Background Shared decision-making (SDM), a process whereby physicians and patients collaborate to select interventions, is not well understood for biologic treatment of autoimmune conditions. Methods This was a cross-sectional survey of adults initiating treatment for Crohn’s disease or ulcerative colitis (inflammatory bowel disease, IBD) or psoriatic arthritis or rheumatoid arthritis (RA/PA). Survey data were linked to administrative claims for 6 months before (baseline) and after (follow-up) therapy initiation. Measures included the Shared Decision Making Questionnaire, Patient Activation Measure (PAM), Morisky Medication Adherence Scale (MMAS), general health, and treatment satisfaction. Claims-based Quan-Charlson comorbidity scores, persistence, medication possession ratio (MPR), and health care costs were examined. Patients were compared by participation (SDM) and nonparticipation (non-SDM) in SDM. Results Among 453 respondents, 357 were eligible, and 306 patients (204 RA/PA and 102 IBD) were included in all analyses. Overall (n=357), SDM participants (n=120) were more often females (75.0% vs 62.5%, P =0.018), had lower health status (48.0 vs 55.4, P =0.005), and higher Quan–Charlson scores (1.0 vs 0.7, P =0.035) than non-SDM (n=237) participants. Lower MMAS scores (SDM 0.17 vs non-SDM 0.41; P <0.05) indicated greater likelihood of adherence; SDM participants also reported higher satisfaction with medication and had greater activation (PAM: SDM vs non-SDM: 66.9 vs 61.6; P <0.001). Mean MPR did not differ, but persistence was longer among SDM participants (111.2 days vs 102.2 days for non-SDM; P =0.029). Costs did not differ by SDM status overall, or among patients with RA/PA. The patients with IBD, however, experienced lower ( P =0.003) total costs ($9,404 for SDM vs $25,071 for non-SDM) during follow-up. Conclusion This study showed greater likelihood of adherence and satisfaction for patients who engaged in SDM and reduced health care costs among patients with IBD who engaged in SDM. This study provides a basis for defining SDM participation and detecting differences by SDM participation for biologic treatment selection for autoimmune conditions.

Background The number of patients with cardiac implantable electronic device (CIED) is increasing, creating a substantial workload for device clinics. Objective This study aims to characterize the workflow and quantify clinic staff time requirements for managing patients with CIEDs. Methods A time and motion workflow evaluation was performed in 11 US and European CIEDs clinics. Workflow tasks were repeatedly timed during 1 business week of observation at each clinic; these observations included all device models and manufacturers. The mean cumulative staff time required to review a remote device transmission and an in-person clinic visit were calculated, including all necessary clinical and administrative tasks. The annual staff time to manage a patient with a CIED was modeled using CIED transmission volumes, clinical guidelines, and the published literature. Results A total of 276 in-person clinic visits and 2173 remote monitoring activities were observed. Mean staff time required per remote transmission ranged from 9.4 to 13.5 minutes for therapeutic devices (pacemaker, implantable cardioverter-defibrillator, and cardiac resynchronization therapy) and from 11.3 to 12.9 minutes for diagnostic devices such as insertable cardiac monitors (ICMs). Mean staff time per in-person visit ranged from 37.8 to 51.0 and from 39.9 to 45.8 minutes for therapeutic devices and ICMs, respectively. Including all remote and in-person follow-ups, the estimated annual time to manage a patient with a CIED ranged from 1.6 to 2.4 hours for therapeutic devices and from 7.7 to 9.3 hours for ICMs. Conclusions The CIED patient management workflow is complex and requires significant staff time. Understanding process steps and time requirements informs the implementation of efficiency improvements, including remote solutions. Future research should examine heterogeneity in patient management processes to identify the most efficient workflow.

Background: We assessed cost–effectiveness of insertable cardiac monitors (ICMs) in a US cryptogenic stroke population. Materials & methods: We modelled lifetime costs and quality-adjusted life years for three monitoring strategies post cryptogenic stroke: ICM starting immediately, ICM starting after Holter monitoring (delayed ICM) and standard of care involving intermittent ECG and Holter monitoring. Patient characteristics and detection efficacy were based on the CRYSTAL-AF trial. AF detection altered the modelled anticoagulation therapy and subsequent stroke and bleed risks. Results & conclusion: Immediate ICM was found to be cost-effective versus standard of care and cost-saving versus delayed ICM. Results were robust to sensitivity analyses. ICMs are a cost-effective diagnostic tool for the prevention of recurrent stroke in a US cryptogenic stroke population.

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Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Medtronic Background Remote monitoring is guideline-recommended to manage cardiac implantable electronic device (CIED) patients. With the continuous growth of implanted patients, clinic workload to review transmissions is increasing. Outsourcing initial data review and triage to an external monitoring center could be a valuable option for more efficient allocation of staff time, as high-skilled healthcare professionals can focus on patients in need rather than non-actionable data. Purpose The objective was to estimate the potential clinic staff time saved when outsourcing part of remote transmission review. Methods A previous time and motion evaluation described workflow tasks and time required for remote transmission review (4 EU sites, 674 observations). From real-world experience with a third-party monitoring service, the steps that can be outsourced were determined considering existing clinic-driven protocols for triage and transmission escalation. Staff time required with and without the monitoring service was thus modeled and compared. Results Outsourcing to an external monitoring center can reduce clinic staff time between 77.4% and 84.7% depending on device type. Absolute time savings range from 32.7 to 82.6 hours per year per 100 patients for therapeutic devices, and 301.3 hours for insertable cardiac monitor (ICM) patients, due to the higher frequency of transmissions in diagnostic devices. Conclusion Time to review remote transmissions can become overwhelming for clinics as growing CIED population often outpaces available staffing resources. Outsourcing initial review and triage to an external monitoring center (ensuring quality and regulatory compliance) can be an efficient option to save dedicated staff and facility time for other crucial healthcare activities. Clinic Staff Time Savings Per YearPacemakerICDCRTICMTRANSMISSIONS PER PATIENT PER YEARGreen (no further review required when outsourcing)3.04.35.020.8Yellow/Red (medical action/decision required)0.60.80.93.8ANNUAL STAFF TIME PER PATIENT, minutesNo outsourcing25.346.658.5219.7Outsourcing to monitoring center5.77.78.938.9ANNUAL STAFF TIME PER 100 PATIENTS, hoursNo outsourcing42.277.697.4366.2Outsourcing to monitoring center9.612.914.964.8TIME SAVED PER 100 PATIENTS, hours (%)32.7 (77.4%)64.7 (83.4%)82.6 (84.7%)301.3 (82.3%)Abstract Figure. Outsourcing Remote Transmission Review