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OUR MISSION: TO REDUCE THE BURDEN OF CARDIOVASCULAR DISEASE
Prof. Carina Blomström-Lundqvist,
Dr. Hein Heidbuchel,
By Hein Heidbuchel, FESC (Leuven, Belgium)View Discussant report
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List of Authors
Hein Heidbuchel1, Gerd Hindricks2, Paul Broadhurst3, Lieselot Van Erven4, Ignacio Fernandez-Lozano5, Maximo Rivero-Ayerza6, Klaus Malinowski7, Andrea Marek8, Rafael F. Romero Garrido9, Steffen Löscher10; Ian Beeton11, Enrique Garcia12, Stephen Cross13, Johan Vijgen14, Ulla-Maija Koivisto15, Rafael Peinado16, Antje Smala17, Lieven Annemans181. University Hasselt and Heart Center, Jessa Ziekenhuis, Hasselt, Belgium2. Heart Center Leipzig, Leipzig, Germany3. Aberdeen Royal Infirmary, Aberdeen, United Kingdom4. Leiden University Medical Center, Leiden, Netherlands 5. University Hospital Puerta de Hierro Majadahonda, Madrid, Spain6. Hospital Oost-Limburg (ZOL), Genk, Belgium 7. Helios Klinikum, Aue, Germany 8. Charite - Campus Mitte (CCM), Berlin, Germany9. Hospital Universitario Nuestra Señora de la Candelaria (HUNSC), St. Cruz, Tenerife10. Klinikum St. Georg, Leipzig, Germany11. St. Peters Hospital, Chertsey, United Kingdom12. Centro Hospitalario Universitario Vigo, Vigo, Spain13. Raigmore Hospital, Inverness, United Kingdom14. Heart Center, Jessa Ziekenhuis, Hasselt, Belgium15. Universital Hospital of Oulu, Oulu, Finland16. Hospital Universitario La Paz, La Paz, Spain17. BIOTRONIK SE & Co. KG, Berlin, Germany18. Ghent University, Ghent, Belgium
AimsRemote follow-up (FU) of implantable cardiac defibrillators (ICDs) allows for fewer in-office visits in combination with earlier detection of relevant findings. Its implementation requires investment and reorganisation of care. Providers (physicians or hospitals) are unsure about the financial impact. The primary endpoint of this randomised prospective multicentre health economic trial was the total FU related cost for providers, comparing home monitoring facilitated FU (HM ON) to regular in-office FU (HM OFF) during the first two years after ICD implantation. Also the net financial impact on providers (taking national reimbursement into account) and costs from a healthcare payer perspective were evaluated.MethodsA total of 312 patients (pts) with VVI- or DDD-ICD implants from 17 centres in six EU countries were randomised to HM ON or OFF, of which 303 were eligible for data analysis. For all contacts (in-office, calendar- or alert-triggered web-based review, discussions, calls) time-expenditure was tracked. Country-specific cost parameters were used to convert resource use into monetary values. Remote FU equipment itself was not included in the cost calculations. Given only two pts from Finland (one each group) a monetary valuation analysis was not performed for Finland. ResultsAverage patient age was 62.4 ±13.1 y, 81% were male, 39% received a DDD system, and 51% had a prophylactic ICD. Resource use with HM ON was clearly different: remote FU was associated with less FU visits (3.79 ±1.67 vs. 5.53 ±2.32; p<0.001) despite a small increase of unscheduled visits (0.95 ±1.50 vs. 0.62 ±1.25; p<0.005), more non-office based contacts (1.95 ±3.29 vs. 1.01 ±2.64; p<0.001), more Internet sessions (11.02 ±15.28 vs. 0.06 ±0.31; p<0.001) and more in-clinic discussions (1.84 ±4.20 vs. 1.28 ±2.92; p<0.03), but with numerically fewer hospitalizations (0.67 ±1.18 vs. 0.85 ±1.43, p=0.23) and shorter length-of-stay (6.31 ±15.5 vs. 8.26 ±18.6; p=0.27), albeit not significant. For the whole study population, the total FU cost for providers was not different for HM ON vs. OFF (mean [95% CI]: €204 [169-238] vs. €213 [182-243]; range for difference [€-36 to 54], NS)(Figure 1). From a payer perspective, FU related costs were similar while the total cost per patient (including other physician visits, examinations and hospitalizations) was numerically (but not significantly) lower. There was no difference in the net financial impact on providers (profit of €408 [327-489] vs. €400 [345-455]; range for difference [€-104 to 88], NS), but there was heterogeneity among countries, with less profit for providers in the absence of specific remote FU reimbursement (Belgium, Spain, Netherlands) and maintained or increased profit in cases where such reimbursement exists (Germany & UK) (Figure 2). Nevertheless, even in countries where remote monitoring reimbursement is available, the total costs for healthcare payers over two years of follow-up did not increase (Figure 3), in line with the fewer hospitalisations and shorter length-of-stay. Quality of life (as measured by SF-36) was not different.ConclusionsFor all patients as a whole, FU related costs for providers are not different for FU based on remote monitoring vs. purely in-office FU, despite clearly reorganised care. However, disparity in the impact on provider budget among different countries illustrates the need for proper reimbursement to ensure effective remote FU implementation.See abstract with all figures in Euro Heart Journal FastTrack
By Carina Blomstrom-Lundqvist, FESC (Uppsala, Sweden)
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Hot Line: Heart failure: devices and interventions
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