7.Electrocardiography (ECG) recommendations

7.1 ECG Working Group membership

The Committee formed a Working Group to consider MBS ECG items 11700–11702. The ECG Working Group included the following members:

  • Δ Professor Mark Harris – Director, Centre of Obesity Management and Prevention Research Excellence in Primary Health Care (COMPaRE – PHC); Foundation Professor of General Practice and Executive Director, Centre for Primary Health Care and Equity, University of New South Wales.
  • Δ Dr Maria Brosnan – Cardiologist, St Vincent’s Hospital, Melbourne, and Baker IDI, Melbourne.
  • Δ Professor Jonathan Newbury – Professor of Rural Health, Adelaide Rural Clinical School, School of Medicine, University of Adelaide.
  • Δ Mr Alex Segler – Independent consumer.
  • Δ Professor Richard Harper (Ex-Officio) – Emeritus Director of Cardiology, Monash Medical Centre; Adjunct Professor of Medicine, Monash University.

The following recommendations were developed by the ECG Working Group and accepted unanimously.

The Committee also endorsed the recommendations unanimously.

7.2 General considerations

  • ΔMore than 2.7 million ECG services are claimed under the MBS every year at a cost of over $71 million. Over 98 per cent of these services are claimed as a trace and report. There is considerable variability in ECG services per population with NSW and QLD having twice as many services as WA and the NT. People in remote and very remote areas claim 25–50 per cent fewer services than people in more urban areas. The Committee voiced concern about the volume and variability of ECG claims and the growth 7 per cent per year (well above population growth 1–2 per cent per year). The Committee agreed that growth at this rate is not driven by shifting disease patterns and felt that the substantial and growing investment in a relatively straightforward activity could be better directed to other necessary services.
  • ΔThe Committee noted that there is significant variation in per-capita services between states, and between urban, regional and remote populations (Figure 20). Drawing on their clinical judgement, Committee members could find no medical explanation for this variation and recommended that it should be addressed.
  • Figure 20: Geographical variation of ECG services (MBS items 11700, 11701, 11702)


    Figure 20 depicts bar graphs that show the geographical variation of ECG services per 100,000 population. There are two bar graphs, one that depicts state-based variation and another for rurality based variation. State-based variation shows up to two fold variation, with NSW, VIC, QLD and SA between 11,873 and 13,282 services per 100,000 population, while the other states are between 6,467 and 9,353 services per 100,000 population. Rurality-based variations outlines that major cities, inner regional and outer regional areas are higher at 11,461, 13,406 and 12,422 respectively. Remote and very remote ares are both under 8,700.

    Data is by date of service extracted on 20 June 2016. Unpublished data from 2014-15 (Department of Health). Remoteness Area classes are based on ARIA. Reference: ASGS: Volume 5 – Remoteness Structure Australia July 2011, 1270.0.55.005. The patient postcode is linked to the Remoteness Area Concordance file.

  • ΔThe Committee noted that when the ECG items were introduced, ECG machines were expensive and more complex and time-consuming to operate. Modern ECG machines are more affordable, and technological improvements (such as sticky electrodes, which have replaced suction cups) have reduced the amount of time and effort required to take an ECG trace.
  • ΔIt was noted that GP clinics must have access to an ECG machine in order to meet accreditation requirements. This is outlined in the Standards for General Practitioners (fourth edition), Standard 5.2, “Equipment for comprehensive care”:
    • – Criteria 5.2.1 Practice Equipment: “practice has timely access to a spirometer and electrocardiograph.” (55)
  • ΔThe Committee discussed the possibility of removing ECGs from the MBS altogether, as it was agreed that they could now be considered a core part of patient history and examination (similar to taking blood pressure). However, it was ultimately agreed that ECGs do offer clinical value and should remain on the MBS, although steps need to be taken to reduce variability and improve the clinical value of these services.
  • ΔThe Committee agreed that an ECG has two components: performing the trace and reviewing the trace. These should be considered separately, given that a medical practitioner almost never performs the trace, but should always perform the review (with or without a formal report).
  • ΔThe Taskforce has indicated it may consider these recommendations in conjunction with other deliberations affect General Practice.

