Costs and quality of care optimization in the remote monitoring of cardiac implantable electronic devices (CIEDs). A picture from Veneto, Northern Italy
Authors: Ignatiuk B , Baccillieri M.S , Frigo G , Marinaccio L , Cassinadri E , Montemurro D , Verlato R , Marchese D , Pasquetto G 
Published: November 2020

Abstract

Background
Remote control/monitoring (RC/M) of cardiac implantable electronic devices (CIEDs) is still underutilized, with a significant heterogeneity of use across and within countries. Not all models are equivalent in terms of effectiveness and efficiency.

Purpose
This cost comparative study aimed to analyse different models of following patients with CIEDs in three districts (four implanting facilities) merged into the same administrative area, to assess the impact of RC/M on expenditure, and to propose a common practice with the objectives of standardisation of approach, optimisation of efficiency, and future capillary implementation of RC/M.

Methods
The workload related to CIED-patient follow-ups was assessed in four public hospitals reflecting three different models with different proportions of patients followed by RC/M and different modus operandi. All CIED-patients in charge were scrutinized at 31/08/2019. The workload analysis was based on one-year data, collected retrospectively. Costs were calculated in terms of nursing and physician hours and based on public tariffs. Five variables, identified as drivers of costs, were tested by the simulation model. The main outcome was a total expenditure and cost per patient followed by RC/M compared to the standard care (SC) (in-office only).

Results
A total of 6830 patients with CIEDs were followed, 34.8% by RC/M (five platforms, 19.7% high voltage devices). An additional 25.8% had monitorable devices. The proportion of RC/M-patients across centres was 63.3%, 60.6%, 51% and 2.65%. RC/M resulted more costly than SC in all hospitals. Modelling demonstrated the overall cost in the year 2018 to be €228,075. No single factor optimisation tested separately (number of transmissions, nursing time for each transmission revision, doctor time for transmission processing, nursing time for phone calls, time for single enrolment) was able to reduce the cost per patient below the cost of SC. Providing monitoring to all compatible patients increased the costs of total care to €248,785. After the optimisation of other factors, the additional benefit of extending RC/M to compatible devices was achieved, with the final result of a total expenditure of €128,181 and of €15.97 per RC/M-patient per year vs. €27.93 per SC-patient, below the reimbursement tariff of monitoring recently approved in Veneto (€25.55 per patient/year).

Conclusion
Real-world data from an unselected population confirmed the huge inconsistency in managing patients with CIEDs. RC/M was associated with a significant specific workload. RC/M may be cost-saving compared to the standard in-office follow-up; however, organisation needs to be optimised. Improvement can be achieved by implementing new standards for RC/M procedures using Lean Management tools. A common platform might be of help. Centralisation could represent a further step to ensure high quality service and to save money at the same time.

Funding Acknowledgement
Type of funding source: None