What is remote monitoring and how long has it been available?
Remote monitoring is the ability to follow patients who have implantable pacemakers or defibrillators from home. This technology was introduced in the U.S. in 2001 so it’s been available for close to 15 years.
How was this technology developed?
Though I’m not an expert in how this technology was developed, I can speak to why it was developed. Initially it was developed because it was noticed that once patients had a device placed they had a hard time getting back to the doctor because of the time and expense involved.
This technology is very important for patients who do not live very close to their doctor and would have to travel far distances to have their device checked when it was working fine.
Please can you give a brief overview of the remote monitoring systems you studied in pacemaker and implanted defibrillator patients?
In this particular study [presented at HRS 2014], it was limited to one particular remote monitoring system called Merlin.net. This is the proprietary means of the remote monitoring system that belongs to St. Jude Medical that allows one to monitor patients who received a St. Jude model pacemaker or defibrillator. The results of this study could be extrapolated to all patients who have an implantable device.
What did the study involve?
Essentially, the study involved 260,000 patients who had been implanted with a St. Jude Medical device that was capable of being remotely monitored using the Merlin.net system. It sought to answer the question: Do patients who are enrolled in remote monitoring live longer than patients who don’t enroll?
What were the main findings of this study and were you surprised by these results?
There were two main findings of the study. First, we found that patients who were remotely monitored were twice as likely to survive as patients who were not being remotely monitored.
Both pacemakers and defibrillators conferred the same survival event with remote monitoring. This was a surprise because many previously thought that patients with pace makers did not need remote monitoring.
The other key finding in the study is that it mattered how often patients were remotely monitored. Previously, studies used remote monitoring as a binary variable “yes or no” but in this study we looked at the percentage of time in a year patents were remotely monitored to see if that mattered.
We divided patients into two groups: those monitored at a high percentage (more than 75%), those monitored lower than that (more than 0% but lower than 75%) and those who were not remotely monitored at all.
The study found that the patients who were monitored the most had the greatest survival benefit, those monitored lower had the next greatest survival benefit and those without remote monitoring had the least benefit. This type of analysis had never been done before and supports the notion that patients should be remotely monitored.
How do you think the increased survival in patients with high adherence to remote monitoring can be explained?
It is difficult to know for sure but one can speculate that one or a combination of one of the below answers explains the association between remote monitoring and survival:
- It is possible that those who are remotely monitored are more engaged with their health and are more likely to take their medicines, visit their doctor for follow-ups and take better care of themselves with may transfer to an overall better survival.
- Another factor may be that the doctors who are ensuring that patients enrolled are in remote monitoring may be “better” doctors in general. By being at the front of this field they’re also more likely to manage co-morbidic conditions like high blood pressure, diabetes, heart failure, etc. which translates into a survival advantage.
- Ultimately, the reason we use remote monitoring systems is that they serve as an early warning notification system for problems that may be coming about with the patient’s health or device. Doctors may be able to intervene sooner with these issues which may translate into better health outcomes.
What further research is needed to understand this association?
There is still a lot of work to be done. For example, we need to understand why patients do or do not enroll in remote monitoring, and if enrolled, what causes a high or low utilization of remote monitoring. We also need to understand why does remote monitoring seems to be associated with a profound improvement in survival.
What impact do you think this study will have on patient care?
I would hope this study has a major impact and doctors caring for patients with an implantable device will be more likely to recommend remote monitoring and that patients would be more accepting of the need and rationale to undergo remote monitoring.
As part of this study, we found that more than 50 percent of patients are not enrolled in remote monitoring so there is a great opportunity for improvement in this area.
How important do you think remote monitoring will be in the future of medicine?
Yes, I do. Currently, we have this model where patients are routinely asked to go to a doctor on a quarterly basis to have their device checked and then are told the device is fine. An analogy I use for patients is that it’s like taking your car in every three or four months just to be told everything is fine.
Today, we have lights on the dashboard to tell you when something is actually wrong.
I think remote monitoring will have us enter an era when patients will only need to have their device checked when there’s evidence that something is wrong that needs attention by a healthcare provider. If we can do that, it translates to more efficient and cost effective healthcare.
Where can readers find more information?
The study is not yet published in a manuscript form but if readers were interested, they can go online to find out more about remote monitoring. Patients and family members of patients with remote monitoring devices should seek the opinion of their healthcare provider if they are an appropriate candidate to be monitored remotely and really be sure they understand why they are not being remotely monitored if that is the case.
About Dr. Suneet Mittal
Dr. Mittal earned his BA and MD degrees from Boston University as part of a combined 6-year BA-MD program. He did an internship and residency in Internal Medicine as well as a fellowship in Cardiovascular Diseases at the Hospital of the University of Pennsylvania in Philadelphia, Pennsylvania.
He then completed a fellowship in Clinical Cardiac Electrophysiology at the New York Presbyterian Hospital-Weill Cornell Medical Center. Dr. Mittal is board certified in Internal Medicine, Cardiovascular Disease and Clinical Cardiac Electrophysiology.
He is currently the Director of the Electrophysiology Laboratory at The Valley Hospital in Ridgewood, NJ and an Attending Physician at St. Luke’s-Roosevelt Hospital in New York City.
Dr. Mittal’s active research interests include the evaluation and management of patients with unexplained syncope, the role of implantable monitors in patients with known or suspected arrhythmias, and overcoming barriers to remote patient monitoring.
He has been an invited speaker at major academic institutions, an invited faculty member (year in and year out) at the Annual Scientific Sessions of the American Heart Association, American College of Cardiology, and the Heart Rhythm Society, an invited speaker in Europe and India, and for many years has been a member of the faculty at both Cardiostim and Venice electrophysiology meetings.
Finally, Dr. Mittal is an invited reviewer to the leading journals in Cardiology and Electrophysiology and serves as an Editorial Board member of the Journal of the American College of Cardiology, Heart Rhythm, and the Journal of Interventional Cardiovascular Electrophysiology.
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