Value Based Procurement Initiative Reduces Number of Repeat Catheter Ablation Procedures

This article has been refreshed in December 2023.

It is undoubtably true that we have found that using radiofrequency point-by-point ablation in our hands is superior to cryo ablation for first time Atrial Fibrillation (AF) ablation. Both clinically and financially, it therefore made sense for us to switch to radiofrequency ablation vs cryo ablation for all our first time AF ablations where possible.

Dr Richard Balasubramaniam, Consultant Cardiologist, Royal Bournemouth Hospital

Atrial fibrillation (AF) is an increasingly common medical condition worldwide, currently affecting nearly 1.5 million people in England alone.¹ Across Europe, the prevalence is projected to increase by 70% over the next decade, leading to an additional 340,000 strokes and 4 million hospitalisations.²

Characterised by an irregular and fast heartbeat, the treatment for symptomatic AF is primarily focused on restoring and maintaining normal sinus rhythm and preventing stroke.^3-5 Medical therapy, such as antiarrhythmic drugs, are frequently used for the treatment of AF.  

A robust evidence base has shown that for AF patients, catheter ablation is a safe and superior treatment compared to antiarrhythmic drugs, more effectively restoring, and maintaining normal sinus rhythm, and preventing future AF recurrence. ^3,4,6-9 Ablation can also reduce the occurrence of debilitating and expensive cardiovascular events such as stroke, while yielding significant increases in quality of life.

The goal of ablation is to stop symptoms of AF – a key milestone is freedom from AF at 12 months. Most commonly this treatment is delivered by radiofrequency (RF) or cryo ablation.

In April 2021, the NICE AF clinical guideline was published with an updated ablation recommendation – recommending radiofrequency point-by-point (RF PP) as the first ablation option, and only if RF PP is unsuitable to use cryo or laser ablation. This recommendation was driven by NICE’s analysis that RF PP was the most cost-effective treatment option. This business case demonstrates the real-world case for moving from cryo ablation to RF PP ablation. As the goal of ablation is to stop symptoms of AF, (measured as freedom from AF at 12 months), if freedom from AF is not achieved at 12 months patients may undergo a redo ablation procedure.

Before the guidelines were published, Dr Richard Balasubramaniam, Clinical Lead for Electrophysiology at the Royal Bournemouth Hospital, was concerned as he was seeing more patients requiring a redo ablation following a cryo ablation than a RF PP ablation. Due to the potential impact on patient outcomes and the cost impact of a redo, Dr Balasubramaniam decided to audit the data.

A retrospective analysis of hospital redo rates, time in catheter lab (patient in – to patient out), use of anaesthetic and length of stay using the different modalities was carried out.

Staffing and consumable costs were taken from NHS costings and NICE AF clinical guidelines respectively.

Dr Balasubramaniam audited the data and found significantly more RF PP patients were free from RF at 12 months (89%) compared to cryo patients (81%), which is comparable to previously published data.¹⁰ This led the team at Royal Bournemouth Hospital to switch practice from 76% to nearly 100% RF PP.  A cost model was developed which looked at the cost of an ablation procedure including the device cost. The outcome data was then applied to work out the cost per patient.

• 116 procedures were performed over the 12-month period: 84 using RF technology and 32 using cryo ablation.

• No statistical differences were seen in age (65.1 vs 66.0, p=0.87), left atrial size (3.9 vs 4.1cm, p=0.26) and left ventricular ejection fraction (61.7 vs 62.9%, p=0.26) between the two groups of patients.

• Procedure time was significantly longer using RF as expected (162 vs 103 minutes, p<0.001). However, this was offset due to an increase in cardiac catheterisation lab capacity due to the reduction in reinterventions.

• The rate of same day discharge was the same in both groups (90%).

• Redo rates at 12 months were 11% in the RF group and 19% in the cryo ablation group.

The benefits of switching technology from cryo to RF PP, allowed for a reduction of number of repeat ablation procedures, which not only impacts on reducing the cost per patient of achieving freedom from AF, but also allows saved capacity to be used for first time ablation patients.

