E-HeaRT BPA: electronic health record telemetry BPA.

INTRODUCTION: Continuous cardiac monitoring in non-critical care settings is expensive and overutilised. As such, it is an important target of hospital interventions to establish cost-effective, high-quality care. Since inappropriate telemetry use was persistently elevated at our institution, we devised an electronic best practice alert (BPA) and tested it in a randomised controlled fashion. METHODS: Between 4 March 2018 and 5 July 2018 at our 600-bed academic hospital, all non-critical care patients who had at least one telemetry order were randomised to the control or intervention group. The intervention group received daily BPAs if telemetry was active. RESULTS: 275 and 283 patients were randomised to the intervention and control groups, respectively. The intervention group triggered 1042 alerts and trended toward fewer telemetry days (3.8 vs 5.0, p=0.017). The intervention group stopped telemetry 31.7% of the alerted patient-days compared with 23.3% for the control group (OR 1.53, 95% CI 1.24 to 1.88, p<0.001). There were no significant differences in length of stay, rapid responses, code blues, or mortality between the two groups. CONCLUSIONS: Using a randomised controlled design, we show that BPAs significantly reduce telemetry without negatively affecting patient outcomes. They should have a role in promoting high-value telemetry use.

Outcomes and costs of remote patient monitoring among patients with implanted cardiac defibrillators: An economic model based on the PREDICT RM database.

BACKGROUND: Remote monitoring of implantable cardioverter-defibrillators has been associated with reduced rates of all-cause rehospitalizations and mortality among device recipients, but long-term economic benefits have not been studied. METHODS AND RESULTS: An economic model was developed using the PREDICT RM database comparing outcomes with and without remote monitoring. The database included patients ages 65 to 89 who received a Boston Scientific device from 2006 to 2010. Parametric survival equations were derived for rehospitalization and mortality to predict outcomes over a maximum time horizon of 25 years. The analysis assessed rehospitalization, mortality, and the cost-effectiveness (expressed as the incremental cost per quality-adjusted life year) of remote monitoring versus no remote monitoring. Remote monitoring was associated with reduced mortality; average life expectancy and average quality-adjusted life years increased by 0.77 years and 0.64, respectively (6.85 life years and 5.65 quality-adjusted life years). When expressed per patient-year, remote monitoring patients had fewer subsequent rehospitalizations (by 0.08 per patient-year) and lower hospitalization costs (by $554 per patient year). With longer life expectancies, remote monitoring patients experienced an average of 0.64 additional subsequent rehospitalizations with increased average lifetime hospitalization costs of $2784. Total costs of outpatient and physician claims were higher with remote monitoring ($47 515 vs $42 792), but average per patient-year costs were lower ($6232 vs $6244). The base-case incremental cost-effectiveness ratio was $10 752 per quality-adjusted life year, making remote monitoring high-value care. CONCLUSION: Remote monitoring is a cost-effective approach for the lifetime management of patients with implantable cardioverter-defibrillators.

Assessment of Remote Heart Rhythm Sampling Using the AliveCor Heart Monitor to Screen for Atrial Fibrillation: The REHEARSE-AF Study.

