Knowledge Update on the Economic Evaluation of Pacemaker Telemonitoring Systems

(1) Introduction: In the last two decades, telemedicine has been increasingly applied to telemonitoring (TM) of patients with pacemakers; however, presently, its growth has significantly accelerated because of the COVID-19 pandemic, which has pushed patients and healthcare workers alike to seek new ways to stay healthy with minimal physical contact. Therefore, the main objective of this study was to update the current knowledge on the differences in the medium-and long-term effectiveness of TM and conventional monitoring (CM) in relation to costs and health outcomes. (2) Methods: Three databases and one scientific registry were searched (PubMed, EMBASE, Scopus, and Google Scholar), with no restrictions on language or year of publication. Studies published until July 2021 were included. The inclusion criteria were: (a) experimental or observational design, (b) complete economic evaluation, (c) patients with implanted pacemakers, and (d) comparison of TM with CM. Measurements of study characteristics (author, study duration, sample size, age, sex, major indication for implantation, and pacemaker used), analysis, significant results of the variables (analysis performed, primary endpoints, secondary endpoints, health outcomes, and cost outcomes), and further miscellaneous measurements (methodological quality, variables coded, instrument development, coder training, and intercoder reliability, etc.) were included. (3) Results: 11 studies met the inclusion criteria, consisting of 3372 enrolled patients; 1773 (52.58%) of them were part of randomized clinical trials. The mean age was 72 years, and the atrioventricular block was established as the main indication for device implantation. TM was significantly effective in detecting the presence or absence of pacemaker problems, leading to a reduction in the number of unscheduled hospital visits (8.34–55.55%). The cost of TM was up to 87% lower than that of CM. There were no significant differences in health-related quality of life (HRQoL) and the number of cardiovascular events. (4) Conclusions: Most of the studies included in this systematic review confirm that in the TM group of patients with pacemakers, cardiovascular events are detected and treated earlier, and the number of unscheduled visits to the hospital is significantly reduced, without affecting the HRQoL of patients. In addition, with TM modality, both formal and informal costs are significantly reduced in the medium and long term.


Introduction
Telemedicine is the delivery of healthcare services with the help of information and telecommunication technology. Because of the enormous progress made in these technological fields, more and more hospitals have adopted electronic health records, leading to an exponential growth in the use of telemedicine [1,2]. Conventionally, telemedicine has been used to encourage self-care through remote and chronic disease monitoring, to provide consultations to patients who are unable to attend in-person (face-to-face) appointments, and to improve patient care within hospitals and clinics. A key advantage of telemedicine is its ability to increase access to health care by offering patients the opportunity to receive care in their homes and communities [2][3][4]. This becomes more important in the present COVID-19 pandemic, as both patients and health care workers are adopting methods with minimal physical contact [2]. Cardiovascular diseases affect heart and blood vessels and are the leading cause of death globally. A pacemaker is a device that is widely used in cardiac patients to restore normal heart rates, and patients with implanted pacemakers must be followed up regularly. Telemonitoring (TM) systems or remote monitoring of pacemakers provide a convenient means for regular assessment of device-related parameters, such as lead impedance and battery status, which may allow early detection of device and lead malfunctions [5][6][7][8][9][10]. Based on this, if required, changes in medication can be prescribed without consuming time and medical resources [5,[11][12][13][14][15] and causing discomfort to patients and their caregivers [16]. Research indicates that clinically actionable events are detected sooner with telemonitoring than with standard in-office follow-ups [5,16], thereby allowing clinicians to act on these issues before they cause increased morbidity, hospitalizations, and costs [5]. Several studies have shown that TM represents an effective and cost-saving way in which to significantly reduce in-office follow-up visits and lower the burden for both hospitals and patients and their caregivers [17][18][19][20][21][22][23][24][25][26][27][28] without compromising safety [5,[28][29][30]. Besides, TM has been associated with high patient acceptance, satisfaction, and quality of life as it entails less travel time, time off work, and interruption of patient activities, as well as increased adherence to programmed follow-up [5,[31][32][33]. However, in spite of this, TM of users with pacemakers has not been universally adopted [34][35][36] and even hospitals that have incorporated this technology into routine clinical practice for other Cardiac Implantable Electronic Devices (CIEDs) do not routinely use it for pacemakers [37].
The recent strong growth in the number of patients with remotely monitored pacemakers has generated the need for studies comparing TM to conventional in-hospital monitoring (CM). Therefore, the main objective of this study was to conduct a systematic review analyzing the current scientific literature to evaluate the effectiveness and costs of both monitoring modalities

