Heart Failure Care Gets Boost from Technology
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| Unlike earlier-generation devices, newer ventricular assist devices are smaller and more durable, lasting beyond five years. |
A recent development in the field is the nod in September 2008 by the American Board of Medical Specialties to establish a secondary subspecialty certification in Advanced Heart Failure and Transplant Cardiology. “Over the last several years, its has become more evident that some physicians were identifying themselves as heart failure specialists but with no standardized training requirements,” says Marvin Konstam, MD, former president of the Heart Failure Society of America and a professor of medicine at Tufts University. He notes that the move will bring a higher level of care to patients.
Most heart failure programs incorporate teams of cardiologists and allied health personnel such as nurse practitioners, registered nurses and exercise physiologists who specialize in heart failure. Patients are increasingly receiving ventricular assist devices (VADs). Thriving heart failure programs have access to many FDA-approved mechanical VADs including the Heartmate, Novacor, Debakey, Jarvik and other devices. Physicians at the Cleveland Clinic, for example, have implanted more than 500 such devices and researchers there are participating in two randomized trials comparing permanent support with an implantable pump (Novacor) and a continuous flow pump (Debakey) to the Heartmate device.
A recent study from Duke University Medical Center, however, found that VADs are associated with high hospital costs and high rates of early death among Medicare recipients (JAMA 2008;300(20):2398-2406). The researchers concluded that physicians need to do a better job defining the time of optimal intervention and identifying who is most likely to benefit from a VAD.
Study co-author Joseph G. Rogers, MD, medical director of the Cardiac Transplant and Mechanical Circulatory Support Program at Duke, says it’s important to acknowledge the “absolutely dismal prognosis these patients have.” Even though survival rates in the study looked modest (50 percent), they are a “drastic improvement from other options for these patients.” Survival rates for patients on optimal medical therapy are about 10 percent. Newer pumps, which are smaller and more durable, lasting up to six years compared to 18 months for today’s pumps, show a survival rate of 70 percent in preliminary data, Rogers says.
Duke researchers also found a correlation between successful outcomes and procedure volume. “This is not a therapy one can dabble in and expect to have good outcomes,” he says, adding that appropriate surgical and pre- and post-operative infrastructure are key.
Hospitals anticipating opening a heart failure program should expect a reasonable upfront infrastructure cost. Rogers’ experience indicates that many programs are not losing money. In fact, this patient population can be a driver for downstream costs. “They utilize hospital services extensively,” he says.
Remote monitoring
Heart failure patients with severe or moderately severe symptoms are sometimes candidates for cardiac resynchronization therapy (CRT) through the implantation of biventricular pacing devices. Some of these patients benefit from a combination of CRT and an implantable cardioverter defibrillator (ICD) to control concomitant tachycardia. Several trials in progress, including MADIT-CRT and DETERMINE, are studying whether earlier intervention with a device can prevent heart failure in patients with preserved ejection fractions and other concomitant conditions such as coronary artery disease and myocardial infarction.
Researchers have been studying the safety and efficacy of remote monitoring of such devices. A report by economist Robert Litan, “Vital Signs Via Broadband: Remote Health Monitoring Transmits Savings, Enhances Lives,” released Oct. 24, 2008, found that remotely monitoring patients with chronic diseases, such as congestive heart failure, could cut nearly $200 billion from U.S. healthcare costs over the next 25 years. The savings would come primarily by reducing emergency room visits, hospitalizations and hospital lengths of stay. The report also said that remote monitoring could improve health outcomes and quality of life.
At the 2008 Heart Rhythm Society meeting, Elizabeth Ching, RN, and colleagues from the Cleveland Clinic reported that home monitoring of devices via wireless technology is increasingly being embraced by patients. During the course of the five-year study, remote evaluations increased from 94 to more than 5,000 patients. “This growth is a direct result of the clinic’s incorporation of ICD follow-up through remote monitoring evaluations, allowing for better time management and overall improvements in resource allocation,” Ching says.
For now, VADs are not remotely monitored, which is fine with Rogers. “Companies need to choose advances wisely,” he says. “As the price of pumps increases, the margin shrinks.” Rogers would rather see companies invest in technology that allows all components of the pumps to be implanted internally. “That would improve patient acceptance and decrease morbidity associated with the devices.”