Comprehensive analysis of same day discharge after atrial fibrillation ablation: Clinical, cost, and patient reported outcomes.

BACKGROUND: Same day discharge (SDD) following atrial fibrillation (AF) ablation procedure has emerged as routine practice, and primarily driven by operator discretion. However, the impacts of SDD on clinical outcomes, healthcare system costs, and patient reported outcomes (PROs) have not been systematically studied. METHODS: We retrospectively analyzed patients undergoing routine AF ablation procedures with SDD versus overnight observation (NSDD). After propensity adjustment we compared postprocedure adverse events (AEs), healthcare system costs, and changes in PROs. RESULTS: We identified 310 cases, with 159 undergoing SDD and 151 staying at least one midnight in the hospital (NSDD). Compared with NSDD, SDD patients were similar age (mean 64 vs. 66, p = 0.3), sex (26% female vs. 27%, p = 0.8), and with lower mean CHADS2-VA2Sc scores (2.0 vs. 2.7; p < 0.011). The primary outcome of AEs was noninferior in SDD versus NSDD patients (odds ratio 0.45, 95% confidence interval 0.21-0.99; noninferiority margin of 10%). There were also no differences in overall cost to the healthcare system between SDD and NSDD (p = 0.11). PROs numerically favored SDD (p = NS for all scores). CONCLUSIONS: Physician selection for SDD appears at least as safe as NSDD with respect to clinical outcomes and SDD is not significantly less costly to the health system. There is a trend towards more favorable, general PROs among SDD patients. Routine SDD should be strongly considered for patients undergoing routine AF ablation procedures.

Characteristics of a transgender and gender-diverse patient population in Utah: Use of electronic health records to advance clinical and health equity research.

Transgender and gender-diverse (TGD) people, individuals whose gender identity differs from their sex assigned at birth, face unique challenges in accessing gender-affirming care and often experience disparities in a variety of health outcomes. Clinical research on TGD health is limited by a lack of standardization on how to best identify these individuals. The objective of this retrospective cohort analysis was to accurately identify and describe TGD adults and their use of gender-affirming care from 2003-2023 in a healthcare system in Utah, United States. International Classification of Disease (ICD)-9 and 10 codes and surgical procedure codes, along with sexual orientation and gender identity data were used to develop a dataset of 4,587 TGD adults. During this time frame, 2,985 adults received gender-affirming hormone therapy (GAHT) and/or gender-affirming surgery (GAS) within one healthcare system. There was no significant difference in race or ethnicity between TGD adults who received GAHT and/or GAS compared to TGD adults who did not receive such care. TGD adults who received GAHT and/or GAS were more likely to have commercial insurance coverage, and adults from rural communities were underrepresented. Patients seeking estradiol-based GAHT tended to be older than those seeking testosterone-based GAHT. The first GAS occurred in 2013, and uptake of GAS have doubled since 2018. This study provides a methodology to identify and examine TGD patients in other health systems and offers insights into emerging trends and access to gender-affirming care.

Major drivers of healthcare system costs and cost variability for routine atrial fibrillation ablation.

Background: Catheter ablation is an effective treatment for atrial fibrillation (AF) but incurs significant financial costs to payers. Reducing variability may improve cost effectiveness. Objectives: We aimed to measure (1) the components of direct and indirect costs for routine AF ablation procedures, (2) the variability of those costs, and (3) the main factors driving ablation cost variability. Methods: Using data from the University of Utah Health Value Driven Outcomes system, we were able to measure direct, inflation-adjusted costs of uncomplicated, routine AF ablation to the healthcare system. Direct costs were considered costs incurred by pharmacy, disposable supplies, patient labs, implants, and other services categories (primarily anesthesia support) and indirect costs were considered within imaging, facility, and electrophysiology lab management categories. Results: A total of 910 patients with 1060 outpatient ablation encounters were included from January 1, 2013, to December 31, 2020. Disposable supplies accounted for the largest component of cost with 44.8 ± 9.7%, followed by other services (primarily anesthesia support) with 30.4 ± 7.7% and facility costs with 16.1 ± 5.6%; pharmacy, imaging, and implant costs each contributed <5%. Direct costs were larger than indirect costs (82.4 ± 5.6% vs 17.6 ± 5.6%). Multivariable regression showed that procedure operator was the primary factor associated with AF ablation overall cost (up to 12% differences depending on operator). Conclusions: Direct costs and other services (primarily anesthesia) drive the majority costs associated with AF ablations. There is significant variability in costs for these routine, uncomplicated AF ablation procedures. The procedure operator, and not patient characteristic, is the main driver for cost variability.

