Improved hospital discharge and cost savings with esophageal cooling during left atrial ablation

From the 2022 HVPA National Conference

Christopher Joseph BA (University of Texas Southwestern Medical School), Julie Cooper BS, Samuel McDonald MD, Robert Turer MD, Erik Kulstad MD, James Daniels MD

Background

Left atrial ablation to obtain pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) is a technologically-intensive procedure utilizing innovative and continually improving technology.  Changes in the technology utilized for PVI can in turn lead to changes in procedure costs. Because of the proximity of the esophagus to the posterior wall of the left atrium, various technologies have been utilized to protect against thermal injury during ablation. The traditional standard of care, luminal esophageal temperature (LET) monitoring, alerts electrophysiologists when the temperature in the esophagus has reached dangerous levels.  This then leads to pauses in the procedure. Alternatively, a newer device is available that provides active esophageal cooling to proactively dissipate heat in the esophagus.  This approach avoids the need for pauses during ablation, which in turn has been shown to reduce procedure duration.  Additionally, active cooling reduces postoperative symptoms such as chest pain, which facilitates an increased rate of same-day discharge.  The impact of this combined effect on hospital costs has not previously been evaluated.

Objective

We aimed to evaluate the cost impact of implementing active esophageal cooling during left atrial ablation.

Methods

We reviewed recently presented data on procedural timing and same-day discharge rates from a large academic hospital system.  Using these data, we then calculated cost impacts using published metrics on hospital charges in the electrophysiology lab.  Costs were calculated from both a time differential and discharge differential perspective.

Results

Procedural time reduction was obtained from an analysis of 164 patients treated with PVI, with 63 using LET monitoring, and 101 using active esophageal cooling, which showed a mean reduction of 37 minutes when using active esophageal cooling.  Discharge rate improved by 18% with active esophageal cooling.  Cost-per-minute in the EP lab has been reported at $29 per minute, translating into a savings of $1073 per case. The financial impact associated with post-ablation same-day discharge has been estimated as $7116, factoring in the reimbursement available from the additional bed made available by the same-day discharge.  Combined, these estimates suggest a savings of $235,388 per 100 patients treated.  After including the increased cost of the active esophageal cooling device over the standard LET probe, the net savings to the hospital are $155,488 per 100 patients treated.

Conclusions

The use of active esophageal cooling is associated with significant cost-savings when compared to traditional LET monitoring, even after accounting for the additional cost of the cooling device.  These savings originate from a per-patient procedural time savings and a per-population improvement in same-day discharge rate.

Clinical Implications

How did this initiative improve the quality and safety of patient care and/or the patient experience?

Implementation of active esophageal cooling was initially performed to leverage the known safety benefits over traditional esophageal temperature monitoring.  Analysis of the impact of this initiative on hospital costs has uncovered additional benefits in cost savings to the hospital.  An improved same-day discharge rate additionally enhances the patient experience and can also support improved quality measures

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