Changes in healthcare utilisation during implementation of remote atrial fibrillation management: TeleCheck-AF project

Aim To evaluate changes in healthcare utilisation and comprehensive packages of care activities and procedures (referred in the Netherlands to as ‘diagnose-behandelcombinatie (DBC) care products) during the implementation of the TeleCheck-AF approach (teleconsultation supported by app-based heart rate/rhythm monitoring) in a Dutch atrial fibrillation (AF) clinic. Methods and results In the Maastricht University Medical Centre+ AF Clinic, data on healthcare utilisation and DBC care products for patients consulted by both a conventional approach in 2019 and the TeleCheck-AF approach in 2020 were analysed. A patient experience survey was performed. Thirty-seven patients (median age 68 years; 40% women) were analysed. With the conventional approach, 35 face-to-face consultations and 0 teleconsultations were conducted. After the implementation of TeleCheck-AF, the number of face-to-face consultations dropped by 80% (p < 0.001) and teleconsultations increased to 45 (p < 0.001). While 42 electrocardiograms (ECGs) and 25 Holter ECGs or echocardiograms were recorded when using the conventional approach, the number of ECGs decreased by 71% (p < 0.001) and Holter ECGs or echocardiograms by 72% (p < 0.001) with the TeleCheck-AF approach. The emergency department patient presentations showed no statistically significant change (p = 0.33). Overall, 57% of medium-weight DBC care products were changed to light-weight ones during implementation of the TeleCheck-AF approach. Patient satisfaction with the TeleCheck-AF approach was high. Conclusion The implementation of TeleCheck-AF led to a change in healthcare utilisation, a change from medium-weight to light-weight DBC care products and a reduction in patient burden. These results created the basis for a new reimbursement code for the TeleCheck-AF approach in the Netherlands. Supplementary Information The online version of this article (10.1007/s12471-023-01836-6) contains supplementary material, which is available to authorized users.

1. Registration.Once a patient visits the hospital for a specific complaint, a care treatment trajectory is opened.Opening a care treatment trajectory automatically opens a sub-trajectory.A sub-trajectory is a defined period within the care treatment trajectory for which the care provided is invoiced, marked by the cut-off moments.The care treatment trajectory contains one or more sub-trajectories.An initial sub-trajectory has a maximum duration of 90 days.If the care activity has not been completed, a new sub-trajectory can be opened after the initial sub-trajectory for a maximum period of 120 days.The care treatment trajectory is closed if no care activities are registered or planned in the future for a period of three times 120 days after the conclusion of a sub-trajectory, or immediately after the death of the patient.
In this registration process, the healthcare provider gradually records which care activities have been carried out to establish a diagnosis and to treat a complaint or condition per sub-trajectory.

Summary. The registered information (diagnosis and care activities
) is summarized per subtrajectory in one structured dataset.

Derivation.
After the sub-trajectory has been completed, the care provider sends data about the contributed care to a grouper (computer application).A grouper derives the DBC care product based on the data supplied (the claim data set).

Declaration.
The DBC care product that is derived by the grouper is given a declaration code.Healthcare providers can charge healthcare based on this declaration code.In general, there are three weights for DBC care products: light (≤ € 200), medium (€ 300-500)

and heavy (≥ € 600). In the cardiology outpatient clinic either light or medium weight DBC are usual. A light weight DBC care product is 1-2 outpatient clinic visits (including remote consultations) with or without electrocardiogram (ECG). As soon as a patient has an additional examination, e.g., Holter or an echocardiogram examination, or additional visit (≥3) with or without ECG, the weight of the DBC care product increases and turns into a medium weight DBC care product. If there is both an echocardiogram and a
Holter performed, only one of the diagnostic tests adds to the weight of the DBC care product, and if there are three echocardiogram examinations within one DBC care product only the first one adds to the weight.Noteworthy, it is possible that two patients who seem to have the same DBC care product with the same activities have different reimbursement, as reimbursement may vary per every quartile (3 months).To minimize the influence of changing reimbursement between each DBC care product, we standardized the reimbursement per DBC care product, using reimbursement from 2020 from publicly available data on the DBC care product information system from the Dutch healthcare authority (https://www.opendisdata.nl).Among 16 patients with AF or AFl, there was suspicion of AFl in 2 patients because of absence of respiratory arrhythmia, a strict heart rate and presence of blocked beats in the 1 min photoplethysmography recordings, which was confirmed as typical AFl by electrocardiogram.

Supplemental
Plot B shows the additional teleconsultations needed after the first teleconsultation (n=22) and proportion of additional FibriCheck usage needed before additional teleconsultation (n=12).

Note:
The figures may not add up due to rounding.

Supplemental
Figure S1.Diagnosis-treatment combination (DBC) set up model.Legend: Medical billing of care treatment trajectory in the Netherlands.The DBC care product is set up based on the four-step model: