Daniel Bensimhon, MD Cone Health

1. Remote Monitoring:
Tracking Congestion & Beyond
Daniel Bensimhon, MD
Medical Director
Advanced HF & Mechanical Circulatory Support Program
Cone Health

2. Disclosures
◆ Consulting/speaker/ownership interests: Boehringer-Ingelheim,
Pfizer, Janssen, AstraZeneca, Sensible Medical, Caption Health,
AquaPass, scPharmaceuticals, Adjacent Health, Ventricle Health

3. The Importance of Congestion
Congestion:
◆ Most common symptoms experienced
◆ Most common reason patients seek medical
attention
◆ Most common reason for hospital admission
◆ Associated with reduced Quality of Life
◆ Persistent congestion at discharge is associated
with worse outcomes and hospital readmission

4. Admission
89.7% of the Acute HF patients
are wet at admission
Discharge
36.5% of the Acute HF patients
are still wet at discharge
Clinical Outcome
AHF patients presenting as ‘wet-warm’ and ‘wet-
cold’ had the highest 1-year HF hospitalization rate
Patients free of congestion at discharge had a
significantly lower 1-year mortality compared to
patients with residual congestion (18.5 vs. 28.0%;
P<0.001)
Chioncel et al. Eur J Heart Fail 2019; 21;1338-1352
Congestion & Clinical Outcomes

5.  Setting: Hospital discharge with 30d & 90d FU
 Protocol: ReDS reading for HF patients deemed clinically ready for
discharge (N = 108)
 Randomization:
 Treatment:
 ReDS ≥ 39% – additional treatment + 2nd ReDS reading +
referral to HF program
 ReDS < 39% – discharge as planned
 Control: all discharged as planned
 Results:
 43% of the HF patients are discharged wet (ReDS > 35%)
 ReDS guided management led to mean additional weight loss of
5.7 lbs (2.6kg)
 Regardless of study arm wet patients were at higher risk for 30-
day readmission (wet vs dry)
 11.8% vs 1.4%, P= 0.03
Bensimhon D et al. Heart & lung. 50, 1, 59-64, 2021
Patients are being discharged congested
• 32% are discharged with ReDS ≥ 39%
• 44% are discharged with ReDS > 35%
32%
12%
56%
Hospital Discharge– Guided Management & Prognostics

6. 2021 ESC Guidelines
Discharge
Outpatient
Management of patients after HF hospitalization
Prevention and monitoring

7. June 2023
JACC Scientific Statement –
Remote Monitoring for HF Management
◆ Early telemonitoring of weights and symptoms did not decrease heart failure
hospitalizations
◆ A signal that is accurate and actionable with response kinetics for early re-
assessment is required
◆ Tracking of congestion with cardiac filling pressures or lung water content has
shown most impact to decrease hospitalization

8. Modified from: Adamson PB. Curr Heart Fail Rep. 2009;6:287-292.
Window of Opportunity to Intervene
Progression to Acute Decompensated Heart Failure

9. Why RPM in HF?
Mismatch outcomes vs resources
 53% of cardiologists > 50 y/o4
 14,669 people in US per cardiologist4
 Avg time to see cardiologist post d/c = 33d5
 Problem worse in rural states (MT 52, SD 46
ID 46, AK 39, ND 36, WY 16)5
1 Solomon SD Circ 2017;10:63-70
2. Greene S JACC 2018 Jul, 72 (4) 351–366
22.3%
33.3%
40.2%
0
5
10
15
20
25
30
35
40
45
30-day
readmission
rate
60-day
readmission
rate
90-day
readmission
rate
Patients
readmitted
for
all
causes
following
hospitalization
for
heart
failure,
%
 High readmission/mortality rates1
 Low rates GDMT utilization2 with
poor clinical inertia -> 48.6% visits
without GDMT titration3
CHAMP-HF
- 22% on 3/3 classes
GDMT
- 1% optimized
3. Swat S JACC: HF Vol 11 (11), No 2023, 1592-94
4. AAMC 2022 Physician Specialty Data report 5. Kaiser Family Foundation Data

10. Evolution of RPM in HF

11. RPM Key Components
◆ Components of RPM programs
◆ Patient selection/engagement
◆ Choices of devices/data collection
◆ Data transmission
◆ Data analysis/presentation
◆ Care team review & clinical action
◆ Reimbursement/ROI
1. Bhatia IJHF 2021 Jan; 3(1) 31-50

12. ◆ Patient selection
◆ Patients who need it most often resistant or have challenges
with access/technology
◆ Benefit appears limited in stable patients due to low event
rates
◆ Post-d/c & NYHA III patients may have biggest benefit
though trial results have been mixed
◆ TIM-HF1 HF event within past 2 years -> no ↓ in HF events
◆ TIM-HF22 had event in last year -> 20% ↓ hHF days/all-cause
mortality
1.Koehler F. TIM HF Eur J Heart Fail 2010;12:1354–1362
2. Koehler F, TIM HF2 Lancet 2018;392:1047–1051
RPM Optimization

