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EuroEco (European Health Economic Trial on Home Monitoring in ICD Patients): a provider perspective on follow-up costs and net financial impact of remote monitoring in six European countries

ESC Congress 2014 - Hot Line report




By Hein Heidbuchel, FESC (Leuven, Belgium)
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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 Annemans18
1. University Hasselt and Heart Center, Jessa Ziekenhuis, Hasselt, Belgium
2. Heart Center Leipzig, Leipzig, Germany
3. Aberdeen Royal Infirmary, Aberdeen, United Kingdom
4. Leiden University Medical Center, Leiden, Netherlands
5. University Hospital Puerta de Hierro Majadahonda, Madrid, Spain
6. Hospital Oost-Limburg (ZOL), Genk, Belgium
7. Helios Klinikum, Aue, Germany
8. Charite - Campus Mitte (CCM), Berlin, Germany
9. Hospital Universitario Nuestra Señora de la Candelaria (HUNSC), St. Cruz, Tenerife
10. Klinikum St. Georg, Leipzig, Germany
11. St. Peters Hospital, Chertsey, United Kingdom
12. Centro Hospitalario Universitario Vigo, Vigo, Spain
13. Raigmore Hospital, Inverness, United Kingdom
14. Heart Center, Jessa Ziekenhuis, Hasselt, Belgium
15. Universital Hospital of Oulu, Oulu, Finland
16. Hospital Universitario La Paz, La Paz, Spain
17. BIOTRONIK SE & Co. KG, Berlin, Germany
18. Ghent University, Ghent, Belgium


Remote 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.
A 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. 
Average 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.
For 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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The increasing number of device-patients, and in particular the cost-driving treatment of heart failure patients as a major growing public health problem, emphasizes the need for health economic trials focusing on the saving potential of Home monitoring in various healthcare systems. While most previous trials have analyzed the cost impact from the healthcare payer’s perspective and the time required from physicians and nurses/technicians for home monitoring (HM)-based follow-ups (FU) of implantable cardiac defibrillators (ICDs), the primary objective of the EuroEco trial was cost analysis from the provider viewpoint emphasizing that it will influence the willingness to change from classical in-hospital FU to the usually not reimbursed home monitoring.
The main observation that provider’s costs for in-office FU’s did not different from HM-based FUs, nor on their net income, deserves some comments from a methodological and clinical standpoint.
One may question from a clinical and financial perspective whether it is relevant to limit the analyses to provider’s costs and net-income, defining it as the only incentive to use HM. The value of HM compared to its cost is not investigated and an incremental cost-effectiveness ratio (ICER) calculation, examining the balance between additional health benefits and additional costs of achieving those health benefits would have been desired. The use of Qualys is usually recommended for health care analyses and would have been clinically relevant, as it also permit comparisons with other investigations.
One may also question that while total FU related cost for providers was chosen as the primary endpoint, the power calculations for sample size was based on a surrogate, i.e. the anticipated reduction of total time needed for FU by 14.5 min over 2 years, a figure derived from earlier cohorts. If the study population is not representative of the cohorts used, which may occur over time, the calculated difference may be overestimated resulting in an underpowered study.
A more important question is, however, whether this difference is clinically relevant and the only incentive to use HM. The observation that HM is associated with shorter cardiovascular hospitalizations (Connect trial) and reduced mortality in ICD patients with heart failure (IN-TIME trial) thus seem stronger arguments for shifting to HM. A recent study (SAVE HM trial) reporting significantly lower costs for HM compared to office visits, with reduced hospital visits and pre-detecting of events that would have required unscheduled visits, further supports the use of HM.
A potential methodological weakness in the Euroecho trial is that the use of HM was not optimized and predefined but left to the investigators discretion, which explains the higher time consumption for physicians when compared to other trials. Had a more lenient use of HM been adopted, including the elimination of learning curves, the outcome would likely have favored HM use even stronger. This would also be the case if the mandatory in-office FUs for the HM group had been excluded. The study team should however have credit for the detailed analyses and efforts made to over utilization data to minimize underreporting.  
An observation that likely influenced the outcome was that the studied population was quite healthy with only moderately reduced LVEF and therefore expectedly less prone to recurrent arrhythmias, which require less interactions and FU’s.
One potential limitation is that the number of FU-visits is described as a continuous variable instead of a count variable, which may have influenced the results since the calculation of ratios, number of visits per person years, using Poisson regression, was not possible. The advantage of analyzing the number of FU-visits with a Poisson regression is that one can take into account how many days during the study, each patient was available for a FU-visit. The day the patient is admitted to hospital or if the patient is deceased, a new FU-visit is not possible. It is quite a big difference between a patient who had 5-FU visits but was only "available" 180 days, and another who was available 600 days.
The “Take home messages” with this trials, and supported by others,  is that by using optimized HM management routinely, in-office FUs can be replaced by HM FUs leading to a total FU reduction, without increasing costs or effecting the quality of medical treatment.




Hot Line: Heart failure: devices and interventions

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.