The Mantra for 2011: Reduce Complexity

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The incidence of atrial fibrillation (AF) continues to increase and more AF patients than ever are being referred for ablation. Reimbursement, however, has not kept up with the procedure’s complexity, time-consuming nature and relatively expensive technology.

While professional organizations advocate for adequate reimbursement, technology continues to evolve to the point where procedure time could feasibly be cut in half. This is welcome news for electrophysiologists, who consider managing AF patients to be the single biggest factor related to their increasing workload.

One of the biggest concerns for AF patients is stroke, as pooled blood in the left atrial appendage tends to clot. Last year, however, dabigatran (Pradaxa) was approved to reduce the risk of stroke in AF patients. It’s the first new drug in 50 years for this purpose and holds much promise because the current standard, warfarin, has many disadvantages. In fact, one source in the cover story suggested that the use of dabigatran could reduce the utilization of AF ablation because many patients resort to the procedure only to relieve themselves of the intolerable side effects and other problems associated with warfarin.

Another complex procedure whose reimbursement does not reflect the time and skill needed to perform it is recanalizing coronary chronic total occlusions (CTOs). As with AF ablation, the technology and skill associated with CTO PCI has advanced considerably in the last few years and more people with CTOs are considered for PCI. The problem is the dearth of interventionalists trained to perform these complex openings. But the current crop of trained interventionalists offer many hands-on courses and lectures whenever they can to pique the interest of others. Hospitals would be wise to initiate a CTO program as it could bring in revenue otherwise slated for other facilities.

Finally, the complex nature of the superficial femoral artery (SFA) makes it difficult to treat lesions with stenting. The new generation of nitinol self-expanding stents, however, could change that. The FDA recently approved the first such stent for an indication in the SFA based on the RESILIENT trial. There is still much debate as to the best therapy for the SFA, but having a dedicated stent for this vasculature at least opens the options for patients who are sometimes on the verge of amputation.

The research in 2010 associated with these topics shed light on disease etiology and drug and device efficacy, and there is no sign that the momentum will slow in 2011. Tell us how your practice or facility manages these complex patient populations and how new research impacts your patients and practice.