BACKGROUND: Asymptomatic atrial fibrillation (AF) is increasingly common in the aging population and implicated in many ischemic strokes. Earlier identification of AF with appropriate anticoagulation may decrease stroke morbidity and mortality. METHODS: We conducted a randomized controlled trial of AF screening using an AliveCor Kardia monitor attached to a WiFi-enabled iPod to obtain ECGs (iECGs) in ambulatory patients. Patients ≥65 years of age with a CHADS-VASc score ≥2 free from AF were randomized to the iECG arm or routine care (RC). iECG participants acquired iECGs twice weekly over 12 months (plus additional iECGs if symptomatic) onto a secure study server with overread by an automated AF detection algorithm and by a cardiac physiologist and/or consultant cardiologist. Time to diagnosis of AF was the primary outcome measure. The overall cost of the devices, ECG interpretation, and patient management were captured and used to generate the cost per AF diagnosis in iECG patients. Clinical events and patient attitudes/experience were also evaluated. RESULTS: We studied 1001 patients (500 iECG, 501 RC) who were 72.6±5.4 years of age; 534 were female. Mean CHADS-VASc score was 3.0 (heart failure, 1.4%; hypertension, 54%; diabetes mellitus, 30%; prior stroke/transient ischemic attack, 6.5%; arterial disease, 15.9%; all CHADS-VASc risk factors were evenly distributed between groups). Nineteen patients in the iECG group were diagnosed with AF over the 12-month study period versus 5 in the RC arm (hazard ratio, 3.9; 95% confidence interval=1.4-10.4; P=0.007) at a cost per AF diagnosis of $10 780 (£8255). There was a similar number of stroke/transient ischemic attack/systemic embolic events (6 versus 10, iECG versus RC; hazard ratio=0.61; 95% confidence interval=0.22-1.69; P=0.34). The majority of iECG patients were satisfied with the device, finding it easy to use without restricting activities or causing anxiety. CONCLUSIONS: Screening with twice-weekly single-lead iECG with remote interpretation in ambulatory patients ≥65 years of age at increased risk of stroke is significantly more likely to identify incident AF than RC over a 12-month period. This approach is also highly acceptable to this group of patients, supporting further evaluation in an appropriately powered, event-driven clinical trial. CLINICAL TRIAL REGISTRATION: URL: https://www.isrctn.com. Unique identifier: ISRCTN10709813.

Economic impact of remote monitoring after implantable defibrillators implantation in heart failure patients: an analysis from the EFFECT study.

AIMS: Heart failure (HF) patients with implantable cardioverter-defibrillators (ICD) require admissions for disease management and out-patient visits for disease management and assessment of device performance. These admissions place a significant burden on the National Health Service. Remote monitoring (RM) is an effective alternative to frequent hospital visits. The EFFECT study was a multicentre observational investigation aiming to evaluate the clinical effectiveness of RM compared with in-office visits standard management (SM). The present analysis is an economic evaluation of the results of the EFFECT trial. METHODS AND RESULTS: The present analysis considered the direct consumption of healthcare resources over 12-month follow-up. Standard tariffs were applied to hospitalizations, in-office visits and remote device interrogations. Economic comparisons were also carried out by means of propensity score (PS) analysis to take into account the lack of randomization in the study design. The analysis involved 858 patients with ICD or CRT-D. Of these, 401 (47%) were followed up via an SM approach, while 457 (53%) were assigned to RM. The rate of hospitalizations was 0.27/year in the SM group and 0.16/year in the RM group (risk reduction =0.59; P = 0.0004). In the non-adjusted analysis, the annual cost for each patient was €817 in the SM group and €604 in the RM group (P = 0.014). Propensity score analysis, in which 292 RM patients were matched with 292 SM patients, confirmed the results of the non-adjusted analysis (€872 in the SM group vs. €757 in the RM group; P < 0.0001). CONCLUSION: There is a reduction in direct healthcare costs of RM for HF patients with ICDs, particularly CRT-D, compared with standard monitoring. CLINICAL TRIAL REGISTRATION: http://clinicaltrials.gov/Identifier, NCT01723865.

Telemetric intra-cranial pressure monitoring: clinical and financial considerations.

Intracranial pressure (ICP) measurement is an important diagnostic tool in Neurosurgery. Until relatively recently, conventional monitoring has required that subjects be admitted to a hospital bed and the device is only able to be left in-situ for limited periods of time. We have evaluated a Telemetric ICP monitoring system that has been proven, by several other groups worldwide, to permit rapid, repeated and prolonged ICP measurement, in multiple environments. In our unit, 4 patients have been implanted to-date, between the ages of 4 and 16, manifesting a wide range of complex neurosurgical conditions. The sensors have been left in-situ for between 460 and 632 days. There have been no clinical complications and the system has been universally well tolerated. Clinical events, costs and patient experience were all assessed prior to and following implantation. Overall, there was a significant reduction in associated admissions (44.3%), imaging requirements (72.5%) and costs (50.0%). Subjective feedback from both the patients (where possible) and their families was overwhelmingly positive, partly due to (a) the system's ease of use, (b) its ability to reduce the number of admissions/tests required and (c) the facility for rapid measurement of ICP that permitted on-the-spot reassurance of concerns. Additionally, the ability to monitor ICP at home and/or whilst ambulant, has provided measurements that were hitherto inaccessible to our team, facilitating all the potential benefits that analysis of such information would provide. Indeed, we have seen the resultant management in each case has been completely altered by the availability of this data, reaffirming that the importance of being able to obtain it should not be underestimated. The combination of both this and the ability to markedly improve patient experience, along with generating significant cost-savings, lead the authors to suggest that the implantation of this system should be strongly considered in selected individuals.

