Insights from an international clinic survey on CIED patient management practices and perceptions
Authors: Roberts P R , Lyons M , Martens E , Seiler A , Van Heel L , Tsiperfal A , Nicolle E , Lanctin D , De Melis M , Renneboog C L , Meijer C , Allred J 
Published: October 2024

Abstract

Background
Remote monitoring (RM) is recommended as standard of care to manage patients with cardiac implantable electronic devices (CIEDs). However, implementation within overall follow-up (FU) practice is challenging with many organizational aspects to consider. While the 2023 HRS/EHRA/APHRS/LAHRS consensus on management of remote device clinics provided guidance, data on current patient management practice is lacking to understand existing gaps.

Purpose
This survey of device clinic staff characterized the state and perceptions of CIED patient management.

Methods
A Delphi panel of US and EU clinical experts guided the research objectives, structure, and content of the survey. Once consensus was reached, the online survey (Qualtrics) was deployed in partnership with HRS. An available case analysis was performed to handle missing data.

Results
A total of 471 responses were received between September 2023-January 2024 (66% US, 19% Europe, 15% other). Overall, performing a combination of in-office visits and RM was the most frequent FU practice for all devices. Remote-only management was only commonly reported for insertable cardiac monitors (ICM). Adoption of RM was lower in EU compared to US for therapeutic devices, especially pacemakers for which in-person only FU remained high (Figure 1). Frequency of routine visits and transmissions is reported in Figure 2. While the majority of respondents (48-67%, depending on device type) expressed that less than 20% routine visits are actionable, adopting a practice of FU visits scheduled every 2 years as suggested in the 2023 consensus was rarely reported for therapeutic devices. However, alert-based RM seems to emerge for ICM without routine FU. In the US, frequency of scheduled transmissions appeared aligned with reimbursement rules (monthly for ICMs; quarterly for therapeutic devices), whereas there was more variability in EU where RM often lacks clear funding. Divided opinion was observed regarding staff sufficiency as 43% found staffing levels somewhat/very sufficient, while 42% rated it as somewhat/very insufficient. Managing disconnected patients, initial transmission review, and patient phone calls were identified as most burdensome tasks and were the ones for which there was most willingness to outsource. Although 60% respondents rated their practice as somewhat/very efficient, the majority (45%) did not report monitoring performance. The minority (29%) assessing patient management performance primarily tracked workload volume rather than quality-related metrics.

Conclusion
This large international survey characterized contemporary CIED patient management practices. While the 2023 HRS/EHRA/APHRS/LAHRS consensus highlighted the potential for alert-based RM, reducing in-person visits, and third-party resources to streamline patient FU, these practices have yet to be fully implemented. As such, there is opportunity to standardize and optimize workflows to drive efficiency and quality of care.Follow-up paradigm by regionFrequency of routine follow-up