Contemporary procedure characteristics and outcomes of accessory atrioventricular pathway ablations in an integrated community-based health care system using a tiered approach.

BACKGROUND: Since the early descriptions of large series of accessory atrioventricular pathway ablations in adults and adolescents over 20 years ago, there have been limited published reports based on more recent experiences of large referral centers. We aimed to characterize accessory pathway distribution and features in a large community-based population that influence ablation outcomes using a tiered approach to ablation. METHODS: Retrospective analysis of 289 patients (age 14-81) who underwent accessory ablation from 2015-2019 was performed. Pathways were categorized into anteroseptal, left freewall, posteroseptal, and right freewall locations. We analyzed patient and pathway features to identify factors associated with prolonged procedure time parameters. RESULTS: Initial ablation success rate was 94.7% with long-term success rate of 93.4% and median follow-up of 931 days. Accessory pathways were in left freewall (61.6%), posteroseptal (24.6%), right freewall (9.6%), and anteroseptal (4.3%) locations. Procedure outcome was dependent on pathway location. Acute success was highest for left freewall pathways (97.1%) with lowest case times (144 ± 68 min) and fluoroscopy times (15 ± 19 min). Longest procedure time parameters were seen with anteroseptal, left anterolateral, epicardial-coronary sinus, and right anterolateral pathway ablations. CONCLUSIONS: In this community-based adult and adolescent population, majority of the accessory pathways are in the left freewall and posteroseptal region and tend to be more easily ablated. A tiered approach with initial use of standard ablation equipment before the deployment of more advance tools, such as irrigated tips and 3D mapping, is cost effective without sacrificing overall efficacy.

Cardiac Pacing and Defibrillation Devices: Cost and Effectiveness.

Implantable cardiac pacing and defibrillation devices are effective and commonly used therapies for patients with cardiac rhythm disorders. Because device implantation is not easily reversible, as well as the high healthcare costs inherent in device use, a clear understanding of the clinical benefits relative to costs is essential for both appropriate clinical use and rational policy making. Cardiac implantable electronic devices (CIEDs) have been among the best-investigated therapies in medicine; these devices have been the topic of numerous clinical and economic evaluations during the past 30 years. However, many important questions remain unclarified. We review the evidence supporting the clinical benefits of CIEDs, including effectiveness in extending survival as well as improving quality of life. We also summarize the economic studies that have investigated costs associated with these devices and their overall cost effectiveness, and we highlight important potential areas for future research.

Potential cost-effectiveness of wearable cardioverter-defibrillator for patients with implantable cardioverter-defibrillator explant in a high-income city of China.

INTRODUCTION: Wearable cardioverter-defibrillator (WCD) is recommended for patients with implantable cardioverter-defibrillator (ICD) removal. This study aimed to investigate the potential cost-effectiveness of WCD for patients with ICD explant in a high-income city of China. METHODS AND RESULTS: A 5-year decision-analytic model was developed to simulate outcomes of three strategies during the period between ICD explant and reimplantation: discharge-to-home without WCD (home group), discharge-to-home with WCD (WCD group), and stay-in-hospital (hospital group). Outcome measures were mortality rates (during the period between ICD explant and reimplantation), direct medical costs, quality-adjusted life years (QALYs), and incremental cost per QALY saved (ICER). Model inputs were derived from literature and public data. Base-case analysis was performed at four cost levels of WCD. Robustness of model results was examined by sensitivity analyses. In base-case analysis, the 8-week mortality rates of WCD, hospital, and home groups were 7.3%, 8.1%, and 9.4%, respectively. WCD group gained the highest QALYs (3.0990 QALYs), followed by hospital group (3.0553 QALYs) and home group (3.0132 QALYs). The WCD group was the cost-effective option with ICERs less than willingness-to-pay (WTP) threshold (57 315 USD/QALY) at WCD daily cost ≤USD48. In probabilistic sensitivity analysis, the WCD group at daily cost of USD24, USD48, USD72, and USD96 were cost-effective in 100%, 94.16%, 22.08%, and 0.16% of 10 000 Monte Carlo simulations, respectively. CONCLUSIONS: Use of WCD during the period between ICD explant and reimplantation is likely to save life and gain higher QALYs. Cost-effectiveness of WCD is highly subject to the daily cost of WCD in China.

Outcomes and costs of remote patient monitoring among patients with implanted cardiac defibrillators: An economic model based on the PREDICT RM database.

BACKGROUND: Remote monitoring of implantable cardioverter-defibrillators has been associated with reduced rates of all-cause rehospitalizations and mortality among device recipients, but long-term economic benefits have not been studied. METHODS AND RESULTS: An economic model was developed using the PREDICT RM database comparing outcomes with and without remote monitoring. The database included patients ages 65 to 89 who received a Boston Scientific device from 2006 to 2010. Parametric survival equations were derived for rehospitalization and mortality to predict outcomes over a maximum time horizon of 25 years. The analysis assessed rehospitalization, mortality, and the cost-effectiveness (expressed as the incremental cost per quality-adjusted life year) of remote monitoring versus no remote monitoring. Remote monitoring was associated with reduced mortality; average life expectancy and average quality-adjusted life years increased by 0.77 years and 0.64, respectively (6.85 life years and 5.65 quality-adjusted life years). When expressed per patient-year, remote monitoring patients had fewer subsequent rehospitalizations (by 0.08 per patient-year) and lower hospitalization costs (by $554 per patient year). With longer life expectancies, remote monitoring patients experienced an average of 0.64 additional subsequent rehospitalizations with increased average lifetime hospitalization costs of $2784. Total costs of outpatient and physician claims were higher with remote monitoring ($47 515 vs $42 792), but average per patient-year costs were lower ($6232 vs $6244). The base-case incremental cost-effectiveness ratio was $10 752 per quality-adjusted life year, making remote monitoring high-value care. CONCLUSION: Remote monitoring is a cost-effective approach for the lifetime management of patients with implantable cardioverter-defibrillators.

Battery longevity of implantable cardioverter-defibrillators and cardiac resynchronization therapy defibrillators: technical, clinical and economic aspects. An expert review paper from EHRA.

In recent years an extension of devices longevity has been obtained for implantable cardioverter-defibrillators (ICDs), including ICDs for cardiac resynchronization therapy (CRT-D) through improved battery chemistry and device technology and this implies important clinical benefits (reduced need for device replacements and associated complications, particularly infections), as well as economic benefits, in line with patient preferences and needs. From a clinical point of view, the availability of this improvement in technology allows to better tune the choice of the device to be implanted, taking into account that the reasons supporting the value of an extended device longevity as a clinical priority may differ according to the clinical setting (purely electrical diseases or left ventricular dysfunction/heart failure, respectively). From an economic point of view, extension of device longevity may have an important impact in reducing long-term costs of device therapy, with substantial daily savings in favour of devices with extended longevity, up to 30%, depending on clinical scenarios. In studies based on projections, an extension of device longevity allowed to calculate that the cost per day of ICDs may be substantially reduced, and this allows to overcome the frequent perception of ICD and CRT-D devices as treatments with unaffordable costs and to overturn the misconception that up-front costs are the only metric with which to value device treatments. In view of its clinical and economic value, device longevity should be a determining factor in device choice by physicians and healthcare commissioners and should be appropriately considered and valued in comparative tenders.

Issues and Challenges in Diagnostic Sequencing for Inherited Cardiac Conditions.

