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Saturday, December 12, 2020

EP cardiologists farm out monitoring of pacemaker remote interrogations to third party companies

 There are  an estimated 200,000 pacemaker implantations per year in the U.S and only about 2,000 board certified EP cardiologists. I believe many PM implantation must be done by cardiac cath cardiologists with the on-site technical assistance of a PM company rep.There are an estimated 1.5 million patients in the U.S. with pacemakers as well as many patient with ICDs  (defibrillators)

In 2015, the Heart Rhythm Society consensus statement stated that remote interrogations (RI) are the standard of care with one annual in office examination. Typically remote interrogations are done every three months. At least in the US and Germany  government health care programs will pay for RIs.

Medicare ( a high percent of PM patients are Medicare eligible) will pay for a RI every 91 days and the CPT code of a professional interpretation is  typically less than 50 dollars ( as of data from 2019)

So if you look at the math and the economics with several million RIs per year it is not surprising that a number of companies are now offering management services for RI for pacemaker  and ICD patients which  include a screening interpretation as well as follow-up for patients who miss their scheduled RI and reminders for scheduled RIs and perhaps other services as well.

For personal experience I can relate that the first year after my pacemaker was implanted the device clinic at the hospital where my EP practices provided good patient service, answering the phone and giving me a report on the results of my remote interrogation typically within a day or two. Over the next year or so service deteriorated significantly , never answering the  phone and only  getting a call back no soon than 4-5  business days.  

One interrogation report indicated that my PM had recorded 8 episodes of " AT/AF" which stands for atrial tachycardia/atrial fibrillation. The PM did not differentiate between the two. Actually what was being recorded was "far field R wave sensing, which should have been apparent to a trained technician viewing the recorded tracings in the printout but was not.It is not clear if the  EP doc reviewed the details of the report even after I sent a email asking about the "atrial fibrillation"

3 months later I had an in office interrogation and visit with the EP doc. The pacemaker company tech doing the interrogation said that the earlier report of AF was not correct but rather the tracings clearly demonstrated a PM pseudo arrhythmia  issue known as "far field R wave sensing. The atria channel senses R waves and double counts them. The  "fix" was simple.The tech lowered the sensitivity of the atrial channel and no such events occurred again. 

I learned that my PM has a program feature than is supposed to detect Far field sensing  ( aka far field R wave sensing) and not misdiagnose Far field sensing as AF. I contacted the Pace maker company and after several phone calls and emails exchanges I was told that the reason their algorithm missed the correct diagnosis was that my runs of far field  were  slightly too short  for the  algorithm  to detect them. I do not now if the company saw fit to alter their algorithm to be more accurate.

After my written complaints to my cardiologists I have been able to obtain my  RI reports  soon after they are transmitted. As a non cardiologist it took me no small amount of time  (and buying 2 books on PMs and electrophysiology) to learn how to read the reports at least on a basic level arguably with a degree of knowledge approximating the work  quality done by the original clinic. At least in regard to PMs , ICD interrogation reports are a different level of complexity and detail. 

After my complaints about the poor patient service delivered by the hospital device clinic the EP department of which my EP doc is the section head stopped using that device clinic and contracted with an outside proprietary firm to manage the interrogation reports. I am not claiming  my complaints played any role in the  change of procedure for interrogation report review but there is a temporal relationship.

A quick internet search yielded several companies that review PM and ICD interrogations including the following -Ambucor,Iron Rod Health and Cardiac RMS.

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