Patient-reported outcomes and costs associated with vascular closure and same-day discharge following atrial fibrillation ablation.

BACKGROUND: We aimed to measure patient-reported outcomes (PROs) and costs associated with same-day discharge (SDD) for atrial fibrillation (AF) ablation and vascular closure device implantation in clinical practice. METHODS: PROs were prospectively measured in 50 AF ablation patients, comparing complete vascular device closure (n = 25) versus manual compression hemostasis (n = 25). Health-system costs for SDD patients receiving vascular device closure were compared to matched controls with one-night stays who did not receive any closure device. RESULTS: Prospectively enrolled patients receiving vascular device closure for AF ablation had a mean age of 65 years, 17% were female, with a mean CHA2 DS2 -VASc score of 3. The mean number of venous sheaths was higher among patients receiving vascular device closure (3.8 vs. 3.1, p < 0.001), and there was one case of rebleeding in a patient receiving a vascular closure device (no other complications). Same-day discharge rates (76% vs. 8.3%, p < 0.001), patient satisfaction with bedrest time (8.5 vs. 6, p = 0.004) and with pain (8 vs. 5.1, p = 0.009) were significantly better among patients receiving vascular closure. In matched analyses of health-system costs, patients with vascular closure had mean age 66, 32% were female, and the mean CHA2 DS2 -VASc score was 2 (p = NS vs. controls). SDD with vascular closure was associated with the significantly lower facility, pharmacy, and disposable costs, but higher implant costs. Overall costs for ablation were not significantly different (mean difference 1.10%, 95% confidence interval [CI] -3.03 to 5.42). CONCLUSIONS: Vascular closure for AF ablation improves patient experience in routine care. The use of vascular closure and SDD after AF ablation reduces several components of healthcare system costs, without an overall increase.

Association between economic and arrhythmic burden of paroxysmal atrial fibrillation in patients with cardiac implanted electronic devices.

BACKGROUND: As the prevalence of atrial fibrillation (AF) increases, a greater understanding of the costs associated with AF care is required. While individuals with greater arrhythmic burden may interact with the health system more frequently, the relationship between AF burden and costs remains undefined. METHODS: In a longitudinal patient cohort with paroxysmal AF and newly implanted cardiovascular implantable electronic devices (CIED) (2010-2016), we linked CIED remote-monitoring data with Medicare claims to assess the association between the 30-day averaged device-detected daily percentage of time in AF ("AF burden") and healthcare costs. RESULTS: Among 39,345 patients, the mean age was 77.1 ± 8.7 years, 60.7% were male, and the mean CHA2DS2-VASc score was 4.9 ± 1.3. The mean total 1-year costs were $18,668 ± 29,173, driven by hospitalization costs where two-thirds of admissions were due to heart failure. Increasing AF burden was associated with increasing costs: $17,860 ± 28,525 for 0% daily AF burden; $18,840 ± 29,104 for 0-5% daily AF burden; and $20,968 ± 31,228 for 5-98% daily AF burden. There was a linear relationship between AF burden expressed as a continuous variable and 1-year costs (adjusted cost rate ratio 1.031 per 10% daily duration in AF, 95% confidence interval 1.023-1.038; P < .001). CONCLUSIONS: Among older patients with paroxysmal AF and CIEDs, increasing AF burden is associated with higher healthcare costs. As the observational study design is unable to determine causal relationships, prospective study is required to explore the intriguing hypothesis that targeted AF strategies, including comorbidity management, that reduce AF burden may also reduce the high annual costs associated with AF.

Economics and outcomes of sotalol in-patient dosing approaches in patients with atrial fibrillation.

