Despite high levels of satisfaction with wireless monitoring technology, older patients with implanted cardiac devices still greatly prefer in-person physician visits to remote consultations, according to a newly published study from Portugal. But the authors caution not to draw too many general conclusions from their findings, because their sample size was small and the research did not take into account the cost savings to patients from avoiding future hospital admissions.
The report, published in the journal Telemedicine and e-Health, found that 53 percent of patients with pacemakers, defibrillators and other implanted, wireless devices that regulate or measure heart rhythm said they would rather have in-office follow-up with their doctors, while just 27 percent stated a preference for remote monitoring. The other 20 percent were "indifferent" to the two options, according to the study.
These results come despite the fact that 11 of the 15 patients queried said the Medtronic CareLink remote monitoring system used in the study was "easy" to set up and operate and two more called it "very easy" to use. The majority of the patients, ranging from 48 to 83 years old, with a mean age of 63, said the transmission equipment did not require a lot of time to send data from their heart monitors, while every one of those studied were "satisfied" or "very satisfied" with the system.
The findings also contrast with those from an earlier study from Italy, reported in the Journal of Telemedicine and Telecare in 2008, in which 73 percent of patients said they would choose remote monitoring over office visits. "The fact that the patients who preferred the in-office method selected the direct physician observation or the direct contact with health professionals as the chief element in that preference leads us to think that those are possibly the main reasons," the research team, from Centro Hospitalar do Porto in Portugal, write in the new study.
"In our analysis it was not possible to associate the preference for the in-office visit with the occurrence of clinical events or costs, so that the challenge remains to study additional reasons for that preference," they continue.
One thing that may be a key factor in patient preference is waiting time. Among those who said in-office visits were better than remote monitoring, the mean waiting time upon arrival was 17.5 minutes, compared to 45 minutes for the rest of the study panel.
"Furthermore, it was possible to determine that the point that better distinguishes the two groups is to consider that the preference for an in-office visit disappears when the mean waiting time is greater than or equal to 37.5 min (corresponding to real data of waiting times greater than 45 min). This means that if the waiting time indicates that the patient does not prefer the remote appointment, then the patient really does not prefer that modality. In clinical terms this value could be of some importance, namely as the maximum waiting time for in-office visits," the Portuguese researchers say.
They also remain optimistic about the potential for wireless home monitoring to save lives and reduce hospitalizations.
Each patient had two office visits with the hospital's Arrhythmology, Pacing and Electrophysiology Unit, one at the beginning and another at the end of the year-long study period, plus two remote evaluations at the three-month and nine-month marks. Monitoring specialists could intervene if the Medtronic equipment picked up any irregularities between appointments or if patients sought additional treatment.
Researchers counted 15 "events" during the study period, nine picked up by remote monitoring and six brought to their attention by patients. Of those, 40 percent turned out to be asymptomatic. There was an equal, three-way split between clinical events, device-related issues and questions about monitoring hardware or data transmission. All turned out to be minor, though two of the events resulted in hospital admission, two in the scheduling of an office visit and one necessitated a trip to the emergency department of another hospital, the article says.
These interventions might not have been possible without telehealth technology, according to the authors. "Cardiology, because of the nature of physiological and biological signals used in the diagnosis and therapeutic control, benefits tremendously from using this type of application," they write.
"Traditional follow-up is still an activity that requires a considerable amount of time and specialized technical and human resources. It also has the inconvenience of long intervals between follow-ups, in which the physician has no access to the patient's information or the generator," they note. "Therefore, the adoption of new methodologies that allow simultaneously maintaining the same security and reliability levels, follow-up efficiency and a tighter surveillance was deemed necessary. In this context, the possibility of remote monitoring (RM) of different devices poses a viable and safe complementary option in monitoring implantable device carriers between in-office visits."
The researchers do lament the small size of the panel. Even though they initially identified 43 study candidates, 11 didn't have implanted heart devices with wireless capabilities, seven lacked a home phone line, two declined to participate, two were already enrolled in other studies, four died before the test period began and two dropped out after initially agreeing to participate, leaving just 15 subjects.
"The final sample size made extremely difficult the analysis of data, and if the sample size had been slightly bigger, other results could have been added or even verified," the Porto team says. They further note that they did not measure the effect responding to medical and operational events identified through remote monitoring on overall healthcare costs.
"In this situation we have also to highlight the potential impact in the patient's quality of life. It would be important for cost-benefit, cost-effectiveness and cost-utility analysis in this particular area," they write.