Electrophysiology 2009: Making Practical Decisions in Difficult Economic Times

Electrophysiology continues to make advances. However, we have to place these advances in the context of an economy that has slipped into a deep recession (both in the United States and worldwide). For years, electrophysiology has seen double-digit growth in both the number of devices implanted as well as the number of catheter ablation procedures performed. This growth has been unprecedented and coincided with the growth seen on Wall Street and in technology over the past thirty years. As companies like Microsoft and Intel continued to grow and expand, so did the cardiovascular technology companies like Boston Scientific, Medtronic, Johnson and Johnson and St. Jude Medical. However, like the growth that occurred with the technology companies, eventually a threshold was reached in which additional unbridled expansion could not continue. The medical community and hospitals were able to survive and even grow as long as they had the wherewithal to continue to support the development of new services. This occurred based on several factors. First, there has to be a clinical need that can benefit from the new services. Second, new technologies need to be funded and go through a lengthy and expensive research and development phase in order to prove safety and efficacy before achieving U.S. FDA (Food and Drug Administration) approval. Third, medical institutions need money in order to acquire these new products and establish the infrastructure to support them. These services have been able to grow in the past due to a positive cashflow of revenue, produced in part from the income generated from the expansion of new services (such as growth with stents, implantable defibrillators, etc.). In addition, money was able to be borrowed in order to pay for new equipment (leased capital equipment); new bonds were able to be floated to pay for new construction and other services; federal and state support continued for medical education providing an additional resource supporting the hospital with medical and surgical residents and house-staff; and philanthropy helped to fill in the gaps. If physicians and their medical communities become limited in their ability to buy and support new technology (either due to less revenue generation or less reimbursement), then the companies become unable to generate the revenue which is necessary to support all research and development in order to produce new technology. What happens to the above system when the money continues to dry up? (i.e., less philanthropy, less federal and state support, less revenue generated, less availability to borrow money in one form or another and less industrial money.) 1) Companies cut back on services and support, which includes support of philanthropy and education. Other less profitable services and individuals may be abandoned (i.e., entire divisions and programs may be cut, and employees may be reassigned or, even worse, let go). 2) Medical institutions cut back on new construction and capital spending, consolidate staffing and overhead for existing programs, and find it almost impossible to develop new programs in this environment. 3) Physicians (who are seeing rising malpractice costs and decreasing reimbursement) cut back on their overhead and try to find less expensive rental facilities, minimize staffing, and hold off on new capital purchases; 4) Government funding decreases except for programs that may be politically motivated such as electronic medical records and funding for the present uninsured, as proposed by the Obama administration. In addition, there is the threat of some sort of universal health coverage or program that might be pushed forth by the current administration in order to contain healthcare costs (i.e., limit the percentage that healthcare comprises of the gross national product). So where do we make practical decisions in this impractical world? In this issue of the Journal of Invasive Cardiology, we have invited authors to discuss some relevant topics in electrophysiology. First, Dr. Undavia has provided a coding update for 2009.1 He has highlighted some bright spots in terms of device reimbursement, namely the ability to utilize physicians’ services more appropriately and time-efficiently. Many physicians continue to perform most of their device follow-up procedures in person. By converting in-person interrogations into remote interrogations, the doctors and their practices can provide a steady revenue stream for these reimbursed services and free up their time for other medical practices. Second, Dr. Vlay has reviewed the latest guidelines for device implantation.2 To put these in a practical perspective, the doctor now has more flexibility to use his or her judgment to determine whether a patient needs a pacemaker, defibrillator or cardiac resynchronization device. Remember, with an expansion in the guidelines, there is the potential for