Over the past decade, and perhaps even a few years prior to that, the industry has seen a significant evolution in the field of electrophysiology. This evolution involves new technologies in permanent pacemaker, implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy (CRT), and biventricular devices. Overall practice changes have also resulted in more advanced collaborative efforts between electrophysiologists, cardiac surgeons, cardiologists, and even neurologists. These collaborations should not be a shock (pun intended!) to many readers of this article.

Considering Evolution 

Despite the varied options available for EP program offerings, many hospitals do not consider this subspecialty an area of great growth potential. Corazon believes EP can bring a positive impact to the bottom line of a cardiac service line (and hospital at large) while also bringing access to EP care to the community, which can be a competitive differentiator. 

However, given the many program options, how should a hospital go about considering an EP program expansion? Whether currently offering simple device implants or more complex interventional services, the decision of if or when to evolve to the next level is not an easy one. Indeed, many factors need to be considered in the context of cardiac program design, facility, resources (financial and otherwise), and volume potential. (Figure 1)

Over the past few years, Corazon has witnessed through national experience that electrophysiology services remain an opportunity for hospitals of all scopes and sizes. Being armed with even the most basic market information will allow for a better understanding of the opportunity for EP. The statistics cannot be ignored — with each passing year, increasing numbers of the population are diagnosed with some level of heart disease, be it electrical, structural, or circulatory. The age at which patients are being diagnosed or impacted also seems to be getting younger. (Figure 2)

Why Evolve?

Firstly, device implants remain profitable, having a fairly high contribution margin. In our experience, many markets remain underpenetrated for this service. Secondly, the guidelines have evolved, and positive published trial data supports efforts in expanding the candidate pool of patients who may now qualify for more advanced implantable devices such as resynchronization therapies, thus allowing for a higher quality of life. Simple mapping and ablation procedures also remain profitable, and beyond the fiscal impact, these EP services improve the quality of life for patients. For many programs, the motivation to evolve may be to maintain a competitive edge, grow market share, or prevent the outmigration of patients to other facilities or markets. 

In Corazon’s experience, we typically also witness an associated “halo” effect for other diagnostic services offered within an organization. It’s easy for programs to become comfortable and maintain the “status quo”; after all, it takes both fiscal resources and a level of “sweat equity” in order to evolve. Most importantly, hospitals must strategically reflect on how to evolve (the intended goal of change), and then what the evolution will require (the start-to-finish resources of all types). For instance, consider a program evolution from a level I provider to a level II. Careful consideration must be given to understanding the expertise necessary to provide this higher level of services — clinically, operationally, and financially. This effort will no doubt require an evaluation of market demand and the associated physician supply. 

Corazon is actively conducting an EP survey, and one of our questions asks participants whether their facility has considered developing a syncope program. Although our survey remains open and has not concluded, to date, 52% of our respondents are considering syncope as part of their program evolution. Syncope afflicts many Americans, and although its etiology differs from patient to patient, having the ability to monitor and treat this patient population continues to be “top of mind” for program leaders — an evolutionary part of program development as this condition becomes more prevalent or recognized. 

As defined by the American Heart Association, syncope is a temporary loss of consciousness and posture, described as fainting or passing out, usually related to temporary insufficient blood flow to the brain. It most often occurs when the blood pressure is too low (hypotension) and the heart doesn’t pump a normal supply of oxygen to the brain. Although there are many causes of this condition, the following forms of syncope may be considered dangerous for some patients: those with an irregular or fast heart rate on a regular basis for unknown reasons; exercise-induced syncope, which may be harder to anticipate; and those patients with a family history of sudden cardiac death. 

Programs considering a syncope program should first understand the number of visits and/or referrals with a diagnoses of syncope to the emergency department, as well as the underlying reasons for the patient’s episode. Having this data readily available for discussion with the cardiovascular service line administrator as well as the cardiologist, electrophysiologist, emergency room physician, and neurologist will assist in decision-making related to the syncope program evolution. A syncope program would also offer patients the ability to undergo additional diagnostic testing such as electrocardiograms, Holter monitoring, the insertion of a loop recorder, and tilt table testing. If deemed clinically necessary by an electrophysiologist, advanced EP diagnostics or ablative therapies are also options when indicated. 

Many programs that choose to offer a syncope program will do so not only for monetary reasons, but also to complement an existing electrophysiology program, perhaps to address the patients across the entire EP care continuum. Further, the marketing associated with this kind of program expansion affords greater customer satisfaction for both referring physicians and patients. 