INTRODUCTION: There exists variability in the administration of in-patient sotalol therapy for symptomatic atrial fibrillation (AF). The impact of this variability on patient in-hospital and 30-day posthospitalization costs and outcomes is not known. Also, the cost impact of intravenous sotalol, which can accelerate drug loading to therapeutic levels, is unknown. METHODS: One hundred and thirty-three AF patients admitted for oral sotalol initiation at an Intermountain Healthcare Hospital from January 2017 to December 2018 were included. Patient and dosing characteristics were described descriptively and the impact of dosing schedule was correlated with daily hospital costs/clinical outcomes during the index hospitalization and for 30 days. The Centers for Medicare and Medicaid Services reimbursement for 3-day sotalol initiation is $9263.51. Projections of cost savings were made considering a 1-day load using intravenous sotalol that costs $2500.00 to administer. RESULTS: The average age was 70.3 ± 12.3 years and 60.2% were male with comorbidities of hypertension (83%), diabetes (36%), and coronary artery disease (53%). The mean ejection fraction was 59.9 ± 7.8% and the median corrected QT interval was 453.7 ± 37.6 ms before sotalol dosing. No ventricular arrhythmias developed, but bradycardia (<60 bpm) was observed in 37.6% of patients. The average length of stay was 3.9 ± 4.6 (median: 2.2) days. Postdischarge outcomes and rehospitalization rates stratified by length of stay were similar. The cost per day was estimated at $2931.55 (1. $2931.55, 2. $5863.10, 3. $8794.65, 4. $11 726.20). CONCLUSIONS: In-patient oral sotalol dosing is markedly variable and results in the potential of both cost gain and loss to a hospital. In consideration of estimated costs, there is the potential for $871.55 cost savings compared to a 2-day oral load and $3803.10 compared to a 3-day oral load.

Bimodal distribution of atrial fibrillation burden in 3 distinct cohorts: What is 'paroxysmal' atrial fibrillation?

BACKGROUND: Burden of atrial fibrillation (AF), as a continuous measure, is an emerging alternative classification often assumed to increase linearly with progression of disease. Yet there are no descriptions of AF burden distributions across populations. METHODS: We examined patterns of AF burden (% time in AF) across 3 different cohorts: outpatients with AF undergoing Holter monitoring in a national registry (ORBIT-AF II), routine outpatients undergoing Holter monitoring in a tertiary healthcare system (UHealth), and patients >= 65 years with cardiac implantable electronic devices (Merlin.netTM linked to Medicare). RESULTS: We included 2,058 ORBIT-AF II patients, 4,537 UHealth patients, and 39,710 from Merlin.net. Mean age ranged from 56 to 77 years, sex ranged from 40% to 61% male, and mean CHA2DS2-VASc scores ranged from 2.2 to 4.9. Across all cohorts, AF burden demonstrated skewed frequency towards the extremes, with the vast majority of patients having either very low or very high AF burden. This bimodal distribution was consistent across cohorts, across clinically-documented AF types (paroxysmal v persistent), patients with or without a known AF diagnosis, and among patients with different types of cardiac implantable electronic devices. CONCLUSIONS: Across 3 broad, diverse cohorts with continuous monitoring, distribution of AF burden was consistently skewed towards the extremes without an even, linear distribution or progression. As AF burden is increasingly recognized as a descriptor and potential risk-stratifier, these findings have important implications for future research and patient care.

Association of Wearable Device Use With Pulse Rate and Health Care Use in Adults With Atrial Fibrillation.

Importance: Increasingly, individuals with atrial fibrillation (AF) use wearable devices (hereafter wearables) that measure pulse rate and detect arrhythmia. The associations of wearables with health outcomes and health care use are unknown. Objective: To characterize patients with AF who use wearables and compare pulse rate and health care use between individuals who use wearables and those who do not. Design, Setting, and Participants: This retrospective, propensity-matched cohort study included 90 days of follow-up of patients in a tertiary care, academic health system. Included patients were adults with at least 1 AF-specific International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) code from 2017 through 2019. Electronic medical records were reviewed to identify 125 individuals who used wearables and had adequate pulse-rate follow-up who were then matched using propensity scores 4 to 1 with 500 individuals who did not use wearables. Data were analyzed from June 2020 through February 2021. Exposure: Using commercially available wearables with pulse rate or rhythm evaluation capabilities. Main Outcomes and Measures: Mean pulse rates from measures taken in the clinic or hospital and a composite health care use score were recorded. The composite outcome included evaluation and management, ablation, cardioversion, telephone encounters, and number of rate or rhythm control medication orders. Results: Among 16 320 patients with AF included in the analysis, 348 patients used wearables and 15 972 individuals did not use wearables. Prior to matching, patients using wearables were younger (mean [SD] age, 64.0 [13.0] years vs 70.0 [13.8] years; P < .001) and healthier (mean [SD] CHA2DS2-VASc [congestive heart failure, hypertension, age ≥ 65 years or 65-74 years, diabetes, prior stroke/transient ischemic attack, vascular disease, sex] score, 3.6 [2.0] vs 4.4 [2.0]; P < .001) compared with individuals not using wearables, with similar gender distribution (148 [42.5%] women vs 6722 women [42.1%]; P = .91). After matching, mean pulse rate was similar between 125 patients using wearables and 500 patients not using wearables (75.01 [95% CI, 72.74-77.27] vs 75.79 [95% CI, 74.68-76.90] beats per minute [bpm]; P = .54), whereas mean composite use score was higher among individuals using wearables (3.55 [95% CI, 3.31-3.80] vs 3.27 [95% CI, 3.14-3.40]; P = .04). Among measures in the composite outcome, there was a significant difference in use of ablation, occurring in 22 individuals who used wearables (17.6%) vs 37 individuals who did not use wearables (7.4%) (P = .001). In the regression analyses, mean composite use score was 0.28 points (95% CI, 0.01 to 0.56 points) higher among individuals using wearables compared with those not using wearables and mean pulse was similar, with a -0.79 bpm (95% CI -3.28 to 1.71 bpm) difference between the groups. Conclusions and Relevance: This study found that follow-up health care use among individuals with AF was increased among those who used wearables compared with those with similar pulse rates who did not use wearables. Given the increasing use of wearables by patients with AF, prospective, randomized, long-term evaluation of the associations of wearable technology with health outcomes and health care use is needed.

