Remote Monitoring Cuts Admissions, Clinic Visits in HF Patients With Implanted Devices
There are implementation challenges, but “the sooner clinicians get on the bandwagon, the better it will be for patient care,” one expert says.
LISBON, Portugal—When implemented by an experienced team, remote monitoring of patients with heart failure and implanted devices reduces both hospitalizations and outpatient clinic visits, the single-center RESULT trial shows.
Monitoring lowered the primary composite endpoint of all-cause death or CV hospitalization through 1 year compared with standard care (39.5% vs 48.5%; P = 0.048), Mateusz Tajstra, MD, PhD (Silesian Center for Heart Diseases, Zabrze, Poland), reported at the European Heart Rhythm Association (EHRA) Congress 2019 here. That was driven by a reduction in CV hospitalization (37.1% vs 45.5%; P = 0.045) and not death (6% in each group).
The average number of outpatient visits—both scheduled and unscheduled combined—was also lower in the monitored patients (2.5 vs 4.9 per patient per year; P < 0.001), although unscheduled visits were more frequent (2.1 vs 1.5 per patient per year; P = 0.003).
Tajstra concluded, “A well-structured remote monitoring center may be an important element of heart failure [patient] management.”
Heart failure has become an epidemic, he said. The rapidly growing number of patients with implanted devices means that there is increasing demand for remote follow-up, which can facilitate interactions between patients and the healthcare system and trigger the initiation of preventive interventions to improve heart failure outcomes, he added.
Prior trials of remote monitoring have provided mixed results, Tajstra pointed out. But those trials implemented monitoring programs during the run-in phases, he said, adding that there is an important learning curve when it comes to the effectiveness of such efforts.
The RESULT trial is not affected by that issue, as it was conducted at the Silesian Center for Heart Diseases, a tertiary care center that performs about 1,500 cardiovascular implantable electronic device (CIED) procedures each year and has had a remote monitoring unit set up since 2008; there are currently about 3,000 patients under evaluation through the program.
For the trial, investigators enrolled 600 patients (mean age 64 years; 81% men) with mostly NYHA class II or III heart failure with implantable cardioverter-defibrillators (ICDs) or cardiac resynchronization therapy-defibrillators (CRT-Ds) from four different manufacturers and randomized them to standard care or remote monitoring. There were no differences in baseline echocardiographic characteristics and use of guideline-directed medical therapies for heart failure was high.
Although the trial showed that CV hospitalizations were reduced with remote monitoring, costs associated with these admissions were not significantly lower. The main cost reduction—a relative 39% drop (P < 0.001)—came through avoidance of outpatient visits in the monitored group.
Time to Get on the Bandwagon?
Commenting for TCTMD, Jagmeet Singh, MD, PhD (Massachusetts General Hospital, Boston), said it’s nice to see a positive trial involving remote monitoring because many of the prior trials have not made much of an impact. Though there are some limitations that underscore the need for validation in larger trials—the sample size is small, the follow-up period is limited, and the hospitalization rate was high in both arms—the findings overall are very encouraging, he said.
“Folks need to start looking at device diagnostic data from these implanted devices to individualize patient care so as to reduce readmissions and also to improve outcomes,” Singh said.
There has been reluctance to do that, he pointed out, because of the logistics involved with setting up a remote monitoring program and the need to get clinicians to change their practice. “You know how resistant, usually, clinicians are to modifying their practice,” Singh said. “So I would say the institution of a remote monitoring strategy needs to be fairly seamless and integrated into the workflow for it to become practical and then translate into the benefits that you just saw in a clinical trial.”
And it’s time to start making that happen because of the potential to improve patient outcomes, Singh said. “Remote monitoring is the future and I think the sooner clinicians get on the bandwagon, the better it will be for patient care.”
Serving as a discussant following Tajstra’s presentation, Martin Cowie, MD (Imperial College London, England), ran down the strengths and limitations of the RESULT trial. In particular, even though there was a significant advantage for remote monitoring in terms of the primary endpoint, he said, the P value close to 0.05 indicated that the result was not a “slam dunk.”
When considering this trial in the context of other studies of remote monitoring, Cowie said, “Yes, it can be done. Yes, you can organize it. Yes, you can use any of the devices. But is it worth the organizational change to do that and to look at the potential tsunami of data all the time in all of these patients, and [anticipate that] your program will expand and expand and expand as time goes on?”
That question and others remain to be answered, indicated Cowie, who is a member of the EHRA task force on remote monitoring of CIEDs. “I’m sure the debate will continue, and this is an important part of that debate.”
Tajstra M. RESULT: remote supervision to decrease hospitalization rate in patients with heart failure and implanted cardioverter-defibrillator or cardiac resynchronization therapy. Prospective randomized study. Presented at: EHRA 2019. March 18, 2019. Lisbon, Portugal.
- RESULT was funded by the National Center for Research and Development in Poland.
- Tajstra reports no relevant conflicts of interest.
- Cowie reports being a consultant to Medtronic, Boston Scientific, and Abbott.
- Singh reports consulting for Biotronik, Boston Scientific, Abbott, Medtronic, MircoPort, and Impulse Dynamics.