By Doug Beinborn

An estimated three million-plus patients live in the United States with implanted cardiac devices, with 400,000 implanted annually. Follow-up care for these patients continues to evolve and become more challenging due to increasing clinical complexity of patients and diagnostic device features.

Cardiac implantable electronic devices (CIEDs) include pacemakers, implantable cardioverter defibrillators (ICDs) and loop recorders. Patients who receive them must be monitored for device functionality and the physiological data it yields. For this they have two options: in clinic (IC) visits and remote monitoring (RM). One method is costly and allows monitoring every three months; the other provides daily information with increased efficiencies, superior clinical outcomes, and cost savings. Yet, as a whole, the health care industry has been slow to embrace the better choice.

RM offers advantages for clinicians and patients to minimize some of the complexities in cardiac monitoring while maximizing outcomes. Multiple randomized trials and registries have clearly determined the superiority of RM over IC visits including:
• Improved survival rates by over 50%
• Improved patient quality of life
• Improved patient compliance comparing RM to IC follow-up
• Faster detection of actionable clinical events
• Reduction in clinical CIED evaluation time by 58%
• Decreased hospital length of stay by 18%

Now that the COVID-19 pandemic has given patients reason to avoid health care facilities, it’s time to consider fully incorporating remote monitoring into cardiac care for the benefits — financial and clinical — it provides.

The financial case for remote monitoring
The Centers for Medicare & Medicaid Services Current Procedural Technology code for reimbursement includes evaluation for pacemakers and ICDs. Each contains a professional and technical component. The average reimbursement, comparing these two methods, is nearly identical. Current CMS averages across the U.S. for these services show the global reimbursement difference between IC and RM is not a factor: $49 versus $56, respectively, for pacemakers and $66 versus $64 for ICDs.
 
The 2008 Heart Rhythm Society/European Heart Rhythm Association Expert Consensus on Monitoring CIED set international guidelines for minimum device follow-up frequency, though they vary depending on ICD, pacemaker, and implantable loop recorders (ILRs). Health care providers often choose to perform follow-up visits after device implantation every three to six months for pacemakers and ICDs. For RM and IC checks of pacemakers and ICDs, monitoring periods for reimbursement are set up for 90 day periods and can be charged up to four times per year. With ILRs and cardiac resynchronization therapy (CRT) monitoring for heart failure, separate codes have been established that are based on charging for reimbursement every 30 days.

The clinical case for remote monitoring
Despite the underutilization of remote CIED care, multiple studies and publications have clearly shown the superior benefits of RM versus IC models of care. We have transitioned from the 1971 model when transtelephonic monitoring captured battery and cardiac pacing data, to full-fledged device evaluation, where we can monitor effects of pacemaker therapy, lead fractures, atrial fibrillation burden, and status of heart failure intervention.

One of the largest device manufacturers estimates that 99.9% of their devices are now compatible with their remote monitoring network. For patients there is no need to travel to the clinic for routine CIED evaluations. Even better for the patient is that their CIED is evaluated daily through remote monitoring, versus once every 90-180 days based on their clinicians’ choice on how often they should return to the clinic for a follow-up exam.

There are multiple benefits to remote monitoring. Clinics benefit from not needing exam rooms, desk staff, parking space and cleaning of rooms between patients. Nurses and technical staff caring for this population can typically evaluate twice as many patients in a given time versus IC visits. Of significant value during a shortage of exam rooms or during a health crisis such as COVID-19, physicians and nurses can evaluate these patients outside of the traditional clinical setting. Already, an increasing number of hospital systems are allowing nurses to work remotely performing CIED checks, which has shown to increase productivity and staff satisfaction.

Clinicians and administrators should evaluate the clinical practice and make the necessary changes to monitor all existing and future CIED patients remotely. Implementation of remote monitoring into a clinic’s practice needs to be a priority. In the past, clinicians have given patients the option of IC or RM monitoring but all patients with CEIDs can be enrolled in RM, and the latest recommendations from various medical governing bodies advocate it immediately after implantation. Here’s how to convert routine existing IC visits to RM:
• Identify those who are enrolled in the remote monitoring program through the device manufacturer
• Contact patients who are enrolled, but who have not activated their device through their home networks, Wi-Fi source, cell phone adapter or land line to connect their system to the internet
• Identify those who have a CIED but are not enrolled in RM because they opted for IC visits
• Arrange for manufacturer to send RM system to patient
• Provide instructions for enrolling and activating the device and the appropriate contact at device manufacturer to assist with connecting if there are issues

With the need for social distancing because of COVID-19 compounded with the superiority of RM, medical centers should evaluate how to transition all patients to this care model. Providers and hospital leaders should team together to convert IC routine device evaluations into RM. Allowing patients to choose IC for CIED care is no longer in the patient’s best interest.

About the author: Doug Beinborn is an associate principal in strategic supplier partnerships and works closely with industry and hospital members in the cardiovascular, orthopedic and neuro intervention space.