an increase in cost to our healthcare system, which will not go unnoticed in today’s fiscal environment. Third, Dr. Snow and his colleague reviewed laser lead extraction.3 This procedure utilizes expensive resources, and its place in 2009 must be carefully considered. Finally, Darge and Patel and their respective colleagues discuss (in two separate articles) more involved catheter ablation technologies that are used for ablation of atrial fibrillation and ventricular tachycardia/fibrillation.4,5 The first group reviews the current state of affairs with regards to atrial fibrillation.4 The latter team discusses the explosion of technology and the current state of affairs with respect to new catheters, energy modalities, imaging techniques and robotics.5 For all practical purposes, the latter two articles discuss very expensive time-consuming techniques in which multiple expensive catheters, including imaging catheters, are utilized. These procedures expose the operator and their spine to significant radiation and the weight of a heavy lead apron. Both articles discuss robotics (i.e., remote navigation) as a way to minimize the latter problem, however, the complexity and the expense of the two U.S. FDA-released systems will be difficult to swallow in today’s economic environment. The U.S. FDA-approved robotic systems require the insertion of either newer materials such as nonstandard catheters and/or large steerable sheaths, are very expensive and bulky, and often require additional construction or space. Darge’s group touches on the system developed by Catheter Robotics, Inc. (Budd Lake, New Jersey).4 This system (which I helped to develop) may provide a simpler, lower-profile system and a less expensive robotic alternative.6 The Catheter Robotics system, which still needs U.S. FDA approval, inserts only standard steerable catheters and sheaths into the human body, permits easy manual removal and manipulation with replacement of the catheter within the robot, all while maintaining sterility, and operates without a large and intrusive control station. It is important to remember that not everything in electrophysiology is interventional procedure-related. For example, advances in pharmacology may help to improve the treatment of atrial fibrillation and ventricular tachycardia. Recently, dronedarone, an amiodarone-like drug with the potential for less toxicity, was demonstrated to reduce mortality or hospitalizations from cardiac events in patients treated for atrial fibrillation.7 This medication appears close to U.S. FDA approval for the treatment of atrial fibrillation. New advances in electrophysiology and devices will have to be practical, not only from a technological perspective, but from a financial perspective as well. Lastly, when talking of practical things in the year 2009, I have to mention my new book titled Practical Electrophysiology — Second Edition, which should be contemporaneously released with this issue of the Journal of Invasive Cardiology at the Heart Rhythm Society’s Annual Scientific Session in May 2009 in Boston.8 As mentioned earlier, in a recession, companies will be spending less money on educational programs. There is the need for a single resource to provide an easily readable update on all aspects of electrophysiology including pharmacology, catheter ablation and implantable devices. Test questions have been added to this edition to help with the review process for the various certifications/recertifications. The newest ACC/AHA/HRS guidelines for device implantation and atrial fibrillation ablation are included, as well as a new section that reviews BLS/ACLS, and another that reviews laser lead extraction. Hopefully, this editorial and my new book will help put electrophysiology in perspective, and help you make practical decisions in difficult economic times.

1. Undavia M. Current procedural terminology coding in electrophysiology: Focus on 2009 updates. J Invasive Cardiol 2009;21:244–246.

2. Vlay SC. The ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: Their relevance to the cardiologist, internist and family physician. J Invasive Cardiol 2009;21:234–238.

3. Snow JS, Parekh S. Update on laser lead extraction. J Invasive Cardiol 2009;21:230–232.

4. Darge A, Reynolds MR, Germano JJ. Advances in atrial fibrillation ablation. J Invasive Cardiol 2009;21:247–254.

5. Patel D, Burkhardt JD, Sanchez JE, et al. Chronicling the evolution of catheter ablation for atrial fibrillation and ventricular tachycardia. J Invasive Cardiol 2009;21:239–243.

6. Knight B, Ayers GM, Cohen TJ. Robotic positioning of standard electrophysiology catheters: A novel approach to catheter robotics. J Invasive Cardiol 2008;20:250–253.

7. Hohnloser SH, Crijns HJGM, van Eickels M, et al. Effect of dronedarone on cardiovascular events in atrial fibrillation. N Engl J Med 2009360:668–678.

8. Cohen TJ (ed). Practical Electrophysiology — Second Edition. HMP Communications: Malvern, Pennsylvania, 2009.