BACKGROUND: Inherited cardiac conditions are a relatively common group of Mendelian diseases associated with ill health and death, often in the young. Research into the genetic causes of these conditions has enabled confirmatory and predictive diagnostic sequencing to become an integral part of the clinical management of inherited cardiomyopathies, arrhythmias, aortopathies, and dyslipidemias. CONTENT: Currently, the principle benefit of clinical genetic testing is the cascade screening of family members of patients with a pathogenic variant, enabling targeted follow up of presymptomatic genotype-positive individuals and discharge of genotype-negative individuals to health. For the affected proband, diagnostic sequencing can also be useful in discriminating inherited disease from alternative diagnoses, directing treatment, and for molecular autopsy in cases of sudden unexplained death. Advances in sequencing technology have expanded testing panels for inherited cardiac conditions and driven down costs, further improving the cost-effectiveness of genetic testing. However, this expanded testing requires great rigor in the identification of pathogenic variants, with domain-specific knowledge required for variant interpretation. SUMMARY: Diagnostic sequencing has the potential to become an integral part of the clinical management of patients with inherited cardiac conditions. However, to move beyond just confirmatory and predictive testing, a much greater understanding is needed of the genetic basis of these conditions, the role of the environment, and the underlying disease mechanisms. With this additional information it is likely that genetic testing will increasingly be used for stratified and preventative strategies in the era of genomic medicine.

The wearable cardioverter-defibrillator: current technology and evolving indications.

The wearable cardioverter-defibrillator has been available for over a decade and now is frequently prescribed for patients deemed at high arrhythmic risk in whom the underlying pathology is potentially reversible or who are awaiting an implantable cardioverter-defibrillator. The use of the wearable cardioverter-defibrillator is included in the new 2015 ESC guidelines for the management of ventricular arrhythmias and prevention of sudden cardiac death. The present review provides insight into the current technology and an overview of this approach.

EuroEco (European Health Economic Trial on Home Monitoring in ICD Patients): a provider perspective in five European countries on costs and net financial impact of follow-up with or without remote monitoring.

AIM: Remote follow-up (FU) of implantable cardiac defibrillators (ICDs) allows for fewer in-office visits in combination with earlier detection of relevant findings. Its implementation requires investment and reorganization of care. Providers (physicians or hospitals) are unsure about the financial impact. The primary end-point of this randomized prospective multicentre health economic trial was the total FU-related cost for providers, comparing Home Monitoring facilitated FU (HM ON) to regular in-office FU (HM OFF) during the first 2 years after ICD implantation. Also the net financial impact on providers (taking national reimbursement into account) and costs from a healthcare payer perspective were evaluated. METHODS AND RESULTS: A total of 312 patients with VVI- or DDD-ICD implants from 17 centres in six EU countries were randomised to HM ON or OFF, of which 303 were eligible for data analysis. For all contacts (in-office, calendar- or alert-triggered web-based review, discussions, calls) time-expenditure was tracked. Country-specific cost parameters were used to convert resource use into monetary values. Remote FU equipment itself was not included in the cost calculations. Given only two patients from Finland (one in each group) a monetary valuation analysis was not performed for Finland. Average age was 62.4 ± 13.1 years, 81% were male, 39% received a DDD system, and 51% had a prophylactic ICD. Resource use with HM ON was clearly different: less FU visits (3.79 ± 1.67 vs. 5.53 ± 2.32; P < 0.001) despite a small increase of unscheduled visits (0.95 ± 1.50 vs. 0.62 ± 1.25; P < 0.005), more non-office-based contacts (1.95 ± 3.29 vs. 1.01 ± 2.64; P < 0.001), more Internet sessions (11.02 ± 15.28 vs. 0.06 ± 0.31; P < 0.001) and more in-clinic discussions (1.84 ± 4.20 vs. 1.28 ± 2.92; P < 0.03), but with numerically fewer hospitalizations (0.67 ± 1.18 vs. 0.85 ± 1.43, P = 0.23) and shorter length-of-stay (6.31 ± 15.5 vs. 8.26 ± 18.6; P = 0.27), although not significant. For the whole study population, the total FU cost for providers was not different for HM ON vs. OFF [mean (95% CI): €204 (169-238) vs. €213 (182-243); range for difference (€-36 to 54), NS]. From a payer perspective, FU-related costs were similar while the total cost per patient (including other physician visits, examinations, and hospitalizations) was numerically (but not significantly) lower. There was no difference in the net financial impact on providers [profit of €408 (327-489) vs. €400 (345-455); range for difference (€-104 to 88), NS], but there was heterogeneity among countries, with less profit for providers in the absence of specific remote FU reimbursement (Belgium, Spain, and the Netherlands) and maintained or increased profit in cases where such reimbursement exists (Germany and UK). Quality of life (SF-36) was not different. CONCLUSION: For all the patients as a whole, FU-related costs for providers are not different for remote FU vs. purely in-office FU, despite reorganized care. However, disparity in the impact on provider budget among different countries illustrates the need for proper reimbursement to ensure effective remote FU implementation.

