Streamlined care from a specialist. An example of cost effectiveness: Just knowing…

Why would referring a patient directly to a specialist save money, time and patient outcomes?

Exhibit A:

A 75 year old male presents to his family doctor with a heart rate of 120.   Just some palpitations and a little “funny feeling in my chest.”  No pain, no shortness of breath, no dizziness. Examination shows a patient in no distress with only a fast heart rate- no signs of heart failure.  The EKG, a 25 dollar test, shows a regular supraventricular tachycardia or possibly an atypical atrial flutter- a benign rhythm.

Let’s say the family doctor knew there was such a thing as a heart rhythm specialist and referred the patient directly to an electrophysiologist.    The American Board of Internal Medicine recognizes electrophysiology (EP) as a sub-specialty of cardiology.  

Not in this case, the patient gets referred to a general “cards” doctor.   Surely, the patient is relieved as he is referred to a specialist heart doctor.  Here is how the story of a simple minimally symptomatic benign arrhythmia went…

1. The “cards” doctor is not a rhythm specialist and as such, places the patient on successively stronger medicine which do not work.

2. Next, the patient gets a Transesophageal Echo (TEE-a big black tube down the throat) and a cardioversion or shock.  General anesthesia required.

3. The rhythm is now regular, but a very slow heart rate ensues, undoubtedly from the strong medicines which did not work.

4. A pacemaker is recommended and surgery is performed.
Remember, the original presentation was a non-life threatening rhythm with minimal symptoms.

5. The atrial lead (top chamber), which is the one of two leads the patient requires for effective pacing of the heart rate, dislodges and no longer works.  Lead dislodgement is a known complication of pacemaker surgery.

6. No more surgery is planned, the pacemaker is programmed to pace from the ventricular lead (bottom chamber).

7. Pacing from this lead results in severe shortness of breath, which is commonly referred to as “pacemaker syndrome.”  Additionally, there is persistent nausea which the patient relates to the initiation of “my new meds.”  This profound distress goes on for 2 months before an electrophysiologist sees him after numerous hospital admissions.  The patient remarks, “with my stomach upset and shortness of breath, I have no life.”

8. The original rapid heart beat is still not definitively treated despite all the above.

The electrophysiologist’s plan…

1. The ineffective medicines which caused the slow heart rate, and resulted in pacemaker implantation are stopped.  Nausea quickly abates.

2. As the primary reason for seeking medical attention was the rapid heart rate, an EP Study (electrical study) was recommended for diagnosis and cure of the rapid heart beat.

3. The Ep study revealed a sustained typical atrial flutter which was ablated (burned) in less than 60 minutes.  Done. Over. Easy.  No more rhythm medicines needed. The original problem fixed. 

4. While in the Ep Lab, the non-functioning pacing lead was removed and a new one inserted.  40 minutes.
 ((Please note that if the original rhythm was ablated and meds were not used, there would have been no medicine inducing bradycardia and no pacemaker in the first place, however,  since the pacemaker was in place for nearly 3 months a decision was made to leave it in place and simply revise the atrial lead)). 

Summary,  If this patient was referred from a primary care doctor to an electrophysiologist, the patient would have had only one 60 minute procedure resulting in cure.  No medicines, and if no medicines, than no pacemaker, and without a pacemaker there would have been no dislodgement and resultant pacemaker syndrome.  Additionally, an echo done with a painless external probe on chest wall would suffice, versus the big black trans-esophageal probe.  Finally, this patient would not have suffered for months with both medicine side effects and shortness of breath characteristic of pacemaker syndrome.

Lessons...

We heart rhythm specialists need to improve our educational efforts.   Informing primary doctors that direct referrals of arrhythmia issues is appropriate.  Also, we should educate the general cardiology community that curative, low risk, low morbidity and well tolerated ablation procedures offer a stream lined cost effective care for many arrhythmias.  Also, we need to enhance our  availability to the primary medical community.

Education of the general public is also appropriate.  This is 2009, patients can easily find out what an EP doctor does and we as a group should “self promote” our abilities.  

This vignette is not meant to criticize the previous doctors decisions.  They do what is familiar to them.  Ablation is not something they do personally and hence not as familiar as a therapeutic tool.

There are similar stories for the evaluation and treatment of syncope and fainting.  An EP doc get’s to the heart of the diagnosis of syncope expeditiously and much more cost effectively, often by a careful history and avoidance of low yielding tests.

A hospital could use us to reduce the treatment costs of atrial fibrillation, atrial flutter, syncope and many others.

Just ask us, we can often help.

JMM

4 comments

  1. I just went to the Mayo website and read about ablation. Fascinating. My question is: Why isn't your specialty referred routinely when drugs fail or cause unpleasant, life-altering side-effects? It seems like it would certainly save no only money but also a great deal of stress for the patient.
    -Wren

  2. Great article.

    As a former atrial fibrillation patient, and founder of StopAfib.org (http://stopafib.org), an atrial fibrillation patient resource and community, I hear many stories like this every day. My first question is usually "Are you seeing an electrophysiologist?"

    Our health care costs would come down and patients' lives would dramatically improve if they were just referred to EPs in the first place.

    Mellanie True Hills

  3. There are many reasons why EP (arrhythmia doctors) are not referred patients early on. Here are just a few…

    -some primary care doctors are simply not aware of our specialty, even though we have existed for 15 years.

    -surprisingly, many cardiologists, especially outside academia are either not aware of, or do not buy into the concept of a separate sub-specialty of cardiology. Our toolbox of possible treatments are often poorly understood.

    -many cardiology groups do not have an electrophysiologist in their group. This can cause a barrier to referring

    -there are those who believe that sub-specialists provide more expensive care and in some areas of medicine this may be true, but, as technology advances, sub-specialties like EP actually decrease costs by tailoring therapy early, thus avoiding many of the knee jerk type testing of the past. For example, I have been referred young healthy patients with totally benign arrhythmia not related to coronary disease who before seeing me undergo extensive testing like echocardiography, nuclear stress testing and cardiac catheterization -all of which reveals normal findings and all of which is well reimbursed. All they needed was a history, physical, 25 dollar EKG and reassurance.

    Maybe a stretch here, but this is why many health reform experts envision a Mayo or Cleveland Clinic multi-specialty type format where patients are triaged accordingly and reimbursement is less dependent on an individual's singular productivity.

    The case I referenced also illustrates the importance of being an educated patient. It continually surprises me that many read more about a big screen TV or auto purchase than they do about their own health care.

    JMM

  4. I like having the ability (via the Internet) to be an "informed" patient. It certainly wasn't always that way. And I, too, am always surprised by people who just don't seem interested in knowing more about what ails them and, if they're thoughtful, learning how they might help to mitigate that ailment. I've a dear friend who's morbidly obese and has diabetes — and who, despite having a computer at her fingertips — is ignorant of most of the basics regarding the disease. I'm constantly taken aback by this — and constantly trying to inform her. She's a sweet, loving soul and the world will be poorer without her, but I know that she won't be with us much longer. It's a shame. And here I am ranting again… Your posts stimulate thought and invite comment. Thanks for that, Dr. John.
    -Wren

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