Making the Most of Cardiac Device Remote Management

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 14, No. 3Making the Most of Cardiac Device Remote Management Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree CommentaryPDF/EPUBMaking ManagementTowards an Actionable Care Model Jamie Diamond, MD, MPH Niraj Varma, MD Daniel B. KramerMD, DiamondJamie Diamond Richard A. Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical (J.D., D.B.K.). Harvard School, Boston MA Search more papers by this author , VarmaNiraj Varma https://orcid.org/0000-0003-2296-2596 Electrophysiology, Heart Vascular Institute, Cleveland Clinic, OH (N.V.). KramerDaniel Kramer Correspondence to: Kramer, MPH, Center, 375 Longwood Ave, 4th Floor, 02215. Email E-mail Address: [email protected] https://orcid.org/0000-0003-4241-3586 Originally published4 Mar 2021https://doi.org/10.1161/CIRCEP.120.009497Circulation: Electrophysiology. 2021;14:e009497Remote monitoring is a broad term that includes remote interrogation alert transmission. refers routine, scheduled transmissions replace in-office device evaluations occur at predetermined intervals dictated clinical practice, patient indications, reimbursement.1 Guidelines recommend every 3 12 months pacemakers 6 implantable cardioverter-defibrillators with least 1 annual person evaluation. These routine interrogations are complemented (when technology permits) automatic triggered device-detected conditions meeting specific parameters.Remote patients cardiac electrical devices (CIEDs) supports follow-up provides surveillance malfunction. Multiple trials illustrate benefits monitoring, which increasingly leverages wireless functionality Bluetooth connectivity via patients’ smartphones increasing flexibility.1 However, expanded threatens overwhelm clinicians near-constant data streams, may obscure important findings within deluge transmissions. Moreover, current reimbursement policies encourage volume, limit incentives streamline care pathways applicable growing array CIEDs. This article examines barriers optimizing CIEDs proposes technical policy solutions improve clinician experiences enhance its value care.Current Challenges MonitoringSignal-Noise RatioThe major benefit swiftly detecting events without need in-person often transmit reports normally functioning devices—likely well over half all transmissions.2 Unfortunately, alerts (eg, cardioverter-defibrillator shocks, malfunction, new diagnoses atrial fibrillation, etc) become buried amidst high volume normal (nonactionable) data. Millions United States alone living capable various forms, yet engagement only be consistent ?25%.3 If these participated on recommended schedules, plausibly >10 million would generated annually.These burden who must triage interpret large unimportant Each communication takes time review information, identify false alerts, call patients, document encounter. The costs from services difficult quantify but associated both technological expenditures—most adds no patients.Inconsistent Data FormatGuidelines strongly offering CIED monitoring,1 acknowledge limitations placed lack interoperability across manufacturers. Shifting alert-driven structure still requires confronting harmonization between vendors, as each differs somewhat regards type number despite settings. For example, antitachycardia pacing register some vendors not others. Proprietary algorithms vendor-specific reporting capabilities mean reported one manufacturer ignored another.Moreover, sent wirelessly implanted patient’s transceiver when close proximity. Manufacturers dictate size portability transceiver, addition operation device. vendor such timing ranges daily preset only. Several manufacturers opt transmission critical whenever range though others night. onus then falls implanting sort through complex proprietary idiosyncrasies establish true standard care.Reimbursement PolicyIn States, physicians sites largely reimbursed fee-for-service system used private health insurers government form Medicare Medicaid. allows billing 90 days. Though analysis process can tedious, payoff lucrative accounts tens millions expenditures alone.4 cost-effective, it decreases amount spent ambulatory visits social including transportation missed work. Further potential economic