7.3 ECG trace and report

Current item descriptors and MBS data from FY 2014/15

Item 11700 – Schedule fee: $31.25
Services: 2,642,948  Total Benefits: $69,467,252  Average annual growth: 6.5%

Twelve-lead electrocardiography, tracing and report

Public data from 2014-15 (Department of Human Services).

Recommendation 16
  • ΔAmend the descriptor for item 11700 to read:

Item 11700

Twelve-lead electrocardiography, referred service for performing a trace and providing a formal report, separate to any letter, by a medical practitioner.

A copy of trace and report are provided to the referrer, retained by the provider and made available to other clinicians upon request, with patient consent.

Where the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member.

Not claimable for a patient admitted to hospital; in association with a consultation; or for a service to which 11701 or 11702 applies.

Explanatory notes: A formal report is separate to any letter and entails interpretation of the trace commenting on the significance of the trace findings and their relationship to clinical decision making for the patient in their clinical context, in addition to any measurements taken or automatically generated.

A GP referral to a cardiologist or consultant physician for a standard consultation should not be regarded as a referral for an ECG.

Retionale

These recommendations focus on improving the value of the MBS and are based on the following observations.

  • ΔThe Committee determined that item 11700 should remain on the MBS in recognition of the access it gives GPs—particularly rural GPs—to specialist review of a trace. Although all doctors should be capable of interpreting ECGs, the Committee acknowledged that GPs (and other clinicians) who are concerned about a trace, or are unable to obtain an adequate trace, should be able to seek additional support.
  • ΔThe Committee agreed that many ECGs are of low value, particularly those performed without a referral, as the financially objective gatekeeping function is not present in non-referred services. It was also agreed that many providers routinely perform ECGs, screening ECGs or repeat ECGs in the absence of symptoms. There was consensus that defining a service for referred ECGs, particularly in regard to item 11700, would significantly increase the clinical value of the services provided. By involving two providers, there is an element of gatekeeping, which enhances the value of the services. (Appropriate gatekeeping weighs the value of specialist input against the inconvenience to the patient. This function is primarily performed by primary care clinicians and is a cornerstone of the Australian healthcare system.)
  • ΔThe Committee agreed that storing an ECG trace and report, and making them readily available to other clinicians (with patient consent), provides greater value to the patient and the health system. The Committee has not specified the exact format in which the trace and report should be stored or made available, but it was agreed that uploading the trace and report to a patient’s My Health Record would certainly meet the requirement for storage and accessibility. The Committee also emphasised the importance of retaining both the report and a copy of the trace (with sufficient resolution and clarity), so that the trace can be interpreted alongside the report. A formal report should be separate from any referrals or letters, and it should clearly document the relevant measures and findings from the study. The Committee noted that there is value in the extended hours offered by some pathology providers, which allow greater access to previous traces and reports outside standard business hours. Services rendered by providers who are not affiliated with a pathology company but offer an ECG trace and formal report service (including the storage and provision of data to appropriate providers) are of equivalent value.
  • ΔThe Committee discussed at length the issue of co-claiming an ECG trace and report with a consultation. It noted that a referral to see a specialist physician does not constitute referral for a formal ECG, and it agreed that if an ECG trace is performed in association with a consultation, item 11700 should not be claimed. Instead, item 11702 should be claimed. This acknowledges the time and consumable requirements associated with taking an ECG trace, and the review of the trace is reasonably taken to occur as part of the consultation. Formal reports are not routinely provided nor required for traces reviewed during a consultation.
  • ΔThe Committee discussed the potential implications this change may have on rural access, noting that many rural GPs serve dual roles in the community, offering consults in their rooms and supporting the local hospital. In the context of ECGs, this was considered to involve three elements: performing an ECG trace, clinical decision-making, and urgent critical care and management.
    • – Trace: It was agreed that this would be appropriately remunerated under item 11702 and would not present any issues.
    • – Clinical decision-making: A rural GP may review a trace, determine that an acute episode is occurring and requires urgent medical attention, and transfer the patient to hospital. An equivalent process occurs in urban areas. The key distinction is that in an urban environment, the duty of care often ends with the arrival of an ambulance; in a rural environment, the GP often retains duty of care in the hospital setting.
    • – Urgent care in hospital: In an urban area, the patient would be managed in hospital by the relevant clinicians on duty. In a rural area, the GP will often assume the role of hospital clinician and provide the appropriate critical care. However, this is not related to ECG interpretation and would be remunerated through the relevant hospital funding mechanisms.
  • ΔHaving considered the above, the Committee agreed that although the role of rural GPs is different from the role of their urban colleagues, there was no identified inequality with regards to ECG services that would necessitate a specific rural item or exception.
  • ΔThe Committee agreed that these changes would improve the clinical value provided by item 11700 and would not restrict patient access to appropriate ECGs.
  • ΔThe Committee agreed that there was a risk that providers may circumvent the request. For example, providers in large practices may refer to another provider in the same practice. This could also occur with item 11701. It was suggested that referrals could be restricted to GPs only, or to providers who are not located within the same practice. It was agreed that the wording from diagnostic imaging should be used to prevent referrals within a practice.