Impact of Remote Monitoring on Clinical Outcomes.

Follow-up of patients with cardiac implantable electronic devices is challenging due to both their increasing volume and technical complexity coupled to increasing clinical complexity of recipient patients. Remote monitoring (RM) offers an opportunity to resolve some of these difficulties by improving clinic efficiencies and providing a mechanism for device monitoring and patient management. Several recent randomized clinical trials and registries have demonstrated that RM may reduce in-hospital visit numbers, time required for patient follow-up, physician and nurse time, and hospital and social costs. Furthermore, patient retention and adherence to follow-up schedule are significantly improved by RM. Continuous wireless monitoring of data stored in the device memory with automatic alerts allows early detection of device malfunctions and of events, such as atrial fibrillation, ventricular arrhythmias, and heart failure suitable for clinical intervention. Early reaction may improve patient outcome. RM is easy to use and patients showed a high level of acceptance and satisfaction. Implementing RM in daily practice may require changes in clinic workflow. New organizational models promote significant efficiencies regarding physician and nursing time. Data management techniques are under development. Despite these demonstrable advantages of RM, adoption still remains modest, even in health care systems incentivized to use this follow-up method.

Project My Heart Your Heart: An Idea Whose Time Has Come.

It is estimated that nearly 1 million patients in low-income countries die every year from bradyarrhythmias coupled with no access to a pacemaker. At the same time, it is estimated that tens of thousands of used devices could be harvested from hospitals, funeral homes, and crematories in wealthy nations if such a practice was legal and proven to be safe and efficacious. Project My Heart Your Heart is a collaborative, multinational effort with a goal of making pacemaker recycling a reality. Since its inception 4 years ago, the project has studied beliefs and attitudes of this idea among patients, pacemaker recipients, funeral home directors, and arrhythmia specialists. The project has explored the safety and efficacy of this practice in several small pilot studies. Nearly 15,000 used devices have been received and evaluated. Efforts to fully define optimal methods for sterilization and device processing have progressed positively. Safe, effective pacemaker recycling is possible and is generally supported by the public, patients, and cardiovascular specialists. An ongoing dialogue with the FDA will hopefully lead to a large pivotal study in five countries which will definitively establish this practice including optimal strategies for device removal, interrogation, sterilization, handling, implantation, and follow-up at charitable pacemaker facilities servicing low income patients throughout the world.

Safety of pacemaker implantation in nonagenarians: an analysis of the healthcare cost and utilization project-nationwide inpatient sample.

BACKGROUND: Data are scarce on outcomes of pacemaker implantation in nonagenarians (age≥90 years). METHODS AND RESULTS: We identified patients >70 years of age (n=115 683) who underwent initial pacemaker implantation in the 2004 to 2008 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample. Outcomes included in-hospital mortality, complications, length of stay, and charges. Unadjusted outcomes were compared using χ(2) and Mantel-Haenszel tests. Multivariate hierarchical logistic models and stepwise linear regression models adjusted for case-mix variation and clustering. Eleven percent (12 917) were >90 years of age. Relative to patients aged 70 to 79 years, patients >90 years of age were more likely to have moderate/severe comorbidity (Charlson score >1; 43.2% versus 40.1%) and less likely to be admitted electively (17.5% versus 29.9%), all P<0.001. The unadjusted mortality and complication rates in patients aged 70 to 79 years were 0.60% (confidence interval [CI], 0.53-0.67%) and 5.61% (CI, 5.40-5.82%), respectively, and in patients aged >90 years were 1.87% (CI, 1.63-2.11%) and 6.31% (CI, 5.89-6.72%). Length of stay and charges in patients aged 70 to 79 years were 3.22 days (CI, 3.20-3.24 days) and $38 871 (CI, $38 700-$39 043), and in patients aged >90 years, 4.27 days (CI, 4.25-4.30 days) and $41 373 (CI, $41 190-$41 556). Multivariable analysis revealed severe comorbidity (odds ratio, 5.00; 95% CI, 4.05-6.17) was a greater predictor of mortality than increasing age (odds ratio, 2.81 per decade; CI, 2.35-3.35), all P<0.001. Similarly, severe comorbidity (Charlson score >5) was more strongly associated with complications, length of stay, and charges than age. CONCLUSIONS: Although increasing age predicts worsening outcomes in the elderly, the absolute rates are modest, even in nonagenarians, and comorbidity is a stronger predictor.