Ischemic and Bleeding Outcomes in Patients With Atrial Fibrillation and Contraindications to Oral Anticoagulation.

OBJECTIVES: This study sought to describe clinical outcomes among patients with atrial fibrillation (AF) and contraindications to oral anticoagulation (OAC). BACKGROUND: Treatment with OAC prevents stroke and death in patients with AF, but may be contraindicated among patients at high bleeding risk. METHODS: This was an observational, longitudinal analysis of a nationally representative 5% Medicare sample of patients with chronic AF and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category) score ≥2. They were stratified by both the presence of high bleeding risk contraindications to OAC and by OAC use. We assessed 3-year ischemic and bleeding outcomes using multivariable Cox proportional hazards models adjusted for relevant patient characteristics. RESULTS: Among 26,684 AF patients not treated with OAC, 8,283 (31%) had a high bleeding risk contraindication, primarily a blood dyscrasia (75%) or history of gastrointestinal bleeding (40%). Without OAC, patients with contraindications had worse ischemic and bleeding outcomes at 3 years compared with those without contraindications. We also identified 12,454 patients with OAC contraindications who received OAC. Compared with patients not receiving OAC, use of OAC was associated with reduced mortality (adjusted hazard ratio [HR]: 0.79; 95% confidence interval [CI]: 0.76 to 0.83), stroke (adjusted HR: 0.90; 95% CI: 0.83 to 0.99), and all-cause hospitalization (adjusted HR: 0.93; 95% CI: 0.90 to 0.96) but increased risk of intracranial hemorrhage (adjusted HR: 1.42; 95% CI: 1.17 to 1.72). CONCLUSIONS: High bleeding risk contraindications to OAC are common among older patients with AF, and these patients have higher mortality compared with untreated patients without OAC contraindications. The use of OAC in these patients is associated with lower rates of all-cause stroke, hospitalization, and death but higher risk of intracranial hemorrhage.

Implementation of Real-Time Assessment of Patient-Reported Outcomes in a Heart Failure Clinic: A Feasibility Study.

BACKGROUND: Patient-reported outcomes (PROs) quantify, from patients' perspectives, their symptoms, function, and quality of life. Our aim was to determine the feasibility of integrating PRO capture into routine clinical practice at a large heart failure (HF) clinic. METHODS: We examined the practicality of PRO completion at the time of clinic visit, the time required to complete the selected instruments, the completion rate, and the feasibility of immediate PRO scoring and integration of the results into the electronic health record (EHR). We deployed a computer program to capture PROs (Kansas City Cardiomyopathy Questionnaire, Patient-Reported Outcomes Measurement Information System) on a portable computer platform at the time of a clinic visit. An automated algorithm identified patients scheduled for appointments at the HF clinic at registration, provided a portable tablet computer with which to complete the appropriate PRO instruments and then scored and immediately integrated the results in the patient's EHR. RESULTS: In a 12-month period, 862 unique patients completed 1,320 PRO assessments. The mean age of this cohort was 60.1 ± 16.3 years and 66% were male. The average time for PRO assessment was 6.7 minutes and the completion rate among eligible patients was 58%, with 91% of started assessments completed in full. CONCLUSIONS: These preliminary data support the feasibility of serial PRO assessment with real-time integration into the EHR in a large outpatient population of patients with HF. We identified critical steps that should enhance adoption of this approach by clinicians and render PRO results meaningful and actionable in routine clinical care.