Legal Mapping Analysis of State Telehealth Reimbursement Policies.

BACKGROUND: There exists rapid growth and inconsistency in the telehealth policy environment, which makes it difficult to quantitatively evaluate the impact of telehealth reimbursement and other policies without the availability of a legal mapping database. INTRODUCTION: We describe the creation of a legal mapping database of state-level policies related to telehealth reimbursement of healthcare services. Trends and characteristics of these policies are presented. MATERIALS AND METHODS: Information provided by the Center for Connected Health Policy was used to identify statewide laws and regulations regarding telehealth reimbursement. Other information was retrieved by using: (1) LexisNexis database, (2) Westlaw database, and (3) retrieval from legislative Web sites, historical documents, and contacting state officials. We examined policies for live video, store-and-forward, and remote patient monitoring (RPM). RESULTS: In the United States, there are 24 states with policies regarding reimbursement for live video transmission. Fourteen states have store-and-forward policies, and six states have RPM-related policies. Mississippi is the only state that requires reimbursement for all three types of telehealth transmission modes. Most states (47 states) have Medicaid policies regarding live video transmission, followed by 37 states for store-and-forward and 20 states for RPM. Only 13 states require that live video will be reimbursed "consistent with" or at the "same rate" as in-person services in their Medicaid program. DISCUSSION: There are no widely accepted telehealth reimbursement policies across states. They contain diverse restrictions and requirements that present complexities in policy evaluation and in determining policy effectiveness across states.

BRAVO esophageal pH monitoring: more cost-effective than empiric medical therapy for suspected gastroesophageal reflux.

INTRODUCTION: Early referral for catheter-based esophageal pH monitoring is more cost-effective than empiric proton-pump inhibitor (PPI) therapy to diagnose gastroesophageal reflux disease (GERD). We hypothesize that BRAVO wireless pH monitoring will also demonstrate substantial cost-savings compared to empiric PPI therapy, given its superior sensitivity and comfort. METHODS: We reviewed 100 consecutive patients who underwent wireless pH monitoring for suspected GERD at our institution. A cost model and a cost equivalence calculation were generated. Cost-saving analyses were performed for both esophageal and extraesophageal symptoms. RESULTS: Eighty-seven patients were available for analysis. Median PPI use prior to referral was 215 weeks (range 0-520). Forty-three patients (49 %) had BRAVO results diagnosing GERD; 98 % of these had esophageal symptoms. Patients with negative BRAVO studies had a median of 113 (0-520) weeks of unnecessary PPI therapy. Cost-savings ranged from $1048 to $15,853 per patient, depending on sensitivity (75-95 %), PPI dosage, and brand. Maximum cost-savings occurred in patients with extraesophageal symptoms ($2948-$31,389 per patient). The PPI cost equivalence of BRAVO placement was 36 and 6 weeks for low- and high-dose therapy, respectively. CONCLUSIONS: BRAVO wireless pH testing is more cost-effective than prolonged empiric medical management for GERD and should be incorporated early in the treatment algorithm.

Telemonitoring of CPAP therapy may save nursing time.

