Geographic variation in the use of catheter ablation for atrial fibrillation among Medicare beneficiaries

doi:10.1016/j.ahj.2015.03.006

American Heart Journal

Volume 169, Issue 6, June 2015, Pages 775-782.e2

https://doi.org/10.1016/j.ahj.2015.03.006 Get rights and content

Background

Catheter ablation for atrial fibrillation is used increasingly in older patients, yet the risks and benefits are not completely understood. With such uncertainty, local medical opinion may influence catheter ablation use.

Methods

In a 100% sample of Medicare beneficiaries ≥65 years who underwent catheter ablation for atrial fibrillation between January 1, 2007, and December 31, 2009, we investigated variation in use by hospital referral region (HRR) for 20,176 catheter ablation procedures.

Results

Across 274 HRRs, median age was 71.2 years (interquartile range 70.5-71.8), a median of 98% of patients were white, and a median of 39% of patients were women. The median age-standardized prevalence of atrial fibrillation was 77.1 (69.4-84.2) per 1,000 beneficiaries; the median rate of catheter ablation was 3.5 (2.4-4.9) per 1,000 beneficiaries. We found no significant associations between the rate of catheter ablation and prevalence of atrial fibrillation (P = .99), end-of-life Medicare expenditures per capita (P = .09), or concentration of cardiologists (P = .45) but a slight association with Medicare expenditures per capita (linear regression estimate 0.016; 95% CI 0.001-0.031; P = .04). Examined HRR characteristics explained only 2% of the variation in HRR-level rates of catheter ablation (model R² = 0.016).

Conclusion

The rate of catheter ablation for atrial fibrillation in older patients was low, varied substantially by region, and was not associated with the prevalence of atrial fibrillation, the availability of cardiologists, or end-of-life resource use and was only slightly associated with overall Medicare expenditures per capita.

Section snippets

Methods

We obtained a 100% sample of claims data from the US Centers for Medicare & Medicaid Services for patients ≥65 years who underwent catheter ablation for atrial fibrillation. All included patients were enrolled in fee-for-service Medicare and were living in the United States at the time of the procedure. As previously reported,⁶ we identified and included patients from inpatient, outpatient, carrier, and denominator files who underwent intracardiac catheter ablation (Current Procedural

Results

Of 306 HRRs in total, 274 were eligible for the catheter ablation analysis after exclusions. Across the eligible HRRs, a total of 20,176 catheter ablations were performed in Medicare fee-for-service patients between 2007 and 2009. Across HRRs, the median age of patients undergoing catheter ablation for atrial fibrillation was 71.2 years (interquartile range 70.5-71.8) (Table I). A median of 39% (interquartile range 33.3%-45.5%) were women, and a median of <1% (interquartile range 0%-1.9%) were

Discussion

We observed substantial geographic variation in the use of catheter ablation for atrial fibrillation in Medicare fee-for-service beneficiaries. The variation in ablations did not correspond to the underlying prevalence of atrial fibrillation. Although the age-adjusted prevalence of atrial fibrillation was greatest in the major metropolitan areas of the East and West Coasts, catheter ablation rates were higher in areas where the prevalence of atrial fibrillation was relatively low. Hospital

Acknowledgements

Disclosures: Dr Piccini reported serving as a consultant for Janssen Pharmaceuticals, BMS/Pfizer, and Medtronic; and receiving grant funding from ARCA biopharma, GE Healthcare, and Janssen Pharmaceuticals. Dr Curtis reported receiving grant funding from GlaxoSmithKline, Johnson & Johnson, and GE Healthcare. Drs Piccini and Curtis have made available online detailed listings for financial disclosures (https://www.dcri.org/about-us/conflict-of-interest). No other disclosures were reported.

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The Dartmouth Atlas of Healthcare