Methods
This systematic review has followed PRISMA guidelines, and the study has been registered in PROSPERO (PROVISIONAL ID number: 290,328).

Search Strategy
A structured review of the following databases was conducted: Medline via PubMed, EMBASE, Scopus, and Google Scholar. The Boolean operators used were AND OR. The following English search terms were used: "Pacemaker", "Telemedicine", and "Cost-Benefit Analysis." These terms were searched in all the selected databases and in complete articles, including the title, summary, text, and keywords. The inclusion criteria for studies were (a) experimental or observational design; (b) studies based on complete economic evaluations, i.e., studies comparing health outcomes and costs, with no exclusions for analysis method (cost-effectiveness, cost-utility, cost-benefit, and cost-minimization); (c) patients with pacemakers, and (d) comparison of TM with CM. The search was conducted between 13 and 21 July 2021, with no restrictions on language or year of publication. In addition to
The main characteristics of the studies are summarized in Table 1. The selected publications represent a total of 3372 enrolled patients. Out of them, 1773 (52.58%) were part of randomized clinical trials. The sample sizes of the studies varied (50-802 patients). The mean age of the patients in 10 of the publications [7,[43][44][45][46][47][48][49][50][51] was 71.85 ± 22.09 years (minimum age 12; maximum age 88). The major indication for pacemaker implantation was atrioventricular block [7,[44][45][46][47][48][49]51]. The study period ranged from 4 weeks [7] to 372 months [48]. All of the selected studies used the same pacemaker model in both follow-up arms, with the exception of the studies by Folino et al. [45,46] and Lopez-Villegas et al. [50], who used two different pacemaker models in the CM group. None of the selected studies stated if monitoring systems were previously being used for all pacemakers followed up by the hospital. A cost-utility analysis was performed in five of the publications [7,[48][49][50][51]. (1) had a spontaneous ventricular rate < 30 bpm, (2) were in overt heart failure, (3) had a history of cardiac surgery or myocardial infarction within 1 month, (4) were systemically anticoagulated, (5) were unable to understand the TM system, (6) were pregnant or breastfeeding, or (7) they were unwilling to provide written informed consent to participate.

CUA NHS Direct
Lopez-Villegas et al. [49] (4) capable of understanding and correctly performing the home auto-monitoring or had a caregiver who could carry out this function [20,21].

CUA NHS and Social
Direct and indirect AVB, atrioventricular block; bpm, beats per minute; CBA, cost-benefit analysis; CEA, cost-effectiveness analysis; CMA, cost-minimization analysis; CUA, cost-utility analysis; GSM, global system for mobile communications; HM ® , Home Monitoring ® ; IC, informed consent; N/A, not available; NHS, national health system; PM, pacemaker; TM, telemonitoring; TTM, transtelephonic monitoring. Table 2 contains the primary and secondary endpoints analyzed in each of the studies, as well as the most significant results. Only the studies of Folino et al. [45,46] included the number of pacemaker replacements (ranging from 7 to 123), and the reported device longevity ranged from 6.7 years to 8.3 years [7,[44][45][46]. Only two studies [7,48] specified the mean hospital stay, which was 34% to 73.2% shorter in the TM group. Besides, two studies [7,48] administered the SF-36 questionnaire, and the other three studies [49][50][51] used the EuroQol-5D (EQ-5D) questionnaire to evaluate the health-related quality of life (HRQoL). The results indicated no significant differences between the two alternatives of follow-up.

