2023 HSR&D/QUERI National Conference

1012 — Stepped-Wedge Randomized Controlled Trial to Improve Remote Monitoring Adherence for Veterans with Pacemakers/Implantable Cardioverter-Defibrillators

Lead/Presenter: Sanket Dhruva,  San Francisco VA
All Authors: Dhruva SS (San Francisco VA Health Care System), McLaughlin MM (San Francisco VA Health Care System), Tarasovsky G (San Francisco VA Health Care System), Raitt MH (Portland VA Health Care System), Whooley MA (San Francisco VA Health Care System).

Remote monitoring of pacemakers and implantable cardioverter-defibrillators (ICDs) is a Class 1 (Level of Evidence A) recommendation that is the standard-of-care because it reduces hospitalizations and mortality. However, adherence to remote monitoring is suboptimal (60% in 2020). We sought to determine whether (a) an educational postcard could improve remote monitoring adherence, and (b) the effect of an educational postcard on adherence differed by messaging.

We conducted a stepped-wedge randomized controlled trial (RCT) of Veterans with pacemakers/ICDs who had missed the most recently scheduled remote transmission by at least 10 days. In the first wedge, patients were randomized to be mailed a postcard (with protect/warn or encourage/reward messaging) versus no postcard (control). The protect/warn postcard described risks of non-adherence to remote monitoring, and the encourage/reward postcard framed the same content with a positive/beneficial message. Both postcards contained instructions about how to send remote transmissions. In the second wedge, all patients received either a protect/warn or encourage/reward postcard. In both waves, patients who did not send a remote transmission within 28 days were mailed a second, identical postcard. The primary outcome was receipt of a remote transmission within 70 days.

There were 6331 Veteran patients with pacemakers/ICDs randomized (3166 protect/warn messages and 3165 encourage/reward messages); 2400 of these Veterans served as controls in the first wedge. Mean age was 73 years, 76% were white, and 17% were Black. Five percent of postcards were returned as undeliverable. Overall, 2974 patients (49.5%) who received a postcard sent a remote transmission within 70 days, compared to 565 patients (23.5%) who did not receive a postcard (absolute difference 26.0%, p < 0.001). Twenty-six percent of patients who sent a remote transmission did so only after the second postcard. Remote transmission rates were similar between patients randomized to protect/warn versus encourage/reward messaging (49.9% vs 49.1%, p = 0.51).

Informational postcards to Veterans with pacemakers/ICDs who were non-adherent to remote monitoring more than doubled adherence. There was no difference between a protect/warn or encourage/reward strategy.

Because this intervention improved adherence to remote monitoring and, therefore, access to virtual care, for Veterans with pacemakers/ICDs, it has now become a routine part of VANCDSP operations.