Alert-Based ICD Follow-Up: A Model of Digitally Driven Remote Patient Monitoring

OBJECTIVES The goal of this study was to test whether continuous automatic remote patient monitoring (RPM) linked to centralized analytics reduces nonactionable in-person patient evaluation (IPE) but maintains detection of at-risk patients and provides actionable notifications. BACKGROUND Conventional ambulatory care requires frequent IPEs. Many encounters are nonactionable, and additional unscheduled IPEs occur. METHODS Patients receiving implantable cardioverter-defibrillators for Class I/IIa indications were randomized (2:1) to RPM or conventional follow-up, and they were followed up for 15 months. IPEs were conducted every 3 months in the conventional care group but at 3 and 15 months with RPM. Groups were compared for patient retention, nonactionable IPEs, and discovery of at-risk patients during 1 year of exclusive RPM. Frequency and value of RPM alerts were assessed. RESULTS Patients enrolled (mean age 63.5 +/- 12.8 years; male 71.9%; left ventricular ejection fraction 29.0 +/- 10.7%; primary prevention 72.3%; n =1450) were similar between groups (977 RPM vs. 473 conventional care). Mean follow-up durations were 407 +/- 103 days for the RPM group versus 399 +/- 111 days for the conventional care group (p = 0.165). Patient attrition to follow-up was 42% greater with conventional care (20.1% [87 of 431]) versus RPM (14.2% [129 of 908]; p = 0.007). Nonactionable IPEs were reduced 81% by RPM (0.7 per patient year) compared with conventional care (3.6 per patient year; p < 0.001) but event discoveries remained similar (2.9 per patient year). In RPM, alert rate was median 1 per patient (interquartile range: 0 to 3) with > 50% actionability, indicating low volume but high clinical value. Unscheduled IPE was the basis for discovery of 100% of intercurrent problems in RPM and also 75% in conventional care, indicating limited value of appointment-based follow-up for problem discovery. The number of IPEs needed to discover an actionable event was 8.2 in Conventional, 4.9 in RPM, and 2.1 when alert driven (p < 0.001). CONCLUSIONS RPM transformed ambulatory care to IPE directed to those patients with clinically actionable events when required. Filtering patient information by digitally driven remote monitoring expends fewer clinic resources while providing a greater yield of actionable interventions. (Lumos-T Safely Reduces Routine Office Device Follow-up [TRUST]; NCT00336284) (J Am Coll Cardiol EP 2021;7:976 & ndash;987) (c) 2021 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).