p&amp;lt;0.01). Accounting for RM platform costs, there was no difference between ED costs (p=0.42), but significantly lower unplanned admissions costs in the RM group (p=0.02) (Table 1). RM was protective against ED attendances (HR=0.43, p=0.02) and unplanned admissions (HR=0.26, p=0.02), which was sustained after controlling for hypertension (Table 1). Kaplan-Meier analyses found significantly lower probability of ED attendances (p=0.02) and unplanned admissions (p=0.01) in the RM group (Figure 1). Conclusions HFrEF patients with RM were half as likely to attend ED and approximately four times less likely to need short-term unplanned admissions. The economic benefit of RM is driven by lower unplanned admission costs; the cost benefit is equivocal at the ED stage. Participants were younger than the typical HFrEF cohort. RM use could free up valuable resources to enhance standard care for older patients who decline or are unable to use RM. Further evaluation is required of the long-term impact of RM and its effect on outpatient encounters and costs. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Discover data extraction and analyst time were funded by Astra Zeneca. Astra Zeneca did not have any input to study design, analyses or reporting.

Assessment of heart failure parameters by telemonitoring patients with an implantable cardioverter defibrillator

Abstract Introduction Different heart failure (HF) parameters have been evaluated in patients with an implantable cardioverter defibrillator (ICD). Recently, a multi-parameters HF index available in some ICDs has been proposed for patients monitoring in order to prevent hospitalizations for HF. We sought to analyze this index in our patients, based on the occurrence of hospitalizations for HF and/or all-cause mortality. As a second endpoint, the level of NT-pro-BNP, the treatment of HF and the Minnesota score (quality of life) were as well evaluated. Method This was on an open, single-center, case-control study. Inclusions started on March 2017 to end up in November 2020 with the main criteria of HF with left ventricular ejection fraction (LVEF) &amp;lt;35%, DDD or CRT-D implanted in primary prevention. A control group was composed of patients receiving telemonitoring and a control group composed of patients receiving standard monitoring. A 1/1 pairing was carried out, based on 3 criteria: age, sex and the date of ICD implantation. Data collection was carried out in August 2021. Results 74 patients were included in the study; none was lost to follow-up. The occurrence of hospitalization for HF and/or death from any cause was found at the end of the study in 7 of 37 patients in the remote monitoring group versus 22 events of 37 in patients receiving standard monitoring (p=0.011). The number of deaths from any cause was 4 in the study group vs 8 in the control group (NS, p=0.21). The average length of hospital stay is 6.27 days (± 23.6) for patients receiving remote monitoring compared to 9.14 days (± 22.1) p=0.64. NT-pro-BNP was found with a median level of 553 pg/mL [146; 1541] in the remotely monitored group against 498 pg/mL [211; 1400] in controls (p=0.77). The assessment of quality of life by the Minnesota score shows a similar result (p=0.7). Analysis of the treatment of HF shows a significantly (p&amp;lt;0.01) greater presence of anti-aldosterone in patients receiving remote monitoring. Conclusion Our study demonstrates the benefit of the telemonitoring protocol on the occurrence of hospitalizations for heart failure and/or all-cause mortality in heart failure patients with an ICD. We observe a significantly higher percentage of anti-aldosterone treatment in monitored patients, suggesting a more optimized medical treatment. Funding Acknowledgement Type of funding sources: None.

Advantages of using a portable cardiac monitor in outpatients with paroxysmal atrial fibrillation