Cost Analysis
The costs of implementing TM in patients with pacemakers were not included in any of the studies selected in this systematic review ( Table 2). Three of the papers stated that the costs of the "home monitoring system" (remote option) were paid by the hospital [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of implementing TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in this systematic review, the cumulative annual inflation was estimated from the year following the publication of the article to December 2020. Then, direct conversion of each currency to euros (€) based on the price on 12 August 2021, was made. The total costs of all the studies included in this review are lower in the TM group compared to that of the CM group, except in the results presented by Lopez-Villegas [50] (Table 2). In the WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up by the TM modality resulted in a saving of €14,669 per year (associated with ambulance transport) for the Scottish National Health System. A study carried out with a pediatric population [43] indicates that there would have been a saving of €18,611 over the 3 years of study period if the 96 participants had been able to substitute visits to the emergency room in the hospital with the data transmission system. The economic saving in the TM modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with the costs associated with the TM group being 9% to 86.69% lower than that of the CM group. In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM group reported a reduced number of hospital visits (8.34-55.55%) compared to the patients in the CM group. The informal costs associated with each modality of follow-up (costs of transport, productivity, accompanying person, etc.) were estimated in five of the studies included in this systematic review [45,[48][49][50][51], which indicates that in the remote modality of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Table 3 shows the costs of the follow-up alternatives included in this systematic review. Early discharge of patients after pacemaker implantation followed by TM was safe and facilitated the monitoring of patients in the month following the procedure.

Reference, Country Telemonitoring Conventional Monitoring
Shaw et al. [42], United Kingdom costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review. Folino et al. [46], Italy Staff modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review. Telephone room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.    of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review. TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.  TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives  Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review. Staff the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review. Laboratory the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review. ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review. Folino et al. [46], Italy Transport group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives Pang et al. [44], Canada systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review. Folino et al. [46], Italy In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review. Folino et al. [46], Italy Hospital visits menting TM systems were borne by the pacemaker manufacturers. In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review. Folino et al. [46], Italy Equipment rental [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers. In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review. Folino et al. [46], Italy Telephone calls systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives  [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives Folino et al. [45], Italy that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers. In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review. The costs of implementing TM in patients with pacemakers were not include any of the studies selected in this systematic review ( Table 2). Three of the papers s that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.

Cost Analysis
The costs of implementing TM in patients with pacemakers were not include any of the studies selected in this systematic review ( Table 2). Three of the papers s that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review. that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives The costs of implementing TM in patie any of the studies selected in this systematic that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives

Cost Analysis
The costs of implementing TM in patie any of the studies selected in this systematic that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives

Cost Analysis
The costs of implementing TM in patients with pacemakers were not include any of the studies selected in this systematic review ( Table 2). Three of the papers s that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.

Cost Analysis
The costs of implementing TM in patients with pacemakers were not include any of the studies selected in this systematic review ( Table 2). Three of the papers s that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.

Cost Analysis
The costs of implementing TM in patients with pacemakers were not include any of the studies selected in this systematic review ( Table 2). Three of the papers s that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.

Cost Analysis
The costs of implementing TM in patie any of the studies selected in this systematic that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives

Cost Analysis
The costs of implementing TM in patie any of the studies selected in this systematic that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives

Cost Analysis
The costs of implementing TM in patie any of the studies selected in this systematic that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives

Cost Analysis
The costs of implementing TM in patients with pacemakers were not include any of the studies selected in this systematic review ( Table 2). Three of the papers s that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.

Cost Analysis
The costs of implementing TM in patients with pacemakers were not include any of the studies selected in this systematic review ( Table 2). Three of the papers s that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.

Cost Analysis
The costs of implementing TM in patie any of the studies selected in this systematic that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives

Cost Analysis
The costs of implementing TM in patie any of the studies selected in this systematic that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives

Cost Analysis
The costs of implementing TM in patients with pacemakers were not include any of the studies selected in this systematic review ( Table 2). Three of the papers s that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.

Cost Analysis
The costs of implementing TM in patients with pacemakers were not include any of the studies selected in this systematic review ( Table 2). Three of the papers s that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.

