Hospital Rankings for Heart and Heart Surgery Need to Include Electrophysiology Procedures in Their Metrics

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EP LAB DIGEST. 2024;24(9):6.

Bradley P Knight, MD, FACC, FHRS

Dear Readers,

In many hospitals, the electrophysiology (EP) program and EP laboratories remain a relative low priority compared to cardiac surgery and interventional cardiology. Historically, more resources, attention, and personnel are dedicated to the cardiac operating rooms, cardiac intensive care units, and catheterization laboratories than to the EP laboratories. There are many reasons why EP programs are still in the periphery. First, high-quality cardiac surgical and primary percutaneous coronary intervention (PCI) programs are core to the care of patients with acute and advanced heart disease, and are critical to the success of any cardiovascular service line. Second, cardiac surgery and heart transplantation are very profitable. Although interventional cardiology can be profitable, in many hospitals they are often less profitable than the EP program. The absence of a quality cardiac surgical program at a hospital limits the types of cardiac procedures performed to those that are seen as not needing cardiac surgical backup. Third, politics plays a role; the field of interventional cardiology and PCI began in cardiac catheterization laboratories far before the field of interventional EP was born, placing many senior interventional cardiologists in hospital administrator roles. Fourth, cardiac surgeons and structural heart disease cardiologists have created an interdependence as part of their new “heart team” approach. But finally, and perhaps most importantly, an underappreciated reason that EP is not a top priority at many hospitals is that the outcomes of EP procedures are ignored by the hospital rankings.

US News & World Report’s (USNWR) annual hospital rankings for cardiology and cardiovascular surgery programs were recently released.¹ For most hospitals, a high USNWR ranking is cherished. These rankings are so critical that hospitals have staff dedicated to creating strategies solely to optimize an individual hospital ranking. Heart and heart surgery programs are also ranked by other organizations. The methods used to rank hospitals and cardiovascular programs are constantly being modified but are usually based on a scoring system that includes surgical and procedural volumes, patient outcomes, nursing accolades, reputation scores, and access to certain advanced services. For the USNWR rankings, there are 6 conditions/procedures applicable to cardiology as well as heart and vascular surgery used in the scoring system. Each is scored using a 1-5 numbering system, with 5 indicating “high performing.” These 6 conditions/procedures include:

1. Abdominal aortic aneurysm repair
2. Heart attack
3. Aortic valve surgery
4. Heart bypass surgery
5. Heart failure
6. Transcatheter aortic valve replacement (TAVR)

Three of these metric components are surgical, 2 are managed in the cardiac catheterization laboratory, and the remaining condition is managed by internists, general cardiologists, and heart failure specialists. One-half of the components are devoted just to the aorta and aortic valve. None of the conditions or procedures tracked by USNWR are heart rhythm related.

With the explosion of patients with atrial fibrillation (AF) as well as the performance of so many device implantations and ablation procedures, why are these conditions and procedures not included in these rankings? The answer is likely related to the issues listed above. This should change—it would not be difficult. A simple start would be to rank EP programs based on easily tracked outcomes, such as 30-day procedure-related mortality and the incidence of cardiac tamponade related to an EP procedure. These outcomes could be tracked by individual hospital EP laboratory managers requiring few additional resources. Options for systematic data sources include the mandatory National Cardiovascular Data Registry (NCDR) Left Atrial Appendage Occlusion Registry and the voluntary American Heart Association/American Stroke Association’s Get With The Guidelines-AFIB collaborative performance improvement program. 

The outcomes of procedures performed in EP laboratories should be included in hospital rankings, including the annual USNWR rankings for cardiology and cardiovascular surgery programs. The EP community should be advocating for inclusion of EP conditions such as AF as well as procedures such as catheter ablation and device implantation as components in these metrics. This could give EP laboratories the resources and attention needed to optimize the care of patients with heart rhythm disorders. 

Disclosures: Dr Knight has served as a paid consultant to Medtronic and was an investigator in the PULSED AF trial. In addition, he has served as a consultant, speaker, investigator, and/or has received EP fellowship grant support from Abbott, AltaThera, AtriCure, Baylis Medical, Biosense Webster, Biotronik, Boston Scientific, CVRx, Philips, and Sanofi; he has no equity or ownership in any of these companies.

Reference

1. Best hospitals for cardiology, heart & vascular surgery. US News & World Report. Accessed August 8, 2024. https://health.usnews.com/best-hospitals/rankings/cardiology-and-heart-surgery