PURPOSE: Telemonitoring might enhance continuous positive airway pressure (CPAP) adherence and save nursing time at the commencement of CPAP therapy. We tested wireless telemonitoring (ResTraxx Online System®, ResMed) during the habituation phase of the CPAP therapy in obstructive sleep apnea syndrome (OSAS). METHODS: In total, 111 consecutive OSAS patients were enrolled. After CPAP titration, patients were followed with the telemonitoring (TM, N = 50) or the usual care (UC, N = 61). The TM group used fixed pressure CPAP device with and the UC group similar device without wireless telemonitoring. Patients and study nurses were unblinded. The evaluated end-points were hours of CPAP use >4 h/day, mask leak <0.4 L/s, and AHI <5/h. Nursing time including extra phone calls, visits, and telemonitoring time was recorded during the habituation phase. CPAP adherence was controlled in the beginning and at the end of the habituation phase and after 1-year of use. RESULTS: TM and UC groups did not differ in terms of patient characteristics. The average length of the habituation phase was 4 weeks in the TM group and fixed 3 months in the UC group. Median nursing time was 39 min (range 12-132 min) in the TM group and shorter compared to that of 58 min (range 40-180 min) (p < 0.001) per patient in the UC group. Both treatment groups had high CPAP usage hours (>4 h/day) and the change in usage at the end of the habituation phase did not differ between the groups (p = 0.39). Patients in both groups were equally satisfied with the treatment protocol. CPAP adherence (6.4 h in TM vs. 6.1 h in UC group, p = 0.63) and residual AHI (1.3 in TM vs. 3.2 in UC group, p = 0.04) were good in both groups at 1-year follow-up. CONCLUSIONS: Wireless telemonitoring of CPAP treatment could be relevant in closing the gap between the increasing demand and available health-care resources. It may save nursing time without compromising short- or long-term effectiveness of CPAP treatment in OSAS.

A cost analysis of remote monitoring in a heart failure program.

In this study, we examine the cost per outcomes of remote monitoring services in home health care. The methodology followed case matched design via retrospective chart reviews. Results of the chi-square test suggest that there were no significant associations between the intervention and hospital readmissions, χ2 = (1, n = 210, p-value = .71, phi = .71). An independent t-test compared group means of the number of skilled nursing visits and agency costs, p-value of .002 and .000, respectively, favoring the standard of care group. Based on this data set, the home care agency lost $153.46 for each hospital readmission in the intervention group. The cost of care complicated the agency's resources through an increase in nursing visits without offsetting the agency's investment into technology; the cost did not support remote monitoring as a financially viable option to the standard of care.

Cost comparison between home telemonitoring and usual care of older adults: a randomized trial (Tele-ERA).

BACKGROUND: From 1992 to 2008, older adults in the United States incurred more healthcare expense per capita than any other age group. Home telemonitoring has emerged as a potential solution to reduce these costs, but evidence is mixed. The primary aim of the study was to evaluate whether the mean difference in total direct medical cost consequence between older adults receiving additional home telemonitoring care (TELE) (n=102) and those receiving usual medical care (UC) (n=103) were significant. Inpatient, outpatient, emergency department, decedents, survivors, and 30-day readmission costs were evaluated as secondary aim. MATERIALS AND METHODS: Multivariate generalized linear models (GLMs) and parametric bootstrapping method were used to model cost and to determine significance of the cost differences. We also compared the differences in arithmetic mean costs. RESULTS: From the conditional GLMs, the estimated mean cost differences (TELE versus UC) for total, inpatient, outpatient, and ED were -$9,537 (p=0.068), -$8,482 (p =0.098), -$1,160 (p=0.177), and $106 (p=0.619), respectively. Mean postenrollment cost was 11% lower than the prior year for TELE versus 22% higher for UC. The ratio of mean cost for decedents to survivors was 2.1:1 (TELE) versus 12.7:1 (UC). CONCLUSIONS: There were no significant differences in the mean total cost between the two treatment groups. The TELE group had less variability in cost of care, lower decedents to survivors cost ratio, and lower total 30-day readmission cost than the UC group.

The effect of a randomized trial of home telemonitoring on medical costs, 30-day readmissions, mortality, and health-related quality of life in a cohort of community-dwelling heart failure patients.