How well does physician risk assessment predict stroke and bleeding in atrial fibrillation? Results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF).

BACKGROUND: Assessments of stroke and bleeding risks are essential to selecting oral anticoagulation in patients with atrial fibrillation (AF). We aimed to assess outcomes according to physician assessed risk, with comparison to empirical risk scores. METHODS: This was a prospective, observational study of 9,715 outpatients with AF enrolled in ORBIT-AF, a US national registry. Stroke and bleeding risks were quantified by physician assignment, CHADS2 and CHA2DS2-VASc stroke scores, and ATRIA and HAS-BLED bleeding scores. Outcomes were stroke or systemic embolism and major bleeding during a median follow-up of 28 months. RESULTS: Physician-assigned risk was associated with thromboembolic events: low risk (0.71 per 100 patient-years [95% CI 0.56-0.91], n=3,991), intermediate risk (0.98 [95% CI 0.79-1.20], n=4,148), and high risk (1.84 [95% CI 1.43-2.37], n=1,576, P<.0001), and major bleeding: low (3.43 [95% CI 3.07-3.82], n=4,250), intermediate (4.55 [95% CI 4.03-5.15], n=2,702), and high (5.76 [95% CI 4.42-7.50], n=468; P<.0001). Discrimination of stroke risk was similar with CHADS2 (c=0.59, 95% CI 0.57-0.61) vs physician assessment (c=0.58, 95% CI 0.55-0.62). Among patients on oral anticoagulation, bleeding risk discrimination was higher with ATRIA (c=0.63, 95% CI 0.61-0.65) and HAS-BLED (c=0.60, 95% CI 0.59-0.62) than with physician assessment (0.55, 95% CI 0.53-0.57). Physician-assessed risk categories did not add significantly to empirical risk scores, in Cox models for outcomes (Padjusted>.05 for all physician assessments vs Padjusted<.05 for empirical scores). CONCLUSION: Physician-assigned risk showed a graded relationship with outcomes, and both physician-based and empirical scores yielded only moderate discrimination. Although empirical scores provided valuable risk stratification information (with or without physician judgment), physician assessment added little to existing scores. These data support the use of empirical scores for stroke and bleeding risk stratification, and the need for novel approaches to risk stratification in this population.

Contraindications to anticoagulation therapy and eligibility for novel anticoagulants in older patients with atrial fibrillation.

AIMS: Oral anticoagulation therapy prevents stroke and improves survival in patients with atrial fibrillation, but the therapy is underutilized. We sought to identify the prevalence of contraindications for oral anticoagulation and the proportion of patients potentially eligible for different agents. METHODS: We identified patients with nonacute atrial fibrillation in a nationally representative 5% sample of 2009 Medicare data. We divided the population into patients ineligible for any oral anticoagulant, patients eligible for warfarin only, and patients eligible for any anticoagulant. We compared patient characteristics and the use of anticoagulation among the subgroups. RESULTS: Among 86,671 patients with atrial fibrillation, 1872 (2.2%) were ineligible for anticoagulation because of an absolute contraindication, most frequently a history of intracranial hemorrhage (60%). Patients ineligible for any anticoagulant were the same age as the overall group (mean age, 80.5 vs. 80.4 years). However, they had higher rates of dementia (19% vs. 8.6%) and heart failure (59% vs. 43%) and higher mean CHADS2 scores (3.8 vs. 2.8). Of the remaining 84,799 patients eligible for anticoagulation, 7146 (8.4%) were eligible for warfarin only (most commonly because of mechanical heart valves [66%] and end-stage renal disease [12%]). Sixty-five percent of patients eligible for anticoagulation received warfarin, and the proportion was similar for patients with a relatively high risk of bleeding. CONCLUSIONS: Older adults with atrial fibrillation rarely have absolute contraindications to oral anticoagulation therapy. Among patients without contraindications, most appeared to be eligible for any anticoagulant, and relatively high-risk features appeared not to influence warfarin use.

Addressing barriers to optimal oral anticoagulation use and persistence among patients with atrial fibrillation: Proceedings, Washington, DC, December 3-4, 2012.

