title: EuroEco (European Health Economic Trial on Home Monitoring in ICD Patients): a provider perspective in five European countries on costs and net financial impact of follow-up with or without remote monitoring.
abstract: OBJECTIVE
  Remote follow-up (FU) of implantable cardiac defibrillators (ICDs) allows for fewer in-office visits in combination with earlier detection of relevant findings. Its implementation requires investment and reorganization of care. Providers (physicians or hospitals) are unsure about the financial impact. The primary end-point of this randomized prospective multicentre health economic trial was the total FU-related cost for providers, comparing Home Monitoring facilitated FU (HM ON) to regular in-office FU (HM OFF) during the first 2 years after ICD implantation. Also the net financial impact on providers (taking national reimbursement into account) and costs from a healthcare payer perspective were evaluated.
  
  
  RESULTS
  A total of 312 patients with VVI- or DDD-ICD implants from 17 centres in six EU countries were randomised to HM ON or OFF, of which 303 were eligible for data analysis. For all contacts (in-office, calendar- or alert-triggered web-based review, discussions, calls) time-expenditure was tracked. Country-specific cost parameters were used to convert resource use into monetary values. Remote FU equipment itself was not included in the cost calculations. Given only two patients from Finland (one in each group) a monetary valuation analysis was not performed for Finland. Average age was 62.4 ± 13.1 years, 81% were male, 39% received a DDD system, and 51% had a prophylactic ICD. Resource use with HM ON was clearly different: less FU visits (3.79 ± 1.67 vs. 5.53 ± 2.32; P < 0.001) despite a small increase of unscheduled visits (0.95 ± 1.50 vs. 0.62 ± 1.25; P < 0.005), more non-office-based contacts (1.95 ± 3.29 vs. 1.01 ± 2.64; P < 0.001), more Internet sessions (11.02 ± 15.28 vs. 0.06 ± 0.31; P < 0.001) and more in-clinic discussions (1.84 ± 4.20 vs. 1.28 ± 2.92; P < 0.03), but with numerically fewer hospitalizations (0.67 ± 1.18 vs. 0.85 ± 1.43, P = 0.23) and shorter length-of-stay (6.31 ± 15.5 vs. 8.26 ± 18.6; P = 0.27), although not significant. For the whole study population, the total FU cost for providers was not different for HM ON vs. OFF [mean (95% CI): €204 (169-238) vs. €213 (182-243); range for difference (€-36 to 54), NS]. From a payer perspective, FU-related costs were similar while the total cost per patient (including other physician visits, examinations, and hospitalizations) was numerically (but not significantly) lower. There was no difference in the net financial impact on providers [profit of €408 (327-489) vs. €400 (345-455); range for difference (€-104 to 88), NS], but there was heterogeneity among countries, with less profit for providers in the absence of specific remote FU reimbursement (Belgium, Spain, and the Netherlands) and maintained or increased profit in cases where such reimbursement exists (Germany and UK). Quality of life (SF-36) was not different.
  
  
  CONCLUSIONS
  For all the patients as a whole, FU-related costs for providers are not different for remote FU vs. purely in-office FU, despite reorganized care. However, disparity in the impact on provider budget among different countries illustrates the need for proper reimbursement to ensure effective remote FU implementation.
authors.affiliation: Heart Center, Jessa Ziekenhuis, Hasselt, Belgium heinheid@gmail.com.
authors.forename: Hein
authors.initials: H
authors.lastname: Heidbuchel
authors.affiliation: Heart Center Leipzig, Leipzig, Germany.
authors.forename: Gerd
authors.initials: G
authors.lastname: Hindricks
authors.affiliation: Aberdeen Royal Infirmary, Aberdeen, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Broadhurst
authors.affiliation: Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Lieselot
authors.initials: L
authors.lastname: Van Erven
authors.affiliation: University Hospital Puerta de Hierro Majadahonda, Madrid, Spain.
authors.forename: Ignacio
authors.initials: I
authors.lastname: Fernandez-Lozano
authors.affiliation: Hospital Oost-Limburg (ZOL), Genk, Belgium.
authors.forename: Maximo
authors.initials: M
authors.lastname: Rivero-Ayerza
authors.affiliation: Helios Klinikum, Aue, Germany.
authors.forename: Klaus
authors.initials: K
authors.lastname: Malinowski
authors.affiliation: Charite - Campus Mitte (CCM), Berlin, Germany.
authors.forename: Andrea
authors.initials: A
authors.lastname: Marek
authors.affiliation: Hospital Universitario Nuestra Señora de la Candelaria (HUNSC), St. Cruz, Tenerife.
authors.forename: Rafael F
authors.initials: RF
authors.lastname: Romero Garrido
authors.affiliation: Klinikum St Georg, Leipzig, Germany.
authors.forename: Steffen
authors.initials: S
authors.lastname: Löscher
authors.affiliation: St. Peters Hospital, Chertsey, UK.
authors.forename: Ian
authors.initials: I
authors.lastname: Beeton
authors.affiliation: Centro Hospitalario Universitario Vigo, Vigo, Spain.
authors.forename: Enrique
authors.initials: E
authors.lastname: Garcia
authors.affiliation: Raigmore Hospital, Inverness, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Cross
authors.affiliation: Heart Center, Jessa Ziekenhuis, Hasselt, Belgium.
authors.forename: Johan
authors.initials: J
authors.lastname: Vijgen
authors.affiliation: Universital Hospital of Oulu, Oulu, Finland.
authors.forename: Ulla-Maija
authors.initials: UM
authors.lastname: Koivisto
authors.affiliation: Hospital Universitario La Paz, La Paz, Spain.
authors.forename: Rafael
authors.initials: R
authors.lastname: Peinado
authors.affiliation: BIOTRONIK SE & Co. KG, Berlin, Germany.
authors.forename: Antje
authors.initials: A
authors.lastname: Smala
authors.affiliation: Ghent University, Ghent, Belgium.
authors.forename: Lieven
authors.initials: L
authors.lastname: Annemans
mesh_terms: D001145:Arrhythmias, Cardiac / Q000191:economics / Q000628:therapy; D002304:Cardiac Pacing, Artificial / Q000191:economics*; D003365:Costs and Cost Analysis; D017147:Defibrillators, Implantable / Q000191:economics; D018588:Fee-for-Service Plans; D005260:Female; D005500:Follow-Up Studies; D006282:Health Personnel / Q000191:economics / Q000706:statistics & numerical data; D006295:Health Resources / Q000191:economics / Q000706:statistics & numerical data; D006699:Home Care Services / Q000191:economics*; D006801:Humans; D008134:Long-Term Care / Q000191:economics; D008297:Male; D008875:Middle Aged; D018670:Monitoring, Ambulatory / Q000191:economics*; D009819:Office Visits / Q000191:economics; D019114:Remote Consultation / Q000191:economics*
keywords: Devices; Follow-up; Health economics; Implantable cardioverter defibrillator; Remote monitoring