Hospital utilization in adults with single ventricle congenital heart disease and cardiac arrhythmias.

OBJECTIVES: The study sought to identify the impact of cardiac arrhythmias on hospitalizations in adults with single ventricle (SV) congenital heart disease (CHD). BACKGROUND: Surgical advances have dramatically improved survival in patients with CHD. Cardiac arrhythmias and sudden cardiac death are common in adults with CHD. METHODS AND RESULTS: Data from 43 pediatric hospitals in the 2004 to 2011 Pediatric Health Information System database were used to identify patients ≥18 years of age admitted with International Classification of Diseases-9th Revision codes for a diagnosis of either hypoplastic left heart syndrome (HLHS), tricuspid atresia (TA) or common ventricle (CV), and a cardiac arrhythmia. Primary and secondary diagnoses, length of stay (LOS), hospital charges, and interventional procedures were determined. Multilevel models were used to evaluate differences in demographics, diagnoses, and clinical outcomes among the 3 subgroups (HLHS, TA, and CV). Interactions of charges with arrhythmia and admission year were examined using ANOVA. There were 642 admissions in 424 patients with SV CHD and an arrhythmia diagnosis. A single arrhythmia diagnosis was present in 454 admissions (71%). Total hospital charges were $80.7 million with mean charge per admission of $127,296 ± 243,094. The mean charge per hospital day was $16,653 ± 17,516 and increased across the study period (P < 0.01). Arrhythmia distributions were impacted by SV anatomic subtype (P < 0.001). Hospital resource utilization was significantly different among arrhythmia groups (P < 0.001). CONCLUSIONS: In adults with SV CHD, arrhythmias are affected by SV anatomic subtype and impact adversely upon hospital resource utilization.

Impact of COVID-19 pandemic on the volume, cost, and outcomes of cardiac electrophysiology procedures in the United States.

BACKGROUND: During the COVID-19 pandemic, professional societies recommended deferral of elective procedures for optimal resource utilization. OBJECTIVE: We sought to assess changes in procedural trends and outcomes of electrophysiology (EP) procedures during the pandemic. METHODS: National Inpatient Sample databases were used to identify all EP procedures performed in the United States (2016-2020) by International Classification of Diseases, Tenth Revision codes. We evaluated trends in utilization, cost/revenue, and outcomes from EP procedures performed. RESULTS: An estimated 1.35 million EP procedures (82% devices and 18% catheter ablations) were performed (2016-2020) with significant yearly uptrend. During the pandemic, there was a substantial decline in EP procedure utilization from a 5-year peak of 298 cases/million population in the second quarter of 2019 to a nadir of 220 cases in the second quarter of 2020. In 2020, the pandemic was associated with the loss of 50,233 projected EP procedures (39,337 devices and 10,896 ablations) with subsequent revenue loss of $7.06 billion. This deficit was driven by revenue deficit from dual-chamber permanent pacemaker (PPM) utilization ($2.88 billion, 49.3% of lost cases), ablation procedures ($1.84 billion, 21.7% of lost cases), and implantable cardioverter-defibrillator implantation ($1.36 billion, 12.0% of lost cases). To the contrary, there was a 9.4% increase in the utilization of leadless PPM. EP device implantation during the pandemic was associated with higher adverse in-hospital events (9.4% vs 8.0%; P < .001). CONCLUSION: In the United States, the significant decline in EP procedures during the pandemic was primarily driven by the reduction in dual-chamber PPM utilization, followed by arrhythmia ablation and implantable cardioverter-defibrillator implantation. There was a substantial increase in leadless PPM utilization during the pandemic.