Aim. To study the advantages of using a portable electrocardiographic (ECG) monitor in outpatients with paroxysmal atrial fibrillation (AF).Material and methods. We examined 88 patients (26 men, 62 women, mean age, 63 [57;68] years) with paroxysmal AF with an average frequency of arrhythmia episodes of 1,0 [0.3;3.75] per month. Forty three (49%) patients were included in the remote monitoring (RM) group using the ECG Dongle monitor, and 45 (51%) patients were included in the conventional monitoring (CM) group. Patients underwent scheduled examinations 2, 6 and 12 months after the start of therapy. Unscheduled consultations were carried out in case of AF recurrence. Patients from the RM group, using portable cardiac monitor, additionally self-registered ECG 1 time per week and in case of symptoms suggestive of AF. ECG strips were sent to the clinical investigator for analysis.Results. With the help of portable cardiac monitor, 2477 ECG strips were collected and analyzed: 2159 (87,2%) — sinus rhythm, 318 (12,8%) — AF and atypical atrial flutter. Forty four episodes of AF in 3 patients were asymptomatic. In addition, 211 (8,5%) sinus rhythm ECG strips were recorded by 13 patients with symptoms suggestive of AF. In the RM group, 7 (16%) patients were hospitalized due to recurrent AF, while in the CM group, 20 (44%) patients (p=0,004). The total number of emergency hospitalizations was 8 and 29 in the RM and CM groups, respectively. The number of patients who called an ambulance was significantly lower in the RM group: in the CM group, 37 calls for an ambulance were made by 22 patients, while in the RM group — 12 patients made 15 calls (p=0,044). The proportion of calls followed by hospitalization (40 vs 70%, p=0,043) was significantly lower in the RM group.Conclusion. Remote ECG monitoring using the ECG Dongle system is a useful way to monitor patients with paroxysmal AF, which make it possible to register asymptomatic AF episodes, differentiate the causes of palpitations, and significantly reduce the frequency of emergency calls and hospitalizations.

Improved Time in Therapeutic Range with International Normalized Ratio Remote Monitoring for Patients with Left Ventricular Assist Devices.

Despite advances in therapy, bleeding and thromboembolic events are frequent complications in patients with left ventricular assist device (LVAD) support. Maintaining warfarin in therapeutic range has been shown to be more challenging in this patient population compared to other indications. Patients with LVADs on warfarin typically are within goal international normalized ratio (INR) range 36-57% of the time, compared to about 65% for other indications. The goal of this study was to evaluate if an INR remote monitoring system along with the implementation of a standardized warfarin management protocol improves warfarin time in therapeutic range (TTR) for patients with LVADs. This single-center, retrospective, observational study included 78 patients with LVADs that were followed at our academic center from January 2015 to October 2017. In October 2016, we updated our warfarin management protocol and implemented a remote monitoring system with patients' weekly INR results monitored. The primary objective of the study was to determine the difference between TTRs in remote monitoring versus standard monitoring. We found that the average TTR was significantly higher in the remote monitoring group compared to the standard monitoring cohort (61.1% vs. 40.0%, p < 0.005). However, bleeding, thrombotic incidence, and hospital readmission rates were similar between the two patient cohorts. Remote monitoring improved warfarin TTR significantly in this study and may have the potential to improve anticoagulation-related outcomes in patients with LVADs.

Automatic daily remote monitoring in heart failure patients implanted with a cardiac resynchronisation therapy-defibrillator: a single-centre observational pilot study.

The impact of remote monitoring (RM) on clinical outcomes in heart failure (HF) patients with cardiac resynchronisation therapy-defibrillator (CRT-D) implantation is controversial. This study sought to evaluate the performance of an RM follow-up protocol using modified criteria of the PARTNERS HF trial in comparison with a conventional follow-up scheme. We compared cardiovascular (CV) mortality (primary endpoint) and hospitalisation events for decompensated HF, and the number of ambulatory in-office visits (secondary endpoint) in CRT-D implanted patients with automatic RM utilising daily transmissions (RM group, n = 45) and conventional follow-up (CFU group, n = 43) in a single-centre observational study. After a median follow-up of 25 months, a significant advantage was seen in the RM group in terms of CV mortality (1 vs. 6 death event, p = 0.04), although RM follow-up was not an independent predictor for CV mortality (HR = 0.882; 95% CI: 0.25-3.09; p = 0.845). Patient CV mortality was independently influenced by hospitalisation events for decompensated HF (HR = 3.24; 95% CI: 8-84; p = 0.022) during follow-up. We observed significantly fewer hospitalisation events for decompensated HF (8 vs. 29 events, p = 0.046) in the RM group. Furthermore, a decreased number of total (161 vs. 263, p < 0.01) and unnecessary ambulatory in-office visits (6 vs. 19, p = 0.012) were seen in the RM group as compared to the CFU group. Follow-up of CRT-D patients using automatic RM with daily transmissions based on modified PARTNERS HF criteria enabled more effective ambulatory interventions leading indirectly to improved CV survival. Moreover, RM directly decreased the number of HF hospitalizations and ambulatory follow-up burden compared to CRT-D patients with conventional follow-up.