Certainly, a multidisciplinary approach is necessary on all fronts for an EP program expansion. The treatment of atrial fibrillation (AF) is another subspecialty of EP that has experienced significant clinical and technological changes. The evolution here has mainly to do with the increasing number of patients being afflicted with this condition, and those numbers are growing at an alarming rate. Technological advances in the treatment of AF provide patients with an alternative beyond the traditional, more costly medical therapies. 

The rationale for many programs to offer an AF program is no different than when a program decides to take the next step in offering more than just pacemaker implants. However, a caveat would be the need to understand whether a particular state governing agency or department of health has specific regulations around what electrophysiology services are or are not permitted, specifically in a community hospital setting without on-site open heart surgery. 

In our experience, much like other cardiac services (i.e., angioplasty with off-site open heart surgery support), many states have regulations and/or criteria for hospitals that want to add or modify EP services. One example as written within the Heart Rhythm Society (HRS) guidelines dictates that facilities considering a lead extraction program must have on-site open heart surgery. Furthermore, the HRS recommends that not only an open heart suite be open, but that a cardiothoracic surgeon is ready and available during the scheduled procedure time. If something goes wrong with the lead extraction, there are only minutes available to open the chest to prevent a poor outcome. 

Corazon recommends that programs interested in evolving to the next level of EP services should diligently research to understand state regulations, program criteria, and even process or requirements on how to proceed with launching a new EP service or expand upon an existing program. No doubt this effort can be daunting; however, with market trends across the country revealing growth within the subspecialty, the time might be now for your cardiac program to expand or evolve to include the latest in EP. Only then can your organization be positioned to take advantage of the opportunity — ideally before your competitor does.

Corazon “Asks The Expert” 

Dr. Charles Kinder is a renowned expert in the field of electrophysiology, with decades of experience in EP clinical practice and program leadership. As an avid EP practitioner and follower of cutting-edge technology in the field, we asked him some important questions about trends in the specialty:

What are key considerations for organizations moving to offer a syncope program?

The key considerations are buy-in from the emergency room, neurology, ENT physicians, and of course, cardiology. This process/collaboration starts with each of the specialties hosting an educational session about the causes of syncope within their field of expertise. The most common and successful forum for this education is a 20-minute presentation at a monthly or quarterly department meeting. Each specialty needs to be armed with enough knowledge of the differential diagnosis to know when to urgently triage a patient. Additionally important: once there is general agreement on accepting “add-on” office patients on the basis of a phone call from a colleague (this is a must), the lines of communication are open and true collaboration begins! As this flurry of activity successfully rolls out, the hospital should launch: a marketing campaign including internal marketing via the hospital employee website and/or newsletter; a general announcement, e-mail blast, and grand rounds for the primary care physicians; and community outreach programs. The value of a syncope program is its broad appeal — there is little to no capital investment, although the effort most definitely requires “sweat equity.” 

What have you found in your own experience to be successful as programs consider a multidisciplinary approach in caring for the AF patient population?

The key to success for any AF program is a multidisciplinary approach. Collaboration between cardiology, EP, and CV surgery is a must. In addition, expertise is required from radiology in knowing exactly what information is crucial on pre-ablation scans, as well as the post-ablation testing done to evaluate for possible complications. Anesthesia must also be involved from the onset with a flexible schedule, and GI must be willing to accept last-minute add-on esophagogastroduodenoscopy (EGD). Finally, of utmost consideration is patient safety. The ER staff must understand the presentation of the less common, but nevertheless critical, post-ablation complications such as atrioesophageal fistula and pulmonary vein stenosis. Their ability to recognize these and other conditions and be able to mobilize resources for treatment is vital. 

How has customer service evolved to become a key component of service within EP?

Customer satisfaction involves both patients and physicians. The patients that gravitate to an AF program tend to require frequent “touches” (checks and re-checks), which can be addressed by allied health physician support staff.

Dr. Charles Kinder is a Medical Advisor and Amy Newell is a Vice President at Corazon, Inc., a national leader in program development for the heart, vascular, neuro, and orthopedic specialties, offering consulting, recruitment, interim management, and IT solutions across the country and in Canada. To learn more, visit www.corazoninc.com or call 412-364-8200. To reach the authors, e-mail anewell@corazoninc.com or CKinder@heartcc.com.