include enhanced longevity requiring fewer replacements, reduction hospitalizations, decreased adverse cardiovascular events. cost-effective same high-value, program focused clearly points towards opportunities decreasing compromising care.Proposed Solutions Improve Value Monitoring CareWe propose main changes landscape. First, advance support pathway continuous status viewed dashboard-like interface, alert-level directed ultimately medical record. Vendors’ websites, third-party aggregators already whether transmitting normally, rendering merely testifying function redundant. Individualized displays dashboard approach highlight pertinent function, arrhythmias). Those likely actionable—such battery or lead problems ventricular arrhythmias—can configured nearly defined broadly default avoid missing (for example) slow arrhythmias triggering therapy. scheme eliminate nonactionable transmissions, easing clinic while pivoting focus actionable items.Our second recommendation extends reliance create industry standards content, customization, capture, (including electrogram content format) vary vendors. Other according context; fibrillation discovery matters if diagnosis than established one. Yet there compelling reason why systems should representation format customizable leads generators attach other accepted standards, principle apply way monitored. have standardized definitions terminology vendor-neutral platform electronic systems.5 An offshoot robust, improvement distinguishing artifact mimics. Reliance will anchor critically whether, end, trust comprehensive. earned careful studies evaluating performance identification analyzed level cohorts CIEDs.6Last, move away per-transmission payment capitated bundled alternatives. might per-patient/per-year basis maintaining connectivity, regardless provide sufficient incentive enroll care, also motivating appropriate programming reduce unnecessary At time, incentivize struggle access model, particularly those internet cell phone coverage sustain near-continuous surveillance. Failure consider needs exacerbate disparities exclude vulnerable full therapeutic modern CIEDs.Nonstandard Abbreviation AcronymsCIEDcardiac deviceSources FundingThis work was supported part Greenwall Foundation.Disclosures Dr Faculty Scholars Program Bioethics serving consultant Circulatory Systems Advisory Panel Food Drug Administration, Firefly Health. consulting Medtronic, Biotronik, Scientific, Abbott Medical. conflicts.FootnotesThe opinions expressed necessarily editors American Association.For Sources Funding Disclosures, see page 378.Correspondence protected]harvard.eduReferences1. Slotwiner D, N, Akar JG, Annas G, Beardsall M, Fogel RI, Galizio NO, Glotzer TV, Leahy RA, Love CJ, et al.. HRS Expert Consensus Statement devices.Heart Rhythm. 2015; 12:e69–100. doi: 10.1016/j.hrthm.2015.05.008CrossrefMedlineGoogle Scholar2. Epstein AE, Irimpen A, Schweikert R, C; TRUST Investigators. Efficacy safety follow-up: Lumos-T Safely Reduces Routine Office Follow-up (TRUST) trial.Circulation. 2010; 122:325–332. 10.1161/CIRCULATIONAHA.110.937409LinkGoogle Scholar3. Piccini JP, Snell J, Fischer Dalal Mittal S. relationship adherence survival pacemaker defibrillator patients.J Am Coll Cardiol. 65:2601–2610. 10.1016/j.jacc.2015.04.033CrossrefMedlineGoogle Scholar4. Holtzman JN, Wadhera RK, Choi E, Zhao T, Secemsky EA, Fraiche AM, Shen C, DB. Trends utilization spending among beneficiaries.Heart 2020; 17:1917–1921. 10.1016/j.hrthm.2020.05.044CrossrefMedlineGoogle Scholar5. DJ, Abraham RL, Al-Khatib SM, Anderson HV, Bunch TJ, Ferrara MG, Lippman Serwer GA, Steiner PR, Tcheng JE, White Paper (CIEDs).Heart 2019; 16:e107–e127. 10.1016/j.hrthm.2019.05.002CrossrefMedlineGoogle Scholar6. Rosier Mabo P, Temal L, Van Hille Dameron O, Deléger Grouin Zweigenbaum Jacques Chazard Personalized automated fibrillation.Europace. 2016; 18:347–352. 10.1093/europace/euv234CrossrefMedlineGoogle Scholar Previous Back top Next FiguresReferencesRelatedDetails March 2021Vol Issue 3Article InformationMetrics Download: 162 © 2021 Association, Inc.https://doi.org/10.1161/CIRCEP.120.009497PMID: 33657833 publishedMarch 4, Keywordsimplantable defibrillatoratrial fibrillationtechnologysmartphonepolicyPDF download SubjectsHealth ServicesEthics Policy