Cost-utility Analysis of the Follow-up of Exclusive Telemedicine Pacemakers, Compared to Conventional Pacemakers

Professional practice guidelines recommend that pacemakers be followed with at least one to two in-office follow-ups per year, which is both a public health issue (the average time to get a consultation with a cardiologist being 42 days) but also an economic issue considering the number of patients implanted (Brignole EHJ 2013). Remote monitoring of pacemakers could allow an optimization of the long-term follow-up of pacemaker recipients in hospitals.

Compared to CRT and ICD, few studies have highlighted the economic advantage of remote monitoring with PM.

COMPAS study (Eur Heart J. 2012) demonstrated that remote monitoring is a safe alternative to conventional care over a 2 year-follow-up. This study also demonstrated that long-term remote monitoring of pacemakers decreased the number of ambulatory visits and enabled the early detection of important clinical and device-related adverse events.

As the study shows data up to 18 months, this is not sufficient to define the benefit of telecardiology in this population of patients.

SETAM study (Pacing Clin Electrophysiol 2017) demonstrated the benefit of remote monitoring showing an earlier diagnosis and management of atrial arrhythmias and a subsequently reduction of atrial fibrillation (AF) burden. The incidence and prevalence of AF is expected to increase with time, resulting in significant societal and economic impact.

Neither COMPAS nor SETAM were designed as economic evaluations

TELEPACE study proposes the first economic evaluation of an exclusive follow-up by Home-Monitoring of patients implanted with pacemaker for a period of 4 years.

All patients will be implanted with a single or dual chamber pacemaker according the implantation guidelines. Patients enrolled will be then randomized to a control group or an active group:

• The patients randomized in the control group will be followed accordingto the guidelines; i.e. with an in-office follow-up at 30 days post-implantation and after followed with in-office follow-ups according toclinical practice.
• Active group: in-office follow-up at 30 days post-implantation and after by remote monitoring (daily) without scheduled in-office follow-up during the study period (48 months). A remote FU will be planned every 9 months.

Consequently, compared to the guidelines, the patients in the active group will be followed according to the guidelines; except for the in-office follow-ups annually.

By collecting real costs directly on health insurance reimbursement bases (SNIIRAM), this study will define the medico-economic benefit of remote monitoring of pacemakers.

A cost-utility analysis is needed to address the question. The use of QALYs is not intended to demonstrate a difference in clinical efficacy but to ensure that efficacy and costs are studied simultaneously which is required in order to avoid risk inflation when differences in efficacy and costs are studied sequentially.

If there is no significant differences in QALYs (as expected) but there are savings in terms of HSR then the cost-utility ratio will allow to estimate a "net benefit criterion" (NBC) that translates QALYs into money as follows: NBC = WTP.(differences in QALYs) - (differences in costs) where WTP represents the (societal) willingness to pay a QALY.

If there is no differences in QALYs the NBC will then reduce to a cost-minimisation calculus (WTP.(diff QALYs) = 0).

Cost-minimisation alone can only be used (HAS regards it as a sub-category of cost-effectiveness analysis whose use has to be duly justified) provided that there is strong evidence of equivalence in terms of clinical efficacy. If this is not the case, a cost-utility analysis will be more relevant as it will test simultaneously for both differences in efficacy and in costs.

Moreover, the study will confrim the safety of telecardiology and evaluate patients' individual preferences for the different management strategies.