Long-term continuous cardiac monitoring provides effective arrhythmia diagnoses in Medicare beneficiaries
Presenter: Suneet Mittal, MD, Valley Health System, Ridgewood, NJ
Comparative effectiveness of ambulatory monitors for arrhythmia diagnosis: A retrospective analysis of Medicare beneficiaries. Abstract 1600-035. Presented March 5, 2023.
Ambulatory cardiac monitoring using long-term continuous monitoring (LTCM) more effectively diagnoses arrhythmias with both lower healthcare utilization and costs compared with other ambulatory monitoring systems, according to Medicare beneficiary data.
Ambulatory cardiac monitors (ACM) are important diagnostic tools for the assessment and treatment of asymptomatic and symptomatic cardiac arrhythmias and conduction abnormalities. Several classes of ACM device types are available for monitoring strategies. These include short-term continuous monitoring for up to 48 hours (Holter monitors); LTCM for more than 48 hours and up to 14 days; non-continuous, event-based acute event monitoring (AEM) for up to 30 days; and mobile cardiac telemetry (MCT) using direct cellular transmission for up to 30 days.
The choice of ACM is based on the actual or suspected clinical diagnosis, along with frequency and severity of symptoms, according to presenter Suneet Mittal, MD, of Valley Health System in Ridgewood, NJ. “Although professional societies have provided a general framework for which devices to consider, there are no evidence-based recommended monitoring selections, which may be due to a variety of factors, including limited comparative data,” Mittal said.
To address that data shortage, Mittal and colleagues conducted a retrospective cohort study of Medicare fee-for-service claims data, including inpatient and outpatient medical claims. The cohort included 287,789 patients with mean age of 76 years; 61% were female. The patients had no previous arrhythmia diagnosis, and they first used ACM monitoring between 2017 and 2018.
The types of ACM used included Holter (54%), MCT (23%), LTCM (13%), and AEM (10%). Specified arrhythmias included in the study were atrial fibrillation, atrial flutter, supraventricular tachycardia, ventricular tachycardia, atrioventricular block, sick sinus syndrome, and junctional premature depolarization.
The researchers evaluated the 90-day diagnostic yield (arrhythmia diagnosis), 180-day retest (another ACM), and 90-day healthcare utilization.
The 90-day diagnostic yield was highest for LTCM (33.8%) followed by MCT (27.1%), external AEM (24.6%), and Holter (22.7%). The LCTM diagnostic subgroup that used the Zio XT 14-day patch had the highest 90-day diagnostic yield (35.2%). A multivariable analysis showed greater likelihood of a specified arrhythmia diagnosis with Zio XT than all other device manufacturer categories.
ACM retesting within the first 6 months was lowest for Holter (21.2%) and LTCM (21.4%), followed by MCT (36.2%) and AEM (46.6%). The LCTM Zio XT subgroup retest rate was the lowest, at 16.8%. Device-specific analyses showed greater odds of ACM retesting for device manufacturer categories relative to Zio XT.
Annualized all-cause inpatient hospitalizations during follow-up were lowest in the LTCM and Holter cohorts; emergency department visits were lowest in the LTCM cohort. Outpatient visits were lowest in the Holter and external AEM cohorts.
In terms of healthcare resource utilization from baseline to follow-up, the LTCM cohort had lower mean hospitalizations, emergency visits, and outpatient visits than the other cohorts. The increase in total healthcare costs was lowest in the LTCM cohort.
In conclusion, Mittal said: “In this large, contemporary analysis of Medicare beneficiaries receiving ACM, there was substantial differentiation in monitoring strategy. The use of LTCM was associated with the highest diagnostic yield. The Zio XT was independently associated with the highest diagnostic yield and lowest risk for repeat ACM testing and for subsequent acute care hospitalization. Different monitoring strategies may produce different results with respect to diagnosis and subsequent outcomes and care.”
Reference
Reynolds M, Passman R, Swindle J, et al. Comparative effectiveness of ambulatory monitors for arrhythmia diagnosis: a retrospective analysis of Medicare beneficiaries. J Am Coll Cardiol 2023; 81(8 Suppl):2342. doi:10.1016/S0735-1097(23)02786-9
Disclosures
Suneet Mittal, MD: Consultant fees/honoraria from AltaThera Pharmaceuticals, AtriCure, Baylis Medical Company, Boston Scientific, Bristol Myers Squibb, Catawba Research, CVRx, Haemonetics, Implicity, Impulse Dynamics, Medtronic, Philips Healthcare