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Variations in Atrial Fibrillation Ablation Use and Charges in a Modern Cohort of Medicare Beneficiaries
2023, American Journal of Cardiology
Catheter ablation of atrial fibrillation (CAF) is increasingly being used in the United States. This study aimed to identify variations in CAF use among Medicare beneficiaries (MBs) over a 6-year period (2013 to 2019). Using the Center of Medicare and Medicaid Services database, a 100% sample of MBs who underwent CAF from 2013 to 2019 was included. We stratified CAF use data geographically (Northeast, South, West, and Midwest) and identified the number of CAFs per 100,000 MBs, number of electrophysiologists performing CAFs per 100,000 MBs, number of CAFs per individual electrophysiologist, and average submitted charge for CAF. In addition, we stratified the data per urban versus rural areas and gender of the operator. We found that the mean atrial fibrillation (AF) prevalence, rates of CAFs, number of electrophysiologists performing CAFs, and number of CAFs per electrophysiologist have increased steadily in all regions. The mean AF prevalence was different among regions, with the highest prevalence in the Northeast (p <0.001); however, there was a pattern of higher CAFs rates in the West and the South (p ≥0.057). The number of electrophysiologists performing CAFs was not different among regions; however, the number of CAFs per electrophysiologist was higher in the West and the South (p <0.001). The average submitted charge for CAF has decreased over years and was the lowest in the West and the South (p <0.001). There was no major difference in these variables regarding operator gender. In conclusion, there are significant variations in CAF use among MBs in the United States according to geographic and urban versus rural regions. These variations have the potential to impact the outcomes in MBs diagnosed with AF.
Rationale, considerations, and goals for atrial fibrillation centers of excellence: A Heart Rhythm Society perspective
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Citation Excerpt :
Second, there is a significant increase in costs with repeat ablation that emphasizes the need to improve procedural efficacy and patient selection.150 Third, there are marked geographic variances in AF ablation that do not correlate with regional disease prevalence.151 Finally, there is also significant variation in the facility costs associated with AF ablation (median: $25,100; 25th percentile: $18,900; 75th percentile: $35,600; 95th percentile: $57,800).
Trends and predictors of repeat catheter ablation for atrial fibrillation
2016, American Heart Journal
Citation Excerpt :
One-year procedural success rates are often cited in the literature and in discussions with patients, but it is important to note that longer-term follow-up data are comparatively scant and repeat ablation appears to be common among patients who are good candidates for a repeat procedure. Geographic variation in the utilization of AF ablation has been previously described in a large study of the Medicare population (n = 20,176).22 These geographic variations do not necessarily follow patterns of AF prevalence but reflect more broadly the geographic variations in practice patterns and preferences.
Atrial fibrillation (AF) ablation is superior to pharmacologic therapy in achieving maintenance of normal sinus rhythm in selected patient populations. However, the procedure is resource intensive, and repeat ablations are sometimes required. We examined the predictors and trends of repeat ablation using a large national administrative claims database.
Privately insured and Medicare Advantage patients who underwent catheter ablation for AF between January 1, 2004, and September 30, 2014, were included in the study. The primary outcome was repeat AF ablation during enrollment. We examined the associations between repeat ablation and patient demographics (age, gender, socioeconomic demographics), comorbid conditions (CHA₂DS₂-Vasc score and Charlson index), and year of the index ablation. Cox proportional hazard models were used to identify predictors of repeat ablation.
We included 8,648 adult patients in the analysis. Median age was 61.0 (interquartile range [IQR] 54-68) years, and 70.9% were men. Median follow-up was 1.1 (IQR 0.5-2.3) years. A total of 1,263 patients underwent repeat ablation (14.6%) over a total of 14,280 person-years (12.1% at 1 year). The hazard ratio (HR) for repeat ablation was higher in younger patients (HR 0.75 [0.61-0.91; P < .01] for age 65-75 and 0.55 [0.4-0.75; P < .001] for age ≥75 compared with age 18-54), those with higher household income (HR 1.24 [1-1.54; P < .05] for household income ≥$100,000 compared with household income <$40,000), patients treated in the south (HR 1.15 [1-1.31]; P < .05), and those on antiarrhythmic medications (HR 1.15 [1.01-1.31]; P < .05). In particular, younger patients (ages 18-54 years) continued to undergo repeat ablations over the entire follow-up period, and the cumulative rate was approximately 40% among those followed for 5 years. Clinical characteristics including those included in the CHA₂DS₂-Vasc score and Charlson index did not predict likelihood of repeat ablation. The rate of repeat ablation remained constant over the available follow-up.
Approximately 1 in 8 patients treated with catheter ablation for AF will undergo a second procedure within 1 year, although the rate is as high as 40% in young patients at 5 years. The rate of repeat ablation appears to be associated with demographic characteristics (younger age and higher household income) rather than medical comorbidities.
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Socioeconomic and geographic differences in ablation of atrial fibrillation in Norway - a national cohort study
2022, BMC Public Health
Limited duration of antiarrhythmic drug use for newly diagnosed atrial fibrillation in a nationwide population under age 65
2021, Journal of Cardiovascular Electrophysiology

View all citing articles on Scopus

: Jeanne Poole, MD served as guest editor for this article.

^g: Drs Sinner and Piccini contributed equally to the work.

View full text

Clinical InvestigationElectrophysiologyGeographic variation in the use of catheter ablation for atrial fibrillation among Medicare beneficiaries

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Acknowledgements

Heart Rhythm

N Engl J Med

J Am Coll Cardiol

Heart Rhythm

Symptoms and functional status of patients with atrial fibrillation: state of the art and future research opportunities

Circulation

Estimation of total incremental health care costs in patients with atrial fibrillation in the United States

Circ Cardiovasc Qual Outcomes

2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society

Circulation

Pulmonary vein isolation for the maintenance of sinus rhythm in patients with atrial fibrillation: a meta-analysis of randomized, controlled trials

Circ Arrhythm Electrophysiol

Outcomes of Medicare beneficiaries undergoing catheter ablation for atrial fibrillation

Circulation

Geography and the debate over Medicare reform

Health Aff (Millwood)

The Dartmouth Atlas of Healthcare

Clinical Investigation
Electrophysiology
Geographic variation in the use of catheter ablation for atrial fibrillation among Medicare beneficiaries