Cost Analysis
The costs of implementing TM in patie any of the studies selected in this systematic that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives

Cost Analysis
The costs of implementing TM in patie any of the studies selected in this systematic that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives

Cost Analysis
The costs of implementing TM in patients with pacemakers were not include any of the studies selected in this systematic review ( Table 2). Three of the papers s that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.

Cost Analysis
The costs of implementing TM in patients with pacemakers were not include any of the studies selected in this systematic review ( Table 2). Three of the papers s that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.

Cost Analysis
The costs of implementing TM in patie any of the studies selected in this systematic that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives

Cost Analysis
The costs of implementing TM in patie any of the studies selected in this systematic that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives

Cost Analysis
The costs of implementing TM in patients with pacemakers were not include any of the studies selected in this systematic review ( Table 2). Three of the papers s that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.

Cost Analysis
The costs of implementing TM in patients with pacemakers were not include any of the studies selected in this systematic review ( Table 2). Three of the papers s that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.

Cost Analysis
The costs of implementing TM in patie any of the studies selected in this systematic that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives

Cost Analysis
The costs of implementing TM in patie any of the studies selected in this systematic that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives

Cost Analysis
The costs of implementing TM in patients with pacemakers were not include any of the studies selected in this systematic review ( Table 2). Three of the papers s that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.

Cost Analysis
The costs of implementing TM in patients with pacemakers were not include any of the studies selected in this systematic review ( Table 2). Three of the papers s that the costs of the "home monitoring system" (remote option) were paid by the hos [43,49,50]. In contrast, in the articles written by Folino et al. [45,46], the costs of im menting TM systems were borne by the pacemaker manufacturers.
In order to facilitate the economic comparison of the different studies selected in systematic review, the cumulative annual inflation was estimated from the year fo ing the publication of the article to December 2020. Then, direct conversion of each rency to euros (€) based on the price on 12 August 2021, was made. The total costs the studies included in this review are lower in the TM group compared to that of the group, except in the results presented by Lopez-Villegas [50] (Table 2). In WEST-SCOTLAND [42] study, the replacement of the CM modality of follow-up b TM modality resulted in a saving of €14,669 per year (associated with ambu transport) for the Scottish National Health System. A study carried out with a ped population [43] indicates that there would have been a saving of €18,611 over the 3 y of study period if the 96 participants had been able to substitute visits to the emerg room in the hospital with the data transmission system. The economic saving in th modality is evident in almost 82% (n = 9) of the selected studies [7,[43][44][45][46][47][48][49]51], with costs associated with the TM group being 9% to 86.69% lower than that of the CM gr In five (45.45%) of the selected studies [7,46,47,49,51], the patients in the TM grou ported a reduced number of hospital visits (8.34-55.55%) compared to the patients i CM group. The informal costs associated with each modality of follow-up (cos transport, productivity, accompanying person, etc.) were estimated in five of the stu included in this systematic review [45,[48][49][50][51], which indicates that in the remote mod of follow-up, cost savings of up to 56.70% per patient/year can be achieved [49]. Ta shows the costs of the follow-up alternatives included in this systematic review.

Cost Analysis
The costs of implementing TM in patie any of the studies selected in this systematic that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives

Cost Analysis
The costs of implementing TM in patie any of the studies selected in this systematic that the costs of the "home monitoring system [43,49,50]. In contrast, in the articles written menting TM systems were borne by the pace In order to facilitate the economic comp systematic review, the cumulative annual in ing the publication of the article to Decembe rency to euros (€) based on the price on 12 A the studies included in this review are lower group, except in the results presented WEST-SCOTLAND [42] study, the replacem TM modality resulted in a saving of €14 transport) for the Scottish National Health S population [43] indicates that there would h of study period if the 96 participants had be room in the hospital with the data transmiss modality is evident in almost 82% (n = 9) o costs associated with the TM group being 9% In five (45.45%) of the selected studies [7,46 ported a reduced number of hospital visits ( CM group. The informal costs associated transport, productivity, accompanying perso included in this systematic review [45,[48][49][50][51] of follow-up, cost savings of up to 56.70% p shows the costs of the follow-up alternatives