900 The impact of postpartum blood pressure monitoring amongst women with hypertensive disorders of pregnancy

To compare the incidence of hypertension-related readmissions in women with hypertensive disorders of pregnancy (HDP) who use a mobile phone app for remote postpartum blood pressure monitoring versus traditional care. This was a retrospective analysis of all women admitted with HDP (identified by ICD10 codes) who delivered between Jan. 1st, 2016 and Dec. 31st, 2019. The primary exposure was type of postpartum blood pressure monitoring. Remote monitoring (RM) entailed use of a mobile phone app and daily use of a home blood pressure cuff for 10 days. Ambulatory care (AC) consisted of one outpatient visit for a blood pressure check. The primary outcome was readmission due to hypertension complications. Bivariate analyses of baseline characteristics by exposure were conducted and logistic regression modeling was used to adjust for confounders. Of the 2,132 subjects, 612 (28.7%) patients underwent RM and 1,520 (71.3%) underwent AC for postpartum blood pressure monitoring. Baseline maternal demographics differed by age, gravidity, race, weight gain, preterm delivery, mode of delivery, and distribution of specific hypertensive diagnoses. Postpartum readmission for hypertensive complications was more common in the RM group (4.4% vs. 2.3%, p<0.01) (Table 1). When adjusting for age, race, and preterm delivery, this difference remained statistically significant - women in the RM group had an 87% higher odds of needing readmission than women in the AC group (p < 0.001) (Table 2). In this cohort of patients with HDP, use of a mobile phone app for remote postpartum blood pressure monitoring was associated with a higher rate of hypertension-related readmissions compared to traditional care.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Remote Monitoring With Appropriate Reaction to Alerts Was Associated With Improved Outcomes in Chronic Heart Failure: Results From the OptiLink HF Study.

Impedance-based remote monitoring (RM) failed to reduce clinical events in the OptiLink heart failure (HF) trial. However, rates of alert-driven interventions triggered by intrathoracic fluid index threshold crossings (FTC) were low indicating physicians' inappropriate reactions to alerts. We separated appropriate from inappropriate contacts to FTC transmissions in the OptiLink HF trial (Optimization of Heart Failure Management Using OptiVol™ Fluid Status Monitoring and CareLink™). Appropriate contacts had to meet the following criteria: (1) initial telephone contact within 2 working days after FTC transmission, (2) follow-up contacts according to study protocol, and (3) medical intervention initiated after FTC due to cardiac decompensation. We compared time to cardiovascular death or HF hospitalization between RM patients contacted appropriately or inappropriately and patients with usual care. In the RM group, at least one FTC alert was transmitted in 356 patients (70.5%; n=505). Of note, only 55.5% (n=758) of all transmitted FTCs (n=1365) were followed by an appropriate contact. While 113 patients (31.7%; n=356) have been contacted appropriately after every FTC, in 243 patients (68.3%; n=356) at least one FTC was not responded by an appropriate contact. Compared with usual care, RM with appropriate contacts to FTC alerts independently reduced the risk of the primary end point (hazard ratio, 0.61 [95% CI, 0.39-0.95]; P=0.027). RM appropriate reactions to FTC alerts are associated with significantly improved clinical outcomes in patients with advanced HF and implantable cardioverter-defibrillators.