Patient and Clinician Perspectives on Alert-Based Remote Monitoring–First Care for Cardiovascular Implantable Electronic Devices: Semistructured Interview Study Within the Veterans Health Administration

Background: Patients with cardiovascular implantable electronic devices (CIEDs) typically attend in-person CIED clinic visits at least annually, paired with remote monitoring (RM). As the CIED data available through in-person CIED clinic visits and RM are nearly identical, the 2023 Heart Rhythm Society expert consensus statement introduced "alert-based RM," an RM-first approach where patients with CIEDs that are consistently and continuously connected to RM, in the absence of recent alerts and other cardiac comorbidities, could attend in-person CIED clinic visits every 24 months or ultimately only as clinically prompted by actionable events identified on RM. However, there is no published information about patient and clinician perspectives on barriers and facilitators to such an RM-first care model. Objective: We aimed to understand patient and clinician perspectives about an RM-first care model for CIED care. Methods: We interviewed 40 rural veteran patients who were experienced with RM with CIEDs and 22 CIED clinicians who were experienced in using RM regarding barriers and facilitators to an RM-first care model. We conducted a reflexive thematic analysis of interviews. Two authors familiarized themselves with the dataset and generated separate codebooks based on the interview guides and inductively coded notes. These 2 authors met and reviewed each other's codes, sought additional author input, and resolved differences before 1 author coded the remaining interviews and developed candidate themes. These themes were refined, named, and supported with quotations. Results: Patients expressed interest in an RM-first approach, to reduce the burden of long travel times, sometimes in inclement weather, and to enable clinicians to provide care for other patients. However, many preferred routine in-person visits; reasons included a skepticism of the capabilities of RM, a sense that in-person visits provided superior care, and enjoyment of in-person patient-clinician relationships. Clinicians were interested in RM-first care, especially for stable, RM-adherent patients who were not device-dependent. Clinicians most frequently cited the benefit of reducing patient travel burden as well as optimizing clinic space and time to focus on other care such as reviewing routine RM transmissions, but also noted barriers including lack of in-person assessment, patient-perceived diminution of the patient-clinician relationship, possible loss to follow-up, and technological difficulties. Clinicians felt that an RM-first care model should be evaluated for success based on patient satisfaction and assessment of timely addressing of rhythm issues to prevent adverse outcomes. Most clinicians believed that RM-first care represented the future of CIED care. Conclusions: Both patients and CIED clinicians interviewed who were experienced in using RM were open to an RM-first care model that reduces in-person visits but reported some barriers to solely relying on RM and possible diminution of the patient-clinician relationship. Implementation of new RM recommendations will require attention to these perceptions and prioritization of patient-centered approaches.

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