Methodological Quality Assessment
The variables evaluated were scored based on the presence or absence (yes/no answers) of the criterion analyzed (Table 4). If, on the final review of the article, a parameter was not found, a response of "no" was recorded in the table, i.e., the study did not include that parameter.
The study by Bautista-Mesa et al. [51] obtained the highest overall score for methodological quality, with 24 out of a possible 25 points, whereas the lowest score of 7 was obtained in the study by Shaw [42]. The publications evaluated had a mean score of 15.55 ± 5.07 points (minimum 7; maximum 24). The main findings were as follows: (a) Five manuscripts [45,47,[49][50][51] included results with both social and financial perspectives (NHS); (b) Five studies [7,[48][49][50][51] have used social assessment scales for evaluating HRQoL, which were validated on a representative sample of the population; (c) Except for one study [51], none of the studies applied modeling techniques or discounts for costs and benefits or conducted a sensitivity analysis; (d) The results obtained from eight of the selected studies [7,44,45,[47][48][49][50][51] could draw conclusions about the transferability or extrapolation of results to other contexts; (e) The results of all the included studies are presented with an incremental analysis; however, the results of three studies are disaggregated (costs and results of the alternatives) [49][50][51]; (f) Five of the studies [7,[42][43][44][49][50][51] have clearly indicated the financial source of the study.

Intercoder Reliability
The results for each variable are shown in Table 5. Mean and standard deviation values were not calculated because the variables included in this study were categorical. The study by Vincent et al. [43] obtained the lowest percentage agreement of 84%, with other parameters being Scott's pi −0.087, Cohen's kappa −0.087, and Krippendorff's alpha −0.065; the highest percentage agreement of 100% was obtained in four studies [44][45][46]51]. viously published in the COMPAS study [19], which reported that patients of the TM group made 55% fewer hospital visits compared to patients included in the CM group. In contrast, three of the articles (27.27%) [43][44][45] reported results pertaining to the TM group only.
The development and expansion of remote pacemaker monitoring systems have proven that this is a safe and reliable technology [7,[42][43][44][45][46][47][48][49][50][51]. The steady increase in the transmission of information from the patient's home monitor to the service provider's platform has enabled quick and efficient treatment of cardiac patients on an ongoing basis. It is also noted that in the medium to long term, there is a significant reduction in the number of unscheduled visits and/or hospitalizations. In four of the publications included in this review [7,[46][47][48], there were no significant differences between the two follow-up modalities in relation to the number of adverse events detected, which is in accordance with two previously published studies [19,22]. In a previous study on pacemakers [16], it is reported that cardiovascular events were detected around two months earlier in the TM group (5.7 vs. 7.7). In two subsequent studies carried out on patients with implantable cardioverter-defibrillator and cardiac resynchronization therapy, the response time to these episodes was 22-36 days in the case of the CM group; however, in the TM group, it was reduced to 2-4.6 days [22,53].
Five of the selected studies analyzed HRQoL of the included patients (45.46%) [7,[48][49][50][51]. The SF-36 questionnaire was used in two studies [7,48] and the EQ-5D was used by Lopez-Villegas et al. [49,50] and Bautista-Mesa et al. [51]. The results indicate no significant differences between the two follow-up modalities in all patients. These results coincide with those found in the COMPAS [19] and ECOST [22] trials, which used the SF-36 questionnaire, and with the PONIENTE [20] study, which used the EQ-5D questionnaire.
The analysis of the methodological quality of the manuscripts included in this study exhibited significant variability among them, with higher scores obtained by the most recent studies [49][50][51]. The results presented in this systematic review, which coincide with a previous study [54] published in 2016, indicate how difficult it is to assess the methodological quality of studies published in the last two decades based on the current criteria [42,43]. However, different inputs are included in all the selected studies, such as the establishment of an objective and research question, comparison of both follow-up modalities, adjustment of the costs collected to the perspective of the selected analysis, and adaptation of the time horizon to the study objectives. Additionally, they coincide, except for the study by Bautista-Mesa et al. [51], in not implementing modeling techniques, discounting costs, performing sensitivity analysis, justifying key parameters and statistical distribution of the variables, performing equity analysis, and including cost-effectiveness and cost-benefit ratios.

