Telemedicine may improve HF patient care

Remote monitoring (RM) reduced hospitalization rates in patients with heart failure (HF) and implanted cardioverter-defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D), according to data from the RESULT* trial presented at EHRA 2019.

“The rapidly growing number of patients with ICDs translates to increased follow-up. RM can foster patient healthcare interactions and allow pre-emptive clinical decision-making interventions to improve HF outcomes,” said Dr Mateusz Tajstra from the Silesian Centre of Heart Disease in Zabrze, Poland.

Six hundred participants were randomized 1:1 to receive RM or standard care for 12 months. Electrophysiology nurses checked the RM transmissions and contacted participants should further information be required. Cardiology residents examined suspected arrhythmias or device malfunctions and took action as needed. A clinical cardiologist and electrophysiologist stepped in for difficult cases. [EHRA 2019, abstract 630]

The primary endpoint (composite of all-cause death or cardiovascular [CV] hospitalization**) was less frequent in the RM than the standard arm (39.5 percent vs 48.5 percent; p=0.032) primarily due to the lower rates of CV hospitalization (37.1 percent vs 45.5 percent; p=0.045). All-cause mortality in both arms were similar at 6 percent (p=0.9), as the trial was not powered to demonstrate differences in survival alone, noted Tajstra.

Scheduled outpatient visits were also lower in the RM vs the standard arm (2.5 vs 4.9 visits/patient/year; p<0.001).

These findings suggest that RM facilitated prompt treatment, consequently preventing hospital admissions, said Tajstra. “[RM] prevented HF decompensation, where symptoms suddenly get worse and patients are often hospitalized.”

Despite the lack of reimbursement for RM in Poland, the results were convincing enough for health authorities that “it has won reimbursement from the national health system,” said Tajstra. “[T]he holistic model of care, broad diagnostic approach … and comprehensive therapeutic armamentarium may be a key to [its] success … A well-structured RM centre may be an important element of management.”

Nonetheless, Tajstra stressed that RM is not effective “as a plug-and-play gadget … It will only be successful with a specified workflow to act on data retrieved from the devices performed by a dedicated team.”

The good, the bad

In a separate discussion, Prof Martin Cowie from the Imperial College London in London, UK complimented the researchers on the study and noted the wide inclusion criteria, low discontinuation and crossover rates, and highly integrated RM system as strengths of the studies. Moreover, evaluating a whole pathway of care and incorporating both scheduled and unscheduled visits allowed for “a very nuanced understanding of how RM might change interaction between a patient with a device that has been remotely monitored and a healthcare service,” he added. [EHRA 2019, abstract 631]

However, looking at the time-to-first unscheduled outpatient visit, there was only a 6-day gap between the RM arm and the standard arm (median, 48 vs 54 days), Cowie pointed out. “[While RM gives] you a bit of a head start [to see] what might be happening … [it is] not an enormous difference.”

Although the cohort comprised “very well-treated HF patients” as the majority (≥95 percent) were on aldosterone antagonist, it is important to validate the generalizability of the findings as the sample only represents ~20 percent of implanted patients from a single centre, Cowie pointed out.

Moreover, the borderline effect on CV hospitalization and lack of mortality signal may not be enough to influence clinicians to embrace the protocol, added Cowie. “Generally, RM can be done … [However,] is it worth the organizational change?” he added, considering the amount of data tracking involved and the imminent programme expansion as time goes on.

In terms of cost reduction with RM, despite the lower rates of both hospitalizations and outpatient visits, only the latter reached statistical significance (15 percent; p=NS*** vs 39 percent; p<0.001). “Outpatient visits, which are generally very inexpensive, seem to have driven the cost equation,” said Cowie, suggesting that the economic benefit of RM may not be as huge. Therefore, further cost evaluation is warranted, as well as evaluation of patients’ perspectives to determine the potential effect of RM on quality of life, he added.