13. ◆ Patient engagement
◆ Patient engagement can be difficult & adherence wanes
with time
◆ Human contact likely better than automated
◆ Tele-HF1– early HF telemonitoring trial
◆ Adherence to automated voice-response system
◆ 14% never used it
◆ At 1 week 90% used it > 3x/week
◆ At 26 weeks 55% used the system at all
◆ Other strategies to increase adherence2
◆ Ease-of-use, passive monitors, patient rewards/gamification
1. Chaudhry SI, Tele HF NEJM 2010;363:2301–2309
2. Bhatia IJHF Jan; 3(1) 31-50
RPM Optimization

14. ◆ Patient & device selection
◆ Optimal devices not yet determined
◆ Key components likely included accurate/early hemodynamic sensor
+ algorithms that lead to GDMT titration
◆ Non-invasive devices – lower cost/greater access
◆ Passive sensors highest compliance
◆ Cellular-enabled devices – avoid need for Wi-Fi
RPM Optimization

15. ◆ Data transmission, analysis & presentation
◆ Cellular devices over Wi-Fi
◆ Optimize signal-to-noise ratio
◆ ”Don’t measure everything”
◆ Limit # of systems/dashboards
◆ Carefully plan alerts
◆ clinical alerts with poor specificity and high false positive rates ->
↑increase in unnecessary office visits and hospitalizations1
◆ Evaluate HIPPA compliance carefully
1. van Veldhuisen DJ. Circ 2011;124:1719–1726
RPM Optimization

16. ◆ Care team review & clinical action
◆ Centralized monitoring/management with clinically-led
(MD/APP/PharmD) team generally produce best outcomes
◆ More timely & effective responses
◆ EMR nudges -> ↑ GDMT but no ↓ in ER visits or hHF (PROMPT-HF)
◆ Telemonitoring + texting after hHF -> no ↓ BNP, hHF or CVD
(MESSAGE-HF)
◆ Need care algorithms to allow RNs & other team members to
participate
◆ EMR integration
1. Ghazi L. JACC 2022 Jun, 79 (22) 2203-13.
2. Rohde L. JAMA Cardiol. 2024;9(2):105-113
RPM Optimization

17. ◆ Reimbursement/ROI
◆ Most devices do not have CPT code
◆ Can bill CCM time but requires careful documentation
◆ CPT 99490 = 20 mins -> $62/mo
◆ CPT 99492 = add’l 20 mins -> $47/mo
◆ CPT 99487 (Complex CM) = 60 mins -> $132/mo
◆ CPT 99489 (Complex CM) = add’l 30 mins -> $71/mo
◆ Often hard to fund unless part of value-based system of care
RPM Optimization

18. Critical Components of a Successful RPM Program
◆ Summary
◆ High-risk patients likely benefit most
◆ Hemodynamic sensors + GDMT titration
◆ Keep devices simple with limited patient effort
◆ Centralized monitoring with MD/APP/PharmD likely best
◆ Build focused care algorithms and alerts
◆ ROI can be tricky
◆ Excellent Resource – Bhatia A, Maddox TM. IJHF 2021 Jan;3(1):31-50
https://doi.org/10.36628/ijhf.2020.0023

19. Can RPM Partnerships be a Pathway to
HF Success?

20. Todays Journey
Ventricle Health Managed
Patient has been without proper
medication for more than 30 days
22% chance of 30-day readmission
Patient waits for cardiologist for 33+ days,
low GDMT utilization
Patient is hospitalized with HF
but is discharged while
congested and is advised to
see a cardiologist
Patient continues
cycle of
readmission to
hospital and/or 1/3
die in 12 months
Ventricle Health HF Patient Journey
Ventricle Health’s evidence-based medicine approach, supported by an extensive cardiology network, not only
result in reduced hospitalizations but also ensure cost savings while delivering the highest standards of care
Throughout the patient journey we are continually analyzing data to identify at risk patients and HF stage changes
40% chance of 90 days
readmission
Savings
Generated
0
30
90
Transition of Care
Seamlessly transition
the patient into the
stabilization treatment
Cardiology Visit & RPM
Timely start of GDMT
combined with RPM
Post Acute Stabilization
Medication adherence,
disease state education and
lifestyle modification
coaching
Emergency Action Plan
Diuretic regimen established,
ER avoidance,
RPM triage
Graduation
Patient condition remains
stable without HF
readmissions and related
health events.
<5 30 90 120
1
14
Post discharge
PCP follow up
DAY

21. Disclaimer: This presentation contains confidential material. Please do not
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HF Clinical Dashboard

22. Disclaimer: This presentation contains confidential material. Please do not
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Ventricle Health Clinical Outcomes

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