Alert-driven vs scheduled remote monitoring of implantable cardiac defibrillators: A cost–consequence analysis from the TRUST trial

Alert-driven remote patient monitoring (RPM) or fully virtual care without routine evaluations may reduce clinic workload and promote more efficient resource allocation, principally by diminishing nonactionable patient encounters. The purpose of this study was to conduct a cost–consequence analysis to compare 3 postimplant implantable cardioverter-defibrillator (ICD) follow-up strategies: (1) in-person evaluation (IPE) only; (2) RPM–conventional (hybrid of IPE and RPM); and (3) RPM–alert (alert-based ICD follow-up). We constructed a decision-analytic Markov model to estimate the costs and benefits of the 3 strategies over a 2-year time horizon from the perspective of the US Medicare payer. Aggregate and patient-level data from the TRUST (Lumos-T Safely RedUceS RouTine Office Device Follow-up) randomized clinical trial informed clinical effectiveness model inputs. TRUST randomized 1339 patients 2:1 to conventional RPM or IPE alone, and found that RPM was safe and reduced the number of nonactionable encounters. Cost data were obtained from the published literature. The primary outcome was incremental cost. Mean cumulative follow-up costs per patient were $12,688 in the IPE group, $12,001 in the RPM–conventional group, and $11,011 in the RPM–alert group. Compared to the IPE group, both the RPM–conventional and RPM–alert groups were associated with lower incremental costs of –$687 (95% confidence interval [CI] –$2138 to +$638) and –$1,677 (95% CI –$3134 to –$304), respectively. Therefore, the RPM–alert strategy was most cost-effective, with an estimated cost-savings in 99% of simulations. Alert-driven RPM was economically attractive and, if patient outcomes and safety are comparable to those of conventional RPM, may be the preferred strategy for ICD follow-up.