7.4 ECG report only

Current item descriptors and MBS data from FY 2014/15

Item 11701 – Schedule fee: $15.55
Services: 27,158  Total Benefits: $353,149  Average annual growth: -2%

Twelve-lead electrocardiography, report only where the tracing has been forwarded to another medical practitioner, not in association with a consultation on the same occasion

Public data from 2014-15 (Department of Human Services).

Recommendation 17
  • ΔAmend the descriptor for item 11701 to read:

Item 11701

Twelve-lead electrocardiography, referred service for a formal report only, by a medical practitioner, separate from any letter, where the tracing has been forwarded by the referring medical practitioner and where the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member.

A copy of the trace and report are provided to the referrer, retained by the provider and made available to other clinicians upon request, with patient consent. Not claimable in association with a consultation. Claimable for admitted patients in a private hospital only where an unforeseen cardiac problem develops and the attending doctor reviews the trace and requests a second opinion and formal report regarding interpretation of the ECG in the context of clinical decision making. Both the request and report must be in writing and documented in the patient history. Not claimable for routine in hospital ECGs including routine pre-operative ECG.

Claimable up to twice in a day. Not claimable for a trace that has been previously reported; or in association with a service to which 11700 applies.

Explanatory: A formal report is separate to any letter and entails interpretation of the trace commenting on the significance of the trace findings and their relationship to clinical decision making for the patient in their clinical context, in addition to any measurements taken or automatically generated.

Rationale

These recommendations focus on improving the value of the MBS and are based on the following observations.

  • ΔThe Committee agreed that a specialist review of an ECG trace that cannot be adequately interpreted by the referring clinician is a clinically valuable service, when referred in the appropriate circumstances.
  • ΔAs with item 11700, the Committee agreed that an ECG trace and report that is not readily available to other clinicians on request is of lower value. The trace and report should therefore be retained and readily available, or stored in an accessible location (e.g., via my Health Record), in order for the service to be claimable.
  • ΔThe Committee noted that there is a risk that providers could refer within a practice, and it recommended that this should be prevented. A provider could also misuse the item by setting up a service to accept high volumes of digital traces in order to produce high volumes of low-value reports. However, it was noted that there is no financial incentive for referring providers to write referrals for such services, and that the provision of incentives or application of pressure is illegal in contexts such as pathology and diagnostic imaging items. Furthermore, the providers would remain medico-legally responsible for the reports provided, which is a significant risk if simply signing off on automatically generated reports.
  • ΔThe Committee noted that in some private hospitals, there are wards or entire ‘niche hospitals’ where the nurses do not have the expertise to perform an ECG, and the hospital does not have the internal capability to perform an ECG. If ECGs are performed, such hospitals may also not have a doctor on site capable of interpreting them. The hospitals compensate for this by outsourcing this service to pathology providers. Several Committee members expressed strong concern that if there was no MBS funding for this, patients may not receive the appropriate care (for example, if they develop post-operative chest pain).
  • The Committee noted that all accredited GP clinics are required to be capable of performing an ECG, and stated that this should surely be a basic requirement for the accreditation and credentialing of a hospital. As noted in the recommendation from the Working Group, it was felt that a hospital should only outsource services when this is a more cost-effective solution for the hospital, and that this does not justify additional billings.

