The Cardiovascular Roundtable is grateful to the individuals and organizations that shared their insights, analysis, and time with us. We would especially like to recognize the following individuals for being particularly generous with their time and expertise: Drs. Jose Osorio and Anil Rajendra, Grandview AF Clinic; Dr. Jason Zagrodzky, Texas Cardiac Arrhythmia; Judi Everett, Heart Hospital of New Mexico.
CV service line leaders today are managing against many priorities, balancing the challenges of the ongoing pandemic, while also thinking ahead to longer-term strategic priorities for their service lines. One opportunity that we previously explored was 3 reasons why you should prioritize EP in the "new normal".
The EP sub-service line continues to be a clinical, financial, and strategic priority for CV programs today: patients with atrial fibrillation require timely and appropriate treatment to ensure optimal outcomes, and ablation procedures can support financial performance of the hospital.
In fact, according to our market forecasts, outpatient electrophysiology (EP) services are projected to grow 30% by 2025—compared to 8% for outpatient medical cardiology services and -4% for cardiac cath. As CV service lines expect to manage more EP patients in the coming years, we wanted to share some guidance from progressive organizations on how to take an EP program from good to great.
Measuring and demonstrating program quality
One of the greatest challenges EP programs have historically faced is the lack of societal guidance on quality metrics and the appropriate benchmarks for those metrics. CMS also has not focused on EP in its pay-for-performance or quality reporting programs, causing hospitals to focus first on heart failure and other services that are included in those efforts.
However, CV leaders are now recognizing the importance of measuring arrhythmia program quality. Many programs want to know if they have "good" outcomes, but lack the guidance to quantify and compare this data.
To address this, programs first must ensure they have the appropriate infrastructure in place to deliver high-quality arrhythmia care. This begins with ensuring alignment of service offerings with market demands. Although CV programs offer varying levels of EP services, all programs treat patients with arrhythmias. Smaller facilities may treat these patients through general cardiology care, referring on for specialty consults and then managing follow-up care. Larger facilities will offer specialized EP procedures and advanced treatment solutions.
Although there are tiers of EP programs, not every program has to be in the top-tier to be a high-quality program. Instead, it is important to align services with the needs of a particular market and rationalize service distribution across the network. This ensures patients have access to the level of care they need, while allowing sites to maintain the procedural volumes necessary for competency, good outcomes, and resource efficiency.
"A high-quality arrhythmia program must be able to give patients access to every service any arrhythmia patient would need. But that doesn't mean they should offer every service."
– EP Medical Director, Health System in the South
Importantly, progressive programs have found value in an AFib clinic model for delivering high-value care for patients. The AFib clinic model is designed to ensure strong collaboration between referring physicians and EP specialists, timely identification and treatment, and a multidisciplinary and appropriate AFib treatment approach.
In particular, advanced practice provider (APP)-led AFib clinics can ensure top-of-license care delivery and management for AFib patients, and improve access to clinical professionals who can evaluate the patient's need for further services, and intervene earlier to prevent disease progression.
Beyond infrastructural considerations, programs can support and monitor quality of care delivery by tracking outcomes. Registries like the NCDR's AFib Ablation Registry now offer programmatic guidance and assess practices and procedural outcomes for ablation patients. Similarly, societies like AHA's Get with the Guidelines also offer clinical tools, provider education opportunities, and patient education resources for EP programs.
Look for opportunities to improve efficiency across the care pathway
Understanding the EP patient pathway into your health system is key to identify potential barriers to referrals and appointments. The underlying challenges could be referral relationships, reputation within the community, complicated phone trees, or other root causes that would prevent patients from a seamless entry into your EP program.
As on-demand access and convenience continue to be top drivers of health care consumer choices, access to specialists is important to prioritize. According to a 2017 Merritt Hawkins survey, the average wait time for a new cardiology patient appointment was 21.1 days—up from 16.8 days in 2014. In our research we heard from several EP providers that their referrals are increasing from primary care physicians and general cardiologists employed by other health systems because they offer faster access to appointments. Given this and the increasing AFib patient volume, it's important for hospitals to create pathways to ensure they are being seen in a timeline manner.
Timeliness of appointments is important to patients and referring providers, but it is also critical to enable an efficient episode of care for EP patients. We previously explored why same-day discharge is safe—and cost-effective—for EP programs, and how procedural efficiency continues to be a priority for EP programs. Though same-day discharge became a much larger part of the conversation because of the pandemic, it is not a new concept. In the previously mentioned article, we explored the safety of same-day discharge, the financial value to the hospital and how patients respond to the offering.
A key factor in healthcare today is patient satisfaction and the importance of this indicator will only continue to rise in the future. However, as far back as 2004, a study showed that 89% of PCI patients reported being satisfied with same-day discharge. Additionally, a discharge on the same day as a patient's procedure, may lower the psychological barrier and apprehension commonly associated with surgery.
Important to the patient journey is to start these conversations sooner rather than later. Informing the patient that they will come into the hospital, have a procedure, and be walking around within a few hours better mentally prepares them to leave the hospital on the same day as their procedure.
For other procedures, like ablations, achieving same-day discharge involves more coordination with the broader care team. Texas Cardiac Arrhythmia discharges almost 90% of ablation patients on the same day as the procedure, and Dr. Jason Zagrodsky attributes their procedural efficiency in part to their EP's emphasis on collaboration with other departments. An efficient procedure hinges on more than the proceduralist – its dependent on the nurses, anesthesiologists, lab technicians, procedural support staff, and more.
Provide an exceptional experience – to both patients and referring providers
As a specialty service, cardiovascular programs rely heavily on physician referrals. In fact, an Advisory Board survey found 86% of all new CV referrals are physician-driven versus self-referrals from patients. Specialty physicians should be "able, available, and affable" to strengthen referral relationships according to Dr. Jose Osorio at Grandview's AF Clinic.
Whether through community outreach, education events, or prompt communication efforts, building relationships with community providers is essential to building a strong EP business. An AFib clinic model can support this coordination and experience across the continuum for referring providers and patients alike, as the infrastructure is designed to hardwire patient identification and entry into EP team care, as well as patient return to their referring physician.
But these days it's not only about the providers. Prioritizing efficiency and communication can also help improve the patient experience. A standardized and timely patient visit and the capability to immediately schedule patients for procedures when necessary can vastly improve the patient experience. And patients talk to each other.
Approximately 30% of Grandview's EP practice referrals are self-referrals from patients compared to physician referrals, which their physicians in part attribute to word of mouth from former patients who had a positive experience with their practice.
Learn more about how to build a best-in-class AFib program: Six Steps to Build a Best-in-Class Atrial Fibrillation Program