Approximately half of patients with atrial fibrillation and with risk factors for stroke are not treated with oral anticoagulation (OAC), whether it be with vitamin K antagonists (VKAs) or novel OACs (NOACs); and of those treated, many discontinue treatment. Leaders from academia, government, industry, and professional societies convened in Washington, DC, on December 3-4, 2012, to identify barriers to optimal OAC use and adherence and to generate potential solutions. Participants identified a broad range of barriers, including knowledge gaps about stroke risk and the relative risks and benefits of anticoagulant therapies; lack of awareness regarding the potential use of NOAC agents for VKA-unsuitable patients; lack of recognition of expanded eligibility for OAC; lack of availability of reversal agents and the difficulty of anticoagulant effect monitoring for the NOACs; concerns with the bleeding risk of anticoagulant therapy, especially with the NOACs and particularly in the setting of dual antiplatelet therapy; suboptimal time in therapeutic range for VKA; and costs and insurance coverage. Proposed solutions were to define reasons for oral anticoagulant underuse classified in ways that can guide intervention and improve use, to increase awareness of stroke risk as well as the benefits and risks of OAC use via educational initiatives and feedback mechanisms, to better define the role of VKA in the current therapeutic era including eligibility and ineligibility for different anticoagulant therapies, to identify NOAC reversal agents and monitoring strategies and make knowledge regarding their use publicly available, to minimize the duration of dual antiplatelet therapy and concomitant OAC where possible, to improve time in therapeutic range for VKA, to leverage observational data sets to refine understanding of OAC use and outcomes in general practice, and to better align health system incentives.

Periprocedural imaging and outcomes after catheter ablation of atrial fibrillation.

OBJECTIVE: Catheter ablation of atrial fibrillation (AF) has become an increasingly safe and effective therapy. This has been partly attributed to the use of adjunctive imaging modalities. We aimed to describe the use and associated outcomes of periprocedural imaging for AF ablation. METHODS: We studied all Medicare fee-for-service claims for AF ablation from July 2007 to December 2009, and identified associated imaging studies before and during ablation, including transoesophageal echocardiography (TEE), intracardiac echocardiography (ICE), CT and MRI. The primary outcomes were death, stroke or transient ischaemic attack (TIA), repeat ablation, and bleeding (pericardial or vascular) at 6 months. RESULTS: 11 525 patients underwent AF ablation during the study period. There was significant variation in imaging use at the practice level. In addition to electroanatomic mapping, 53% (n=6060/11 525) underwent TEE, 67% (n=7715/11 525) received ICE, and 50% (n=5724/11 525) underwent a preprocedure CT or MRI. Imaging generally increased from 2007 to 2009. After adjustment, the use of preablation CT or MRI was associated with a significantly lower risk of stroke or TIA (0.4% vs 0.9%, adjusted HR 0.46, 95% CI 0.28 to 0.74, p=0.002), and the use of ICE was associated with a lower risk of repeat ablation (5.7% vs 8.5%, adjusted HR 0.59, 95% CI 0.37 to 0.92, p=0.02) but higher risk of bleeding (1.1% vs 0.7%, adjusted HR 1.76, 95% CI 1.15 to 2.70, p=0.009). CONCLUSIONS: Periprocedural imaging for AF ablation is increasingly used, although practice patterns vary widely. Our data suggest that periprocedural imaging is associated with better outcomes after catheter ablation; however, prospective studies of periprocedural imaging strategies are warranted.

Cost analysis of periprocedural imaging in patients undergoing catheter ablation for atrial fibrillation.

Cardiovascular imaging is an important part of procedural planning and safety for catheter ablation of atrial fibrillation (AF). However, the costs of imaging surrounding catheter ablation of AF have not been described. Medicare fee-for-service data were used to evaluate Medicare expenditures before, during, and after catheter ablation for AF from July 2007 to December 2009. Among 11,525 patients who underwent catheter ablation for AF, the mean overall expenditure on the day of the procedure was $14,455 (SD $7,441). The mean imaging expenditure in the periprocedural period, which included the 30 days before the catheter ablation and the day of the ablation itself, was $884 (SD $455). Periprocedural imaging expenditures varied by the imaging strategy used, ranging from a mean of $557 (SD $269) for patients with electroanatomic mapping only to $1,234 (SD $461) for patients with electroanatomic mapping, transesophageal echocardiogram, and computed tomography or magnetic resonance imaging. Mean patient-level imaging expenditures varied by provider (mean $872, SD $249). Periprocedural imaging expenditures also varied by patient risk, with mean expenditures of $862 (SD $444) for patients with a CHADS2 score of ≥2 compared with $907 (SD $466) for CHADS2 score<2 (p<0.001). In conclusion, periprocedural imaging accounts for approximately 6% of mean Medicare expenditures for catheter ablation of AF. The expenditures for periprocedural imaging vary both at the patient and at the provider level and they are inversely related to stroke risk by CHADS2 score.