Home Monitoring - is it really that effective?

With the launch of the first Home Monitoring system some seven years ago, there came a new and unique concept. Since that time, the technology has advanced at an exponential rate. Such systems are now capable of providing data on device and lead integrity, asymptomatic episodes, transmit IEGM’s and even real-time follow up information.

Home Monitoring brings with it numerous advantages. Most systems can be incorporated into any patient’s standard follow up regime with minimal difficulty and depending on the manufacturer, there is little or no patient compliance required. However, to get the most from these systems they need to have a few prerequisites including automaticity and the ability to be as tailorable as possible.

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Enhanced patient safety is one of the principal benefits of Home Monitoring. A system that can notify Physicians and/or Cardiac Physiologists of any adverse changes in device measurements or behaviour automatically and in a timely manner can only be beneficial for Physician and patient alike. Documented examples of automatically detected device/lead problems include:

Sebastian Spencker and faculty, reported on a severe pacemaker lead perforation. “The issue was detected when the automatic home-monitoring system transmitted a lead impedance that compared with the previous daily lead impedance measurement, had increased to the pathological range”. 1

P.A Zartner and team described how Home Monitoring predicted lead failure in a pacemaker dependent 4-year-old girl due to an increased threshold rise. 2

MF Sholten et al reported on another case of Home Monitoring aiding patient safety, they discovered a 68 year old patient with Twiddlers syndrome. One month post implantation of an ICD, the patient was admitted and the lead replaced. 3

These examples really show the enhanced safety and often peace of mind patients receive with Home Monitoring.

Depending on the device manufacturer, automatically transmitted data can include information on:

• ERI

• Lead/shock impedance

• Threshold values

• P/R wave values

• HD IEGM – Arrhythmic episodes

• Heart failure status

• Device deactivation

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Another particularly important advantage of Home Monitoring is the potential to perform virtual follow up’s. With the increasing rate of device implantations, follow up burden is due to grow at an exceptional rate. According to the ACC/AHA/NASPE 2006 guideline update (figure 5) in 2008 there will be 1.5 million patients requiring follow up care in the US.

Professor P Brugada’s analysis of 271 ICD patients demonstrated that Home Monitoring has the potential to reduce the number of routine follow-up visits by nearly half without impairing patient safety. 4

Virtual follow up’s can be performed easily and quickly from any office with internet access, with all the relevant data being available that would be present at any routine follow up. The notion of Home Monitoring is not to completely replace in-hospital device follow up’s, it is to be used as an additional facility, one that tailors patient care and directs resources to those patients that really need it. Therefore, patients that have a potential device issue can be monitored more closely and effectively whilst those “routine” patients do not have to attend the follow up clinic quite as often.

While patient safety remains paramount, there are further benefits to reducing hospital based follow up’s, cost effectiveness being one. The REFORM study looked at Home Monitoring against regular follow-up in MADIT II patients and looked at additional visits and cost impact specifically. The study revealed no significant difference in hospitalisations and mortality, whilst potential cost savings and reduction of patient visits at higher effectiveness was highly significant. For a group of 100 patients a sum of 81 physician hours could be saved along with transportation, administration and hospital costs equating to 71.231 € saved p. a. by Home Monitoring in the hospital. 5

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Another issue to consider is cost effectiveness from a patients’ perspective. If patients have to travel to all of their appointments things can get quite costly, public transport, taxi fares, fuel costs, parking charges and taking time away from work can add up to quite a sum over the lifetime of a device.

The incorporation of Home Monitoring into the post implant care of PM, ICD and CRT patients is increasing. The automatic transmission capabilities of scheduled and event information to the Physician and/or Cardiac Physiologist allows for a more streamlined approach to device surveillance. With the ability to tailor the service to the needs and preferences of the follow up clinic and patient, Home Monitoring is capable of improving patient care, patient quality of life, enhancing safety and reducing hospital expenditure.

References:

1. Sebastian Spencker, Dirk Mueller, Andrea Marek, and Markus Zabel. Severe pacemaker lead perforation detected by an automatic home-monitoring system. doi:10.1093/eurheartj/ehl495

2. P.A. Zartner, R.P Handke, A.M. Brecher, and M.B.E. Schneider. Integrated home monitoring predicts lead failure in a pacemaker dependent 4-year-old girl. Europace Feb 2007

3. Scholten MF, Thornton AS, Theuns DA, Res J, Jordaens LJ. Twiddler’s syndrome detected by home monitoring device. Pacing Clin Electrophysiol 2004;27:1151–2.

4. Professor Pedro Brugada. What evidence do we have to replace in-hospital implantable cardioverter defibrillator follow-up? Clin Res Cardiol 95:Suppl 3, 111/3-111/9 (2006)

5. CH Elsner, P Sommer, C Piorkowski, M Taborsky, H Neuser, J Bytesnik, JC Geller, H Kottkamp, H Wiesmeth, G Hindricks. A prospective multicenter comparison trial of Home Monitoring against regular follow-up in MADIT II patients: Additional visits and cost impact.