    The Committee determined that the recommendation should be amended to allow item 11701 to be retained for inpatient use as a referred service, not associated with consultation, or when a patient is seen by a provider who is capable of interpreting the ECG. The reporting provider should be external to the hospital and not involved in the care of the patient, with no financial or other incentives provided to the referring provider or hospital. This service is intended for patients with an unforeseen heart problem in a private hospital with no on-site cardiologist, or when the attending doctor wants a second opinion. The Committee felt that providing access to the reporting item may also reduce the volume of consults billed, which would be cost-effective as the schedule fee is considerably lower. It should be noted that this service should not be claimable for routine ECGs, including routine pre-operative ECGs.

7.5 ECG trace only

Current item descriptors and MBS data from FY 2014/15

Item 11702 – Schedule fee: $15.55
Services: 106,606  Total Benefits: $1,338,865  Average annual growth: 10.9%

Twelve-lead electrocardiography, tracing only

Public data from 2014-15 (Department of Human Services).

Recommendation 18
  • ΔAmend the descriptor for item 11702 to read:

Item 11702

Twelve-lead electrocardiography, tracing only, where the trace is clinically indicated to inform clinical decision making and where the trace is reviewed by the provider in a clinically appropriate timeframe.

Not claimable for a patient admitted to a hospital or attending a hospital for the purposes of routine pre-operative assessment.

Rationale

This recommendation focuses on improving the value of the MBS and promoting best practice care. It is based on the following observations.

  • ΔThe Committee acknowledged that (i) GPs provide a significant proportion of ECG services; (ii) the standard for accreditation requires ECG equipment to be present; and (iii) meeting accreditation standards is currently incentivised through the Practice Incentives Program (PIP). It felt that removing this item from the MBS may result in GPs no longer offering this service, which would mean that all services may become referred services, as occurred with joint injections. This would be detrimental to patients, providers and the health system. As a result, the Committee agreed that it is important to continue remunerating GPs for this service.
  • ΔIt was acknowledged that although taking an ECG trace is easier than with previous technologies, it still requires time (usually that of a practice nurse) and consumables. For this reason, the Committee did not recommend removing item 11702 from the MBS.
  • ΔThe Committee discussed whether it would be reasonable to consider an ECG an integral component of a specialist consultation, particularly a cardiologist consultation. Although it was acknowledged that many cardiologist consults do incorporate an ECG, the Committee agreed that the trace still takes time for the specialist or practice nurse to complete. For this reason, it felt that access to this item should not be restricted by provider type.
  • ΔThe Committee agreed that ECG traces should only be taken where clinically indicated, and to support clinical decision-making. Regardless of the clinical indication for an ECG, there is also a chance that a life-threatening abnormality may be detected. For these reasons, item 11702 should only be claimable if the provider has reviewed the trace. This does not require a formal report, but good clinical practice would include documentation of ECG findings in the patient’s medical record.
  • ΔThe Committee recommended that ECGs not be claimable for routine pre-operative ECGs as these are not evidence based and are not recommended practice(5660).

7.6 In-hospital ECG

Recommendation 19
  • ΔMake items 11700 and 11702 claimable only for patients not admitted to hospital.

Rationale

This recommendation focuses on improving the value of the MBS and is based on the following observations.