The effects of cannabis use on major adverse cardiovascular outcomes, mortality, cost of hospitalization, and cardiac arrhythmias: A Retrospective analysis using the national inpatient sample.

As cannabis use is rising and federal restrictions are easing, it is important to recognize its potential adverse cardiovascular effects for better risk stratification and informed guidance. We conducted a retrospective study using the National Inpatient Sample database from 2016 to 2019, where 39,992 subjects were enrolled. The extracted population was classified into two groups based on the presence of cannabis-related disorders. The primary outcomes of the study were cardiovascular-related adverse events, in-hospital mortality, total cost of hospitalization, and cardiac dysrhythmias. The study concluded that cannabis use disorder was not significantly associated with the likelihood of having a cardiovascular adverse event, cardiac dysrhythmias, or with the cost of hospitalization when controlling for other variables (p = 0.257, p=0.481 & p = 0.481, respectively). However, it was significantly associated with the likelihood of mortality (p < 0.0001). Further randomized trials are needed to confirm these findings and elaborate on identified associations.

Rising charges and costs for pediatric catheter ablation.

INTRODUCTION: Catheter ablation has been shown to be effective for pediatric tachyarrhythmias, but the associated charges and costs have not been described in the recent era. Understanding such contemporary trends may identify ways to keep an effective therapy affordable while optimizing clinical outcomes. METHODS: We used the 1997-2009 Kids' Inpatient Databases to examine trends in charges and costs for pediatric catheter ablation and identify determinants of temporal changes. RESULTS: There were 7,130 discharges for catheter ablation in the sample. Mean age at ablation was 12.1 ± 0.2 years. Patients with congenital heart disease (CHD) made up 10% of the sample. Complications occurred in 8% of discharges. Mean total charges rose 219% above inflation (from $23,798 ± 1,072 in 1997 to $75,831 ± 2,065 in 2009). From 2003 to 2009, costs rose 25% (from $20,459 ± 780 in 2003 to $25,628 ± 992 in 2009). Charges for ablation increased markedly relative to surgical procedures, but with a similar slope to other catheter-based interventions. Multivariable analysis revealed that year (P < 0.0001), payer (P = 0.0002), CHD (P < 0.0001), valvular heart disease (P = 0.0004), cardiomyopathy (P = 0.0009), hospital region (P < 0.0001), length of stay (P < 0.0001), and complications (P < 0.0001) predicted increased charges. The same factors also predicted increased costs. Charges and costs varied considerably by region, particularly for high-volume centers (P < 0.0001). CONCLUSIONS: Charges and costs for pediatric catheter ablation increased relative to other procedures and significantly outstripped inflation. Further study of complications, length of stay, and regional differences may help control rising costs while maintaining quality of care.

Cost-of-illness study of patients subjected to cardiac rhythm management devices implantation: results from a single tertiary centre.

AIMS: The aim of the present study is to estimate the procedure (implantation) cost, the total hospitalization cost and annual follow-up cost, in patients subjected to pacemaker (PM) and implantable cardioverter-defibrillator (ICD) implantation. METHODS AND RESULTS: A single-center, prospective, cost-of-illness study was conducted between August 2008 and July 2009. In total, 464 consecutive patients were recruited (370 were subjected to PM implantation and 94 to ICD implantation). Resource data were assessed at patients' enrolment in the study and at 6th and 12th months of patients' follow-up. Then, the procedure cost, the total hospitalization cost as well as the annual patients' follow up costs were calculated using a bottom-up approach. The mean (95% confidence interval) procedure cost of PM and ICD implantation (including the costs of devices, electrodes, other supplies, and personnel's time) was calculated to be €1803 (€1758-€1858) and €13,521 (€13,153-€13,892), respectively. The mean total hospitalization cost (including procedure cost, hospitalization cost, cost of laboratory and imaging diagnostic examinations and the indirect cost attributed to productivity lost due to patient's hospitalization) was €3926 (€3711-€4167) for PM and €17,764 (€16,852-€18,692) for ICD. The mean annual cost (direct and indirect) was €1816 (€1433-€2421) for PM and €2819 (€2115-€3703) for ICD. No difference was detected in the annual cost between patients with initial implantation and replacement. CONCLUSION: These data revealed that although these devices are associated with a relatively high upfront cost, the annual societal cost following the implantation is low. Therefore, implantation of such devices should be encouraged since these devices reduce the morbidity and mortality without a high economic burden to society.

