8. AECG and electrophysiology recommendations

8.1 AECG and Electrophysiology Working Group membership

The Committee formed a Working Group to consider the AECG and electrophysiology MBS items. This Working Group subsumed the AECG Review Working Group (AECG RWG), which was created prior to the MBS Review. The CSCC Working Group reviewed and accepted the AECG report, which was prepared under the direction of the AECG RWG (61). The AECG Review Report is available online at http://www.health.gov.au/internet/main/publishing.nsf/Content/ReviewsCMFM.

The AECG/EP Working Group included the following members:

  • ΔAssociate Professor Glenn Young (Chair) – Senior Clinical Lecturer, University of Adelaide; Electrophysiologist, Adelaide Cardiology.
  • ΔAssociate Professor Andrew McGavigan – Professor of Cardiology, Flinders University; Director of Arrhythmia Services, Flinders Medical Centre, South Australia; Chair EP and Pacing Council, CSANZ.
  • ΔDr David O’Donnell – Director of Electrophysiology, Austin Hospital.
  • ΔDr Elizabeth Marles – Director of Hornsby Brooklyn General Practice Unit. Immediate Past President of the Royal Australian College of General Practitioners (RACGP).
  • ΔDr Hans Tu – Consultant Neurologist, Footscray Hospital and Sunshine Hospital; Research Fellow, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne.
  • ΔAssociate Professor Harry Mond – Medical Director Cardioscan Pty Ltd.
  • ΔMs Karen Carey – Member, National Health and Medical Research Council (NHMRC) & Chair, Community and Consumer Advisory Group; Consumer representative.
  • ΔDr Paresh Dawda – GP and Regional Medical Director, Ochre Health; Honorary Associate Professor, Australian National University (ANU) and the University of Canberra.
  • ΔProfessor Richard Harper – Emeritus Director of Cardiology, Monash Medical Centre; Adjunct Professor of Medicine, Monash University (Ex-Officio).

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

The Committee also endorsed the recommendations unanimously.

8.2 AECG

8.2.1 Item 11708

Current item descriptors and MBS data from FY 2014/15

Item 11708 – Schedule fee: $127.90
Services: 6,216  Total Benefits: $649,412  Average annual growth: 21.7%

Continuous ECG recording of ambulatory patient for 12 or more hours (including resting EECG and the recording of parameters), not in association with ambulatory blood pressure monitoring, involving microprocessor based analysis equipment, interpretation and report of recordings by a specialist physician or consultant physician. Not being a service to which item 11709 applies. The changing of a tape or batteries does not constitute a separate service. Where a recording is analysed and reported on and a decision is made to undertake a further period of monitoring, the second episode is regarded as a separate service.

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

Recommendation 21
  • ΔObsolete – remove item 11708 from the MBS.

Rationale

This recommendation focuses on modernising the MBS and is based on the following observations.

  • ΔThere was consensus that item 11708 should be considered obsolete and removed from the MBS, with the expectation that providers will use item 11709 instead.
  • ΔThe Committee noted that use of items 11708 and 11709 has grown significantly since FY2010/11: 22 per cent annual growth for item 11708, and 11 per cent annual growth for item 11709. However, it was suggested that some providers were using item 11708 in error, instead of item 11709.

8.2.2 Item 11709

Current item descriptors and MBS data from FY 2014/15

Item 11709 – Schedule fee: $167.45
Services: 277,643  Total Benefits: $39,795,143  Average annual growth: 10.9%

Continuous ECG recording (Holter) of ambulatory patient for 12 or more hours (including resting ECG and the recording of parameters), not in association with ambulatory blood pressure monitoring, utilising a system capable of superimposition and full disclosure printout of at least 12 hours of recorded ECG data, microprocessor based scanning analysis, with interpretation and report by a specialist physician or consultant physician. The changing of a tape or batteries does not constitute a separate service. Where a recording is analysed and reported on and a decision is made to undertake a further period of monitoring, the second episode is regarded as a separate service.

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

Recommendation 22
  • ΔAmend the descriptor for item 11709 to read:

Item 11709

Continuous ECG recording of a patient who is not admitted to an acute hospital, for 12 or more hours (including resting ECG and the recording of parameters), not in association with ambulatory blood pressure monitoring, utilising a system capable of superimposition and full disclosure printout of at least 12 hours of recorded ECG data, microprocessor based scanning analysis, with interpretation and report by a specialist physician or consultant physician.

For the evaluation of syncope, pre-syncopal episodes or palpitations where episodes are occurring greater than once a week or where another asymptomatic arrhythmia is suspected with an expected frequency of greater than once a week. With documentation of the indication for the investigation in the report.


Claimable once in any 4-week period.

Explanatory notes: The following indications would be considered appropriate even in patients who may not experience symptoms more often than once a week.

  1. For the detection of asymptomatic atrial fibrillation (AF) following a transient ischaemic attack (TIA) or cryptogenic stroke.
  2. For the surveillance of paediatric patients following cardiac surgeries that have an established risk of causing dysrhythmia.
  3. For young children and other patients where a cardiac dysrhythmia is suspected, but due to the patient’s age, cognitive capacity or expressive language impairment, it is not possible to accurately assess symptom frequency based on medical history.