  • ΔThe Committee agreed that the costs of performing an ECG trace—including nurse time and consumable costs—are already included in the accommodation fee for an admission. It was agreed that the care of an admitted patient reasonably includes the review of ECG traces associated with that admission, and that items 11700 and 11702 should therefore not be claimed for an admitted patient. However, it was agreed that there may be instances where a provider requires a second opinion from a specialist on a non-routine inpatient trace (as described above), and that item 11701 should be retained for in-hospital use in these circumstances.
  • ΔConsideration was given to a potential exemption from this requirement for paediatric populations. Regarding the ECG trace, these costs are covered under the appropriate accommodation fees in an inpatient setting, and hospitals generally receive a paediatric loading to account for the higher care needs of these patients. Regarding the review of the trace to inform clinical decision-making, the Committee felt that this was not materially different (in terms of either time or skill) compared to when performed on an adult patient. Finally, it was noted that inpatient paediatric ECGs account for less than 0.05 per cent of services. Without significant evidence of a negative impact on patient outcomes, an exception would therefore be inappropriate.
  • ΔIt was noted that ECG reporting is frequently claimed for the review of traces taken in conjunction with pre-anaesthetic checks. The Committee agreed that anaesthetists should be capable of interpreting an ECG in the acute setting, and that these items should not be claimed for ECGs taken in association with a pre-anaesthetic check.

7.7 Repeat ECG services

Recommendation 20
  • ΔMake item 11701 claimable up to twice per day, where each service is clinically necessary.

Rationale

This recommendation focuses on improving the value of the MBS and is based on the following observations.

  • ΔThe Committee agreed that repeat ECGs are of lower value and should be restricted. However, it also noted the relatively low proportion of patients with same-day repeats (8 per cent) and acknowledged that there may be reasonable indications for this.
  • ΔIt was agreed that the majority of same-day and same-week repeat ECGs are inpatient services, which will be addressed through the above recommendations for items 11700 and 11702. For item 11701, the Committee noted that there are many instances in which multiple ECGs would be appropriate for a patient. However, it felt that it would be reasonable to cap the number of services that are claimable under the MBS, as is done in areas such as intensive care. The Committee agreed that where a subsequent trace is referred for specialist reporting, a formal report must be provided. The Committee also agreed that there should be a maximum of two services claimable per day, as a patient requiring multiple ECGs for ongoing symptoms should have the direct involvement of a clinician capable of managing the patient.
  • ΔThe Committee agreed that there is little value in screening ECGs in low-risk populations, and that such ECGs should not be funded by the MBS.
  • ΔIt was noted that repeated screening ECGs could provide some benefits to higher risk patient populations. For instance, the offspring of patients with inherited cardiac disease, such as hypertrophic obstructive cardiomyopathy (HOCM), may receive repeat ECGs as part of evidence-based cascade screening.
  • ΔThe Committee also reviewed the data presented on repeat ECG services performed in out-of-hospital settings (Figure 21). It noted that although fewer than 2 per cent of services are out-of-hospital same-day repeats, this still represents a significant volume of services (estimated 27,000 services) due to the volume of ECGs performed annually. Various clinical indications for repeat studies were discussed, and the Committee agreed that there are many clinical situations in which a same-day repeat ECG would be a clinically valuable service—for example, where a patient presents with a history of chest pain for review and is found to have a normal ECG, but returns later the same day in acute chest pain and is found to have ischaemic changes. The Committee therefore determined that a maximum of two services per day would be a reasonable limit. However, fewer than 3,000 services would be affected each year by a limit of two claims per patient per day. This would not justify the associated administrative costs and the Committee therefore agreed not to recommend a frequency restriction.

Figure 21: In‐hospital and out‐of‐hospital repeat ECG services


Figure 21 is a table that shows the rates of in-hospital and out-of-hospital repeat ECG services. There are 4 rows, out-of-hospital and in-hospital each have 2 sub rows that shows the occurrence whether it's same day or same week. There are 7 columns of data: Columns 1-6 show information on % of services by # of repeates within the period (same day or same week). Column 1 total services in sample population (2014/15) as % and count. Columns 2-6 show the percentage of services which are repeats broken down by number of repeats a patient recieves in the period (i.e. 1% of services same day out-of-hospital are episodes which contain 1 repeat same day). Column 7 shows the % of repeats for the row and number of services per year.

1 Sample population is all ECG trace and report services (item 11700) with date of service in 2014/15. Only includes 11700, excludes additional 11702 (trace only) which may have been performed in the same period. For patients who received both in-hospital and out-of-hospital services on the same day, these counted to their respective categories only. 2 All services except 1st in period by date of service. Trigger services rendered between 1 July 2014 and 30 June 2015 processed to 30 June 2016: Unpublished data from 2014-15 (Department of Health).



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