Adverse psychological effects and costs associated with waiting for radiofrequency ablation.

BACKGROUND: Radiofrequency ablation (RFA) is undertaken as a potentially curative treatment for a variety of heart rhythm disturbances. Previous studies have demonstrated improved quality of life and reduced symptoms after ablation. In many health care environments waiting lists exist for scheduling of procedures. However, the psychological effects of waiting for radiofrequency ablation have not previously been assessed. We hypothesized that waiting for this intervention may be associated with increased psychological morbidity and health care costs. METHODS: Ninety-two patients scheduled for elective RFA completed repeated questionnaires comprising the Medical Outcomes Short Form 36, Hospital Anxiety and Depression Scale, and an in-house questionnaire designed to assess the burden of symptoms related to arrhythmia (arrhythmia-related burden score). Mean scores were generated and compared at time points while waiting, before and after the procedure. Regression analyses were carried out to identify predictors of increased psychological morbidity while waiting and immediately prior to the procedure. Health care costs during the waiting period as a consequence of arrhythmia were quantified. RESULTS: Mean scores for parameters of psychological morbidity worsened during the period of waiting and improved after the procedure. Predictors of adverse effects within the cohort varied according to the time point assessed for each of the measures of psychological morbidity. A conservative estimate of the health care cost incurred while waiting exceeds £ 181 per patient. CONCLUSIONS: Waiting for radiofrequency ablation appears to be associated with adverse psychological effects and health care costs. These results may support strategies to reduce waiting times and prioritize resource allocation.

Health economics and the European Heart Rhythm Association.

The management of healthcare is becoming extremely complex in developed countries, as a result of increasing age of the population and increasing costs of care, coupled with diminishing resources due to global financial crisis. This situation threatens access to appropriate care, and a more or less explicit rationing of some types of treatment may occur in 'real world' clinical practice. This is particularly true for those treatments or interventions with a relatively high up-front cost, such as cardioverter defibrillators, devices for cardiac resynchronization therapy or ablation procedures for atrial fibrillation. The European Heart Rhythm Association (EHRA) is strongly convinced that the skills of electrophysiologists and cardiologists responsible for the management of rhythm disorders have to evolve, also embracing the knowledge of health economics, clinical epidemiology, health-care management and outcome research. These disciplines do not belong to what is considered as the conventional cultural background of physicians, but knowledge of comparative cost effectiveness and of other economic approaches nowadays appears fundamental for a dialogue with a series of stakeholders, such as policy makers, politicians, and administrators, involved in budgeting the activity of hospitals and health-care services, as well as in approaching health technology assessment.

Cardioverter-defibrillators: a cost or an investment?

Implantable cardioverter-defibrillator (ICD) therapy has emerged as the most effective treatment for life-threatening ventricular arrhythmias. Most studies indicate that ICD therapy in appropriately selected patients at high risk of sudden cardiac death (SCD) is associated with cost-effectiveness ratios similar to, or better than, other accepted treatments, including renal dialysis. The up-front costs of ICD therapy are admittedly high and as such, ICD implantation is more akin to an operation than a drug. As would be the case for a life-saving operation, the adoption of short time horizons is apt to lead to underestimations of cost effectiveness. As well as the time horizon, the underlying aetiology of the arrhythmic substrate, implantation technique, ICD battery life, and the presence of co-morbidities are important issues in maximizing cost effectiveness. Above all, we should consider that ICD therapy is the only available option for prolonging survival in patients who are at risk of SCD.