The frequency restriction does not apply to paediatric patients as it is acknowledged that response to medications may be monitored at shorter intervals than in adults and these patients are often too young to describe their symptoms.

  • ΔInclude an exception to the “once in any four-week period” restriction for paediatric patients, as this service is used more frequently to assess medication responses in children who are too young to provide symptom information. This should be added to the descriptor or explanatory notes.

Rationale

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

  • ΔThe Committee discussed the possibility of restricting the indications for AECG but ultimately agreed that this investigation is useful for a broad range of indications. It is not practical to list specific indications, but the Committee agreed that if symptoms are infrequent, the yield and value of the test decreases significantly and alternate longer term monitoring should be used. It also noted that repeat studies are of low yield and value and should not be performed.
  • ΔThe revised descriptor reflects contemporary clinical practice, allowing for studies that last longer than 48 hours if necessary. Repeat studies within 24 hours of a negative result are low yield and of low clinical value, and the Committee agreed that these should not be reimbursed.
  • ΔThe Committee agreed that due to the short duration of monitoring for this AECG service, symptoms/episodes should be appropriately frequent in order to improve the yield of the service. Drawing on their clinical judgement, Committee members felt that it was reasonable to require that episodes occur at least two to three times per week. There will be other relevant clinical indications, and these should be included in the explanatory notes:
    • – For the detection of asymptomatic atrial fibrillation (AF) following a transient ischaemic attack (TIA) or cryptogenic stroke.
    • – For the surveillance of paediatric patients following cardiac surgeries that have an established risk of causing dysrhythmia.
    • – For young children and other patients where a cardiac dysrhythmia is suspected, but due to the patient’s age, cognitive capacity or expressive language impairment, it is not possible to accurately assess symptom frequency based on medical history.
  • ΔThere was consensus that restricting the frequency of testing to once in a four-week period would not adversely affect patient outcomes. Although a longer period of exclusion is appropriate in many cases, there may be instances where a repeat study at four weeks would be clinically useful, such as monitoring rate control in atrial fibrillation following medication changes. In FY 2014/15, 13 per cent of repeat AECG claims occurred within four weeks, with a further 30 per cent occurring in each of the following intervals: one to six months, 6 to 12 months and 12 to 18 months.
  • ΔA concern was raised that repeat studies in less than four weeks may be more common in the paediatric population. Data reveals similar rates of repeat studies in less than four weeks, compared to the adult population, but paediatric cardiologists felt that these services were clinically valuable (Table 16: Paediatric repeat holter monitor services). The Committee sought input from colleagues who specialise in paediatric arrhythmias, and in their clinical judgment, an exception should be created for children up to and including primary school age.

Table 16: Paediatric repeat holter monitor services (items 11709)

0-4yrs 5-14yrs
Services 1,529 4,491
% of services that are repeats 43% 17%
% of services that are repeats within four weeks 10% 15%

Data is by date of service. Unpublished data from 2014-15 (Department of Health).

  • ΔIf an AECG study produces a negative result, the Committee agreed that repeat studies are exceedingly low yield. However, it was acknowledged that there may be instances where a provider chooses to discretionally conduct a study for less than 48 hours. For this reason, the Committee recommended that no maximum duration should be specified in the descriptor. Studies that last longer than 48 hours should not be claimed multiple times, as these repeats do not reflect value for patients or the health system. If further monitoring after a negative study is required, providers should consider the utility of external loop recorders (ELR; item 11710) or implanted loop recorders (ILR) to facilitate monitoring in the longer term.
  • ΔThis investigation is intended for outpatient use. It is not intended for inpatients, including patients on cardiac monitoring or telemetry. It was noted that some patients (such as post-syncope patients) benefit from cardiac monitoring, which is sometimes provided by private hospitals by outsourcing a Holter monitor service to a pathology provider. The Committee agreed that inpatients requiring cardiac monitoring can be remunerated through other mechanisms, and that these funds should be used to cover any provider outsourcing of this monitoring.
  • ΔThe Committee discussed the implications of device failure during a study, including the implications for the consumer. There was consensus that device failure should render a service incomplete, which means that it is not claimable on the MBS. The provider should repeat the service, and the patient should incur no additional out-of-pocket costs. Members who have worked extensively with pathology providers indicated that this is already the standard and accepted practice among such providers.
  • ΔThe Committee considered whether rural and remote areas could be disadvantaged by the proposed changes to this item, due to an inability to access longer term monitoring. Figure 22 shows that with the exception of very remote areas, remoteness does not significantly affect per-capita service rates. Furthermore, performing a short-term monitoring study on a patient with infrequent symptoms was felt to be clinically inappropriate, inconvenient for the patient and of low value and it may result in a missed diagnosis or repeat testing if an appropriate service is not performed. Providers in rural and remote areas who use Holter studies for longer term monitoring of patients with infrequent symptoms will now be incentivised to provide ELR and ILR as longer term options. Where a remote provider is unable or unwilling to do so, it is in the patient’s best interests to receive the appropriate investigation at the nearest available location.

