Is interventional electrophysiology poised for a paradigm shift? The American College of Cardiology and Heart Rhythm Society may think so. In a joint scientific statement, they offer guidance on performing certain procedures, such as cardiac ablation, in facilities that provide same-day surgical care without the need for hospital admission.

The transition of specific electrophysiology procedures to ambulatory surgical centers aligns with an increasing need for arrhythmia intervention, according to the statement that was published in both Heart Rhythm and the Journal of the American College of Cardiology.

The statement analyzes worldwide clinical data, provides a framework for recommended best clinical practices, and addresses the ever-changing reimbursement and regulatory side of the ambulatory surgical center market, according to Amit Shanker, MD, an attending physician at St. Lawrence Health System in Potsdam, New York. He also serves on the FDA’s Medical Devices Advisory Committee and sits on the board of Heart Rhythm Advocates.

Since the first freestanding ambulatory surgical center opened in Phoenix in 1970, more than 11,000 of these facilities have been established in the US, according to ASCData. Over the past decade, the number of Medicare-certified ambulatory surgical centers has grown by 25%.

As Americans age, the need for ambulatory surgical center services is growing. The ASCData indicate more than 49 million people, or 15% of the US population, are 65 years or older and this demographic is projected to grow to 24% of the overall population by 2060.

“New real-world data from thousands of ambulatory surgical center-based ablations reveal complication and transfer rates comparable to, or lower than, hospital outpatient departments,” Shanker, who co-chaired the statement’s writing committee, said. “The Centers for Medicare and Medicaid Services’ inclusion of cardiac ablation on the covered procedure list for ambulatory surgical centers is an acknowledgment of how our field has advanced, through better safety data, more efficient workflow, and improved technology.”

Patient-Centric and Cost-Effective

For selected patients — those not requiring overnight hospitalization and whose stay is not expected to exceed 24 hours — ambulatory surgical centers offer a more streamlined and patient-centric experience, such as shorter wait times and lower out-of-pocket costs, according to Shanker.

“Clinicians benefit from ambulatory surgical center’s predictable schedules, reduced administrative burden, preserved autonomy, and the ability to deliver high-volume and efficient care, all of which addresses the growing demand for arrhythmia services,” he said.

By diverting eligible outpatient procedures to ambulatory surgical centers, hospitals could be better positioned to prioritize complex, urgent, and emergent cases, according to the statement.

“The streamlined, patient-centric environment of an ambulatory surgical center may expedite recovery times, minimize administrative complexities, and diminish risk for hospital-acquired infections,” Shanker said, adding that ambulatory surgical centers located in underserved, particularly rural, geographic locations with limited hospital services can remove geographic barriers to healthcare.

However, Shanker noted regulatory fragmentation, workforce recruitment challenges, and existing reimbursement disparities hinder the successful scalability of this model.

“In select regions of the US, a rapid and sustained shift in procedural volumes could unexpectedly reduce healthcare access by creating economic and workforce strain on local hospitals,” he said. “To mitigate any unintended harm to vulnerable communities, we advocate collaborative policies that expand access and efficiency while safeguarding systemwide ability to conduct complex and emergent cardiac care.” 

‘Decades of Innovation’ Have Led Here

Mark Willcox, MD, an electrophysiologist at Alaska Heart and Vascular Institute in Anchorage, Alaska, echoed Shanker’s perspective on what may become a new era of outpatient cardiac electrophysiology in the US.

Electrophysiologists have observed major gains in safety and efficacy of electrophysiology procedures, with the shared goal of reducing the burden of arrhythmias and their treatment, Willcox, who was not involved with the scientific statement, noted.

“Decades of innovation have brought us here, from digoxin as a primary treatment for atrial fibrillation, to open-heart surgical ablation, to early catheter ablation performed in cardiac operating rooms with a surgeon on standby, to modern percutaneous radiofrequency and cryoablation, and now, same-day discharge and non-thermal energy systems,” he said.

Historically, electrophysiology procedures have been confined to hospitals because Medicare and Medicaid reimbursement outside of that setting was not possible, Willcox explained.

“While hospital-based care allowed physicians to remain somewhat insulated from the business side of medicine, it also limited our ability to negotiate directly with insurance companies,” he said. “Defining patient-centered quality measures will be challenging, but electrophysiologists have never backed away from complexity.”

Willcox added that approval of ablation in ambulatory surgical centers will inevitably decentralize procedural healthcare.

“Our previous experience shows that it can be done safely, effectively, and with significant cost savings, as long as patient-centered outcomes remain our mission,” he said.

Shanker and Willcox had no financial disclosures.

Martta Kelly is a medical journalist who lives in the New York metropolitan area.