BACKGROUND: Telemonitoring has been advocated as a way of decreasing costs and improving outcomes, but no study has looked at true Medicare payments and 30-day readmission rates in a randomized group of well treated patients. OBJECTIVE: The aim of this work was to analyze Medicare claims data to identify effects of home telemonitoring on medical costs, 30-day rehospitalization, mortality, and health-related quality of life. METHODS: A total of 204 subjects were randomized to usual-care and monitored groups and evaluated with the SF-36 and Minnesota Living With Heart Failure Questionnaire (MLHF). Hospitalizations, Medicare payments, and mortality were also assessed. Monitored subjects transmitted weight, blood pressure, and heart rate, which were monitored by an experienced heart failure nurse practitioner. RESULTS: Subjects were followed for 802 ± 430 days; 75 subjects in the usual-care group (316 hospitalizations) and 81 in the monitored group (327 hospitalizations) were hospitalized at least once (P = .51). There were no differences in Medicare payments for inpatient or emergency department visits, and length of stay was not different between groups. There was no difference in 30-day readmissions (P = .627) or mortality (P = .575). Scores for SF-36 and MLHF improved (P < .001) over time, but there were no differences between groups. The percentage of patients readmitted within 30 days was lower with telemonitoring for the 1st year, but this did not persist. CONCLUSIONS: Telemonitoring did not result in lower total costs, decreased hospitalizations, improved symptoms, or improved mortality. A decrease in 30-day readmission rates for the 1st year did not result in decreased total cost or better outcomes.

Costs of remote monitoring vs. ambulatory follow-ups of implanted cardioverter defibrillators in the randomized ECOST study.

AIMS: The Effectiveness and Cost of ICD follow-up Schedule with Telecardiology (ECOST) trial evaluated prospectively the economic impact of long-term remote monitoring (RM) of implantable cardioverter defibrillators (ICDs). METHODS AND RESULTS: The analysis included 310 patients randomly assigned to RM (active group) vs. ambulatory follow-ups (control group). Patients in the active group were seen once a year unless the system reported an event mandating an ambulatory visit, while patients in the control group were seen in the ambulatory department every 6 months. The costs of each follow-up strategy were compared, using the actual billing documents issued by the French health insurance system, including costs of (i) (a) ICD-related ambulatory visits and transportation, (b) other ambulatory visits, (c) cardiovascular treatments and procedures, and (ii) hospitalizations for the management of cardiovascular events. The ICD and RM system costs were calculated on the basis of the device remaining longevity at the end of the study. The characteristics of the study groups were similar. Over a follow-up of 27 months, the mean non-hospital costs per patient-year were €1695 ± 1131 in the active, vs. €1952 ± 1023 in the control group (P = 0.04), a €257 difference mainly due to device management. The hospitalization costs per patient-year were €2829 ± 6382 and €3549 ± 9714 in the active and control groups, respectively (P = 0.46). Adding the ICD to the non-hospital costs, the savings were €494 (P = 0.005) or, when the monitoring system was included, €315 (P = 0.05) per patient-year. CONCLUSION: From the French health insurance perspective, the remote management of ICD patients is cost saving. CLINICAL TRIALS REGISTRATION: NCT00989417, www.clinicaltrials.gov.

Financial impact of adopting implantable loop recorder diagnostic for unexplained syncope compared with conventional diagnostic pathway in Portugal.

BACKGROUND: To estimate the short- and long-term financial impact of early referral for implantable loop recorder diagnostic (ILR) versus conventional diagnostic pathway (CDP) in the management of unexplained syncope (US) in the Portuguese National Health Service (PNHS). METHODS: A Markov model was developed to estimate the expected number of hospital admissions due to US and its respective financial impact in patients implanted with ILR versus CDP. The average cost of a syncope episode admission was estimated based on Portuguese cost data and landmark papers. The financial impact of ILR adoption was estimated for a total of 197 patients with US, based on the number of syncope admissions per year in the PNHS. Sensitivity analysis was performed to take into account the effect of uncertainty in the input parameters (hazard ratio of death; number of syncope events per year; probabilities and unit costs of each diagnostic test; probability of trauma and yield of diagnosis) over three-year and lifetime horizons. RESULTS: The average cost of a syncope event was estimated to be between 1,760€ and 2,800€. Over a lifetime horizon, the total discounted costs of hospital admissions and syncope diagnosis for the entire cohort were 23% lower amongst patients in the ILR group compared with the CDP group (1,204,621€ for ILR, versus 1,571,332€ for CDP). CONCLUSION: The utilization of ILR leads to an earlier diagnosis and lower number of syncope hospital admissions and investigations, thus allowing significant cost offsets in the Portuguese setting. The result is robust to changes in the input parameter values, and cost savings become more pronounced over time.

A ubiquitous and low-cost solution for movement monitoring and accident detection based on sensor fusion.