Figure 22: Geographical variation by remoteness for different durations of AECG monitoring items


Figure 22 is a stacked bar chart that shows the geographical variation by remoteness for different durations of AECG monitoring items. Major cities has the highest percentage of services for all short, medium, and long term items at 68%, 75% and 70% respectively. Inner regional areas are second at 22%, 15% and 21%. Remote and very remote areas is the lowest at nothing over 1%.

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. AECG items, 11709, ELR item 11711, ILR item 11722.

8.3 External loop/event recorder (ELR)

8.3.1 Item 11710

Current item descriptors and MBS data from FY 2014/15

Item 11710 – Schedule fee: $51.90
Services: 4,308  Total Benefits: $199,735  Average annual growth: 5.2%

Ambulatory ECG monitoring, patient activated, single or multiple event recording, utilising a looping memory recording device which is connected continuously to the patient for 12 hours or more and is capable of recording for at least 20 seconds prior to each activation and for15 seconds after each activation, including transmission, analysis, interpretation and report — payable once in any 4 week period

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

Recommendation 23
  • ΔSplit item 11710 into two items, with the following descriptors:

Item 11710A

Ambulatory ECG monitoring, patient activated, single or multiple event recording, utilising a memory recording device which is connected continuously to the patient for between 7 and 30 days and is capable of recording for at least 20 seconds prior to each activation and for 15 seconds after each activation. Including transmission, analysis, interpretation and report.

For the investigation of recurrent episodes of unexplained syncope, palpitation or other symptoms where a cardiac rhythm disturbance is suspected and where episodes are infrequent. With documentation of the indication for the investigation in the report.

Claimable once in any 3-month period.

Item 11710B

Ambulatory ECG monitoring, patient activated, single or multiple event recording, utilising a memory recording device which is connected continuously to the patient for up to 7 days and is capable of recording for at least 20 seconds prior to each activation and for 15 seconds after each activation. Including transmission, analysis, interpretation and report.

For the investigation of recurrent episodes of unexplained syncope, palpitation or other symptoms where a cardiac rhythm disturbance is suspected and where episodes occur at least weekly. With documentation of the indication for the investigation in the report.

Claimable once in any 3 month period.

  • ΔRemove 75 per cent benefit from item 11710 (or 11710A and 11710B if split) as the service is intended for patients not admitted to a hospital.

Rationale

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

  • ΔThe Committee agreed that it was important for the indications for ELR services to remain broad, in order to reflect the wide variety of potential situations for which this investigation is appropriate.
  • ΔAs with other AECG items, the Committee agreed that this investigation is intended for outpatient use. It is not intended for inpatients, including patients on cardiac monitoring or telemetry.
  • ΔThe Committee felt that repeat studies were of low clinical value. Various situations that may trigger a repeat study were discussed, and it was agreed that the three-month timeframe is reasonable and will not have a negative impact on patient outcomes.
  • ΔA specific concern was raised about patients with very frequent symptoms who may fill a device in a short period of time and require a repeat study in order to complete their seven-day monitoring. However, there was clinical consensus that symptom/ECG correlation could be assessed based on the many captured episodes, and that further monitoring was unlikely to yield new information.
  • ΔThe Committee agreed that due to the costs associated with holding and losing equipment, these services are often low-profit or loss-making services. As such, misuse is highly unlikely.
  • ΔIt was agreed that the rebate for item 11710A should be slightly higher due to the longer period of monitoring and additional data for reporting.

8.3.2 Item 11711

Current item descriptors and MBS data from FY 2014/15

Item 11711 – Schedule fee: $28.30
Services: 813  Total Benefits: $21,622  Average annual growth: 20.4%

Ambulatory ECG monitoring for 12 hours or more, patient activated, single or multiple event recording, utilising a memory recording device which is capable of recording for at least 30 seconds after each activation, including transmission, analysis, interpretation and report — payable once in any 4 week period

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

Recommendation 24
  • ΔObsolete – remove item 11711 from the MBS.

Rationale

This recommendation focuses on modernising the MBS and is based on the following observation.

  • ΔThe Committee agreed that item 11711 is used for devices that lack the ability to provide pre-event recording, rendering the item obsolete. There was consensus that this item should be removed from the MBS, and that providers should use item 11710 instead. The Committee felt that these devices add negligible clinical value and could delay or prevent the use of appropriate contemporary investigations.

8.4 Implanted loop recorder (ILR)

8.4.1 Item 11722

Current item descriptors and MBS data from FY 2014/15

Item 11722 – Schedule fee: $34.75
Services: 7,076  Total Benefits: $212,526  Average annual growth: 27.8%

Implanted ECG loop recording for the investigation of recurrent unexplained syncope if: (a) a diagnosis has not been achieved through all other available cardiac investigations; and (b) a neurogenic cause is not suspected; and (c) the patient to whom the service is provided does not have a structural heart defect associated with a high risk of sudden cardiac death; including reprogramming when required, retrieval of stored data, analysis, interpretation and report, not being a service to which item 38285 applies

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

Recommendation 25
  • ΔRestrict the claiming frequency of item 11722 to once per