Following the data audit, the pilot site switched an additional 32 patients from cryo to RF PP technology achieving an efficiency saving of £1,853 per patient.  This correlates with published data surrounding efficacy of the two technologies and NICE cost effectiveness.¹¹

It is suggested that if the introduction of the technology was aligned to a service redesign within the trust, and potentially across an ICS footprint, this could further optimise productivity opportunities and reduce waiting times.

Undertaking the pilot has contributed to the wider learning in relation to Value Based Procurement adoption in healthcare. Specifically, in relation to the need to have greater visibility of longer-term patient outcomes vs costs.

In this case, by conducting a financial analysis of the procedural costs, and the patient outcomes, it was possible to identify reinterventions which were absorbing already stretched capacity.  In this instance, the adoption of one type of technology over another provided a reduced likelihood of repeat procedures for clinically suitable patients.

To discuss this case study and opportunities for your trust to explore using this technology please contact:

Please note:

This case study was carried out at Royal Bournemouth Hospital in conjunction with Biosense Webster. Savings relate to a product chosen by the trust from a range of products available through NHS Supply Chain Frameworks, this may not be suitable for all NHS trusts. There are other comparable solutions within the market that are suitable in addressing the challenges highlighted in this report.

All consumable costs paid, and efficiency savings have been calculated based upon contractual arrangements in place including but not limited to the percentage of point-by-point radiofrequency and cryo ablation procedures undertaken by one consultant at Royal Bournemouth Hospital during a 12-month period.

EP procedure consumable costs for individual trusts will vary depending upon the length of any commitment term; the associated spend and/or market share for EP consumables awarded to each supplier.

References:

1. Public Health England. Atrial fibrillation prevalence estimates. 2015; https://www.gov.uk/government/publications/atrial-fibrillation-prevalence-estimates-for-local-populations. Accessed Feb 9, 2021.
2. Zoni-Berisso M, Lercari F, Carazza T, Domenicucci S. Epidemiology of atrial fibrillation: European perspective. Clin Epidemiol. 2014;6:213-220.
3. National Institute for Health and Care Excellence: Clinical Guidelines. In: Atrial fibrillation: management. London: National Institute for Health and Care Excellence (UK) Copyright © NICE 2020.; 2014.
4. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019;140(2):e125-e151.
5. Kirchhof P, Camm AJ, Goette A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. The New England journal of medicine. 2020;383(14):1305-1316.
6. Noheria A, Kumar A, Wylie JV, Jr., Josephson ME. Catheter ablation vs antiarrhythmic drug therapy for atrial fibrillation: a systematic review. Arch Intern Med. 2008;168(6):581-586.
7. Reynolds MR, Walczak J, White SA, Cohen DJ, Wilber DJ. Improvements in symptoms and quality of life in patients with paroxysmal atrial fibrillation treated with radiofrequency catheter ablation versus antiarrhythmic drugs. Circulation Cardiovascular quality and outcomes. 2010;3(6):615-623.
8. Reynolds MR, Zimetbaum P, Josephson ME, Ellis E, Danilov T, Cohen DJ. Cost-effectiveness of radiofrequency catheter ablation compared with antiarrhythmic drug therapy for paroxysmal atrial fibrillation. Circulation Arrhythmia and electrophysiology. 2009;2(4):362-369.
9. Rodgers M, McKenna C, Palmer S, et al. Curative catheter ablation in atrial fibrillation and typical atrial flutter: systematic review and economic evaluation. Health Technol Assess. 2008;12(34):iii-iv, xi-xiii, 1-198.
10. Gupta D, De Potter T, Disher T, et al. Comparative Effectiveness of Catheter Ablation Devices in the Treatment of Atrial Fibrillation: A Network Meta-analysis of Patients in Prospective Studies. Journal of Comparative Effectiveness Research. 2020;9(2):115-126.
11. NICE. Guideline atrial fibrillation Evidence Review J3 Ablation cost-effectiveness analysis. https://www.nice.org.uk/guidance/ng196/evidence