Remote monitoring and prioritisation for patients awaiting transcatheter aortic valve implantation safely mitigates longer waiting times
Authors: Kelshiker M A , Chhatwal K , Mansell J , Bachtiger P , Jin E , Molloy O , Tang M , Pearse S , Malik *I S , Peters *N S 
Published: October 2024

Abstract

Background
• The UK National Health Service (NHS) faces an unprecedented backlog of over 400,000 patients awaiting critical cardiac procedures, incurring thousands of excess deaths (1).
• Longer waiting times to transcatheter aortic valve implantation (TAVI) can increase rates of unplanned hospitalisation and death (2).
• Remote patient monitoring (RPM) can improve cardiovascular clinical outcomes (3), but its effectiveness in detecting and managing TAVI waiting list deterioration is untested.

Purpose
1. Measure the systemic increase in waiting time to TAVI
2. Determine if RPM and prioritisation:
· Is acceptable to patients
· Detects clinical deterioration
· Mitigates the expected increase in adverse events associated with longer waiting times
· Does not unfairly disadvantage patients who are not prioritised

Methods
• We performed an observational cohort study including all patients awaiting TAVI at one UK regional centre between 24th April and 15th November 2023.
• Patients were supported to complete an online or telephone-based weekly symptom questionnaire.
• Responses were monitored by non-specialist nurses staffing a 'hub', with rule-based escalation to the TAVI team, who could prioritise treatment (Figure 1).
• A historical control cohort who did not receive RPM was identified, as sequential unselected patients on the TAVI waiting list in reverse order, from 24th April 2023 to 1st January 2023. This cohort was propensity score-matched to adjust for age, sex, ethnicity and comorbidities.
• Waiting time was defined as the date difference between a patient being placed on the waiting list and TAVI completion.
• We defined patient acceptability as &gt;80% engagement with at least one symptom questionnaire.
• Sensitivity was calculated as the percentage of escalations to the TAVI Consultant resulting in prioritisation.
• Kaplan-Meier survival analysis was performed for the primary endpoint of adverse events, defined as emergency department presentation, unplanned hospitalisation or death.

Results
• The median waiting time to TAVI increased by one month (104 days versus 75 days, p&lt;0.001).
• There was 99% (200/202) engagement with RPM
• Despite the increased waiting time, there was no significant difference in rate of adverse events between the propensity score-matched RPM and historical control groups (12.5% versus 13.7%, p=0.86) (Figure 2)
• 87% (27/31) of escalations to the TAVI Consultant resulted in treatment prioritisation
• There was a non-significant difference in median waiting time between prioritised and non-prioritised patients during the study period, but with no clinical consequence to the delay (97 versus 120 days, p=0.16).

Conclusions
• An RPM pathway can detect patient deterioration on TAVI waiting lists with high sensitivity
• RPM-based prioritisation for patients awaiting TAVI can mitigate the increased risk of adverse events associated with longer waiting times, without unfairly disadvantaging non-prioritised patients.Figure 1.RPM pathwayFigure 2