The low average birth rate in developed countries and the increase in life expectancy have lead society to face for the first time an ageing situation. This situation associated with the World's economic crisis (which started in 2008) forces the need of equating better and more efficient ways of providing more quality of life for the elderly. In this context, the solution presented in this work proposes to tackle the problem of monitoring the elderly in a way that is not restrictive for the life of the monitored, avoiding the need for premature nursing home admissions. To this end, the system uses the fusion of sensory data provided by a network of wireless sensors placed on the periphery of the user. Our approach was also designed with a low-cost deployment in mind, so that the target group may be as wide as possible. Regarding the detection of long-term problems, the tests conducted showed that the precision of the system in identifying and discerning body postures and body movements allows for a valid monitorization and rehabilitation of the user. Moreover, concerning the detection of accidents, while the proposed solution presented a near 100% precision at detecting normal falls, the detection of more complex falls (i.e., hampered falls) will require further study.

Telemetry discontinuation education for Nurse Practitioners decreases hospital costs-A quality-improvement project.

BACKGROUND: Despite updated American Heart Association guidelines, interventions designed to reduce telemetry misuse are uncommon. LOCAL PROBLEM: There was a systemic failure within the institution to adopt the most recent guidelines, resulting in poor use of resources and downstream costs. METHODS: Case-control. Pre-post educational intervention, quality-improvement (QI) project in an urban academic cancer institution. Baseline telemetry usage was observed in 2,984 nonintensive inpatients in 21 hospital services over 6 months. Outcome measures were weekly telemetry usage in total minutes and cost savings based on a cost-predicted algorithm. Performance was compared between the intervention group and a control group for 3 months. Measures were compared using QI control charts and inferential statistics. INTERVENTION: Three high-using telemetry services primarily staffed by certified nurse practitioners (CNPs) were provided with a telemetry education intervention. The intervention consisted of four ten-minute educational sessions over 2 weeks delivered to the highest three telemetry using services. RESULTS: Forty-five providers received the educational intervention (78% CNPs and physician assistants [PAs] and 22% medical doctors [MDs]) and 272 did not (57% CNPs and PAs and 43% MDs). Only the educational intervention group showed measurable decreases shown by shifts in QI control charts. Decreased usage in the intervention group produced greater cost savings per patient when compared with the control group ($71.98 vs. $60.68), resulting in an estimated total annual cost savings of $94,740. CONCLUSIONS: Educational interventions for inpatient CNPs that reinforce national policies for telemetry discontinuation improve practice efficiency and potentially decrease health care costs.

Comparing the outcomes and costs of cardiac monitoring with implantable loop recorders and mobile cardiac outpatient telemetry following stroke using real-world evidence.

Aim: Patients with ischemic stroke (IS) commonly undergo monitoring to identify atrial fibrillation with mobile cardiac outpatient telemetry (MCOT) or implantable loop recorders (ILRs). The authors compared readmission, healthcare cost and survival in patients monitored post-stroke with either MCOT or ILR. Materials & methods: The authors used claims data from Optum's de-identified Clinformatics® Data Mart Database to identify patients with IS hospitalized from January 2017 to December 2020 who were prescribed ambulatory cardiac monitoring via MCOT or ILR. They compared the costs associated with the initial inpatient visit as well as the rate and causes of readmission, survival and healthcare costs over the following 18 months. Datasets were balanced using patient baseline and hospitalization characteristics. Multivariable generalized linear gamma regression was used for cost comparisons. Cox proportional hazard regression was used for survival and readmission analysis. Sub-cohorts were analyzed based on the severity of the index IS. Results: In 2244 patients, readmissions were significantly lower in the MCOT monitored group (30.2%) compared with the ILR group (35.4%) (hazard ratio [HR] 1.23; 95% CI: 1.04-1.46). Average cost over 18 months starting with the index IS was $27,429 (USD) lower in the MCOT group (95% CI: $22,353-$32,633). Survival difference bordered on statistical significance and trended to lower mortality in MCOT (8.9%) versus ILR (11.3%) (HR 1.30; 95% CI: 1:00-1.69), led by significance in patients with complications or comorbidities with the index event (MCOT 7.5%, ILR 11.5%; HR 1.62; 95% CI: 1.11-2.36). Conclusion: The use of MCOT versus ILR as the primary monitor following IS was associated with significant decreases in readmission, lower costs for the initial IS and total care over the next 18 months, significantly lower mortality for patients with complications and comorbidities at the index stroke, and a trend toward improved survival across all patients.