Cost Analysis
The results presented in this systematic review confirm that TM of pacemakers can significantly decrease the length of hospital stays [7,48] reaching in some cases a reduction of up to 80.49%. One of the most significant findings is the substantial reduction of 9% to 86.69% [7,[42][43][44][45][46][47][48][49][50][51] in the costs of TM with respect to that of CM.
In addition, the results of most of the studies included in this review indicate that TM systems significantly reduce direct costs, such as for staff and health administration, as well as indirect costs related to monitoring, such as transport costs, maintenance of consultations, and waiting rooms, etc. The results found in this systematic review are similar to those obtained in previous studies that were carried out on different types of cardiovascular electronic devices [2,15,26,27,55], and on remote follow-up performed in other pathologies, such as rheumatoid arthritis [56], mental health [57], teleglaucoma [58], teledermatology, and tele radiology [59][60][61]. In a study published in 2009 by Raatikainen, it was reported that a lower number of hospital visits resulted in up to 41% reduction in costs per patient [27]. A study published by Elsner [62] reported a 61% increase in savings due to a reduction of 63% in the number of visits and the transport costs associated with them. Finally, and coinciding with the results obtained in this review, Crossley published a study reporting that reducing the number of days spent in hospitals can achieve savings of almost $1700 per patient per year [16].

Study Limitations
Although the results presented in this systematic review are highly relevant in relation to the effectiveness of TM in patients with pacemakers, the analysis carried out presents several limitations that should be taken into account.
First, the number of included studies (n = 11) and enrolled participants (n = 3427) were less, mainly due to the limited use of TM technology compared to CM. The second limitation is the variability in the methodological quality of the selected studies; except for one study [51], none of them used modeling techniques and discounts in costs and results. Apart from this, the key parameters of the study and the statistical distribution of the variables examined in the sensitivity analysis were not explained properly. The third limitation is the small number of studies [48,51] analyzing the medium-and long-term effectiveness of remote monitoring, as TM is a relatively new technology. The fourth limitation is the large time span of 39 years between the first and the last published study [42,51], during which, exponential changes in these technologies have occurred. Furthermore, in this study, the differences and similarities between both monitoring modalities have been verified in different spatiotemporal contexts. Finally, cost-effectiveness studies were less generalizable compared to effectiveness studies since they depend on both the duration and the context in which the studies are carried out; yet their importance is enormous since they facilitate decision-making by the different professionals involved [54]. This systematic review presents the significant results of studies carried out in the last 40 years (1981-2020), mainly focusing on the health outcomes and costs associated with TM of patients with pacemakers. Therefore, the findings of this systematic review have led to an update in scientific knowledge in this area, and the results can be further utilized to facilitate decisionmaking and the implementation of new health policies. The authors of this study advise future researchers to focus on economic evaluations, comparing both follow-up modalities, including the cost-effectiveness ratios and the informal costs associated with the follow-up. In addition, the time horizon should be medium and long term.
The results presented in this study can be used by both healthcare managers and cardiology unit professionals to promote the sustainability of current healthcare systems.

Conclusions
Most of the studies included in this systematic review confirm that in the TM of patients with pacemakers, there is a reduction in cardiovascular events and hospital visits without affecting the HRQoL of patients. In addition, both formal and informal costs are significantly reduced in the medium and long term.
Supplementary Materials: The following are available online at https://www.mdpi.com/article/10 .3390/ijerph182212120/s1, File S1: References not included in the systematic review. Funding: This study was funded by the Instituto de Salud Carlos III through the project "No. PI17/02056" (Co-funded by European Regional Development Fund/European Social Fund "A way to make Europe"/"Investing in your future").

Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.

Data Availability Statement:
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.