Remote follow-up of pacemakers in a selected population of debilitated elderly patients.

AIMS: The majority of patients with pacemakers are very elderly, many being >85-years old. They often suffer from serious illnesses and have great difficulty in walking. The aim of our study was to compare remote pacemaker monitoring with in-home checks of pacemakers, in terms of applicability, efficacy, and cost in a selected population of debilitated elderly patients. METHODS AND RESULTS: We selected 72 subjects (mean age 87 ± 8 years) among elderly debilitated patients with Medtronic pacemakers, compatible with the Carelink(®) remote monitoring system (13 patients with DDD pacemaker; 59 patients with single-lead VDD pacemaker). Remote follow-up was compared with in-home checks performed by nurses in 326 patients in similar clinical conditions. A total of 190 transmissions were received by remote monitoring (mean transmissions per month: 7.0; mean per patient: 2.6; range 1-6) during 27 months of follow-up. In this period, seven pacemakers were replaced owing to battery exhaustion, after a mean of 6.7 years from implantation. The occurrence of atrial or ventricular high-rate episodes was reported in 98 transmissions (53%). Nineteen patients died (annual mortality: 11.7%). On comparing the costs borne by the hospital for in-home checks, both for medical personnel and transportation, the estimated average saving was €32 per year per patient. CONCLUSION: Our study shows that the remote follow-up of pacemakers is a reliable, effective, and cost-saving procedure in elderly, debilitated patients. Moreover, remote controls provided an accurate and early diagnosis of arrhythmia occurrence.

Home telemonitoring for chronic disease management: an economic assessment.

OBJECTIVES: There have been very few assessments of the economics of home telemonitoring, and the quality of evidence has often been weakened by methodological flaws. This has made it difficult to compare telehomecare with traditional home care for the chronic diseases studied. This economic analysis is an attempt to address this gap in the literature. METHODS: We have analyzed the consumption of healthcare services by 95 patients with various chronic diseases over a 21-month period, that is, 12 months before, 4 months during home telemonitoring use, and over 5 months after withdraw of the technology. RESULTS: Our findings indicate significant benefits to the home telemonitoring program as evidenced by large reductions in number of hospitalizations, length of average hospital stay, and, to a lesser extent, number of emergency room visits. Contrary to expectations, however, the number of home visits by nurses increased both during and after the telemonitoring intervention. In terms of the financial analysis, the telehomecare program resulted in significant savings: the equivalent of over CAD1,557 per patient as calculated on an annualized basis. This represents a net gain of 41 percent as compared to traditional home care. CONCLUSIONS: While the present economic analysis led to positive results, additional assessments should be conducted to confirm the cost-effectiveness of this mode of care delivery.

Telehealth remote monitoring for community-dwelling older adults with chronic obstructive pulmonary disease.

OBJECTIVE: To determine if self-monitoring via home-based telehealth equipment could, when combined with ongoing remote monitoring by a nurse, reduce the incidence of hospitalizations and emergency department (ED) presentations for people with chronic obstructive pulmonary disease (COPD). SUBJECTS AND METHODS: A randomized controlled trial was used to compare the outcomes for participants receiving the telehealth equipment and monitoring with those for participants in an information-only control group, over a period of 6 months. Participants receiving the telehealth intervention were taught to measure and record their vital signs (blood pressure, weight, temperature, pulse, and oxygen saturation levels) on a daily basis. These were then transmitted automatically via telephone to a secure Web site where they were monitored each day by the telehealth nurse. RESULTS: The telehealth group had fewer ED presentations and hospital admissions and a reduced length of stay in comparison with the control group. These results were not statistically significant. However, the reduction in health service use was large enough to result in significant cost savings, with the annual cost savings of the telehealth group compared with the control group being $2,931 per person. CONCLUSIONS: Telehealth monitoring of patient vital signs reduced health service utilization for individuals with COPD and resulted in significant cost savings. In terms of individual health benefits, improvements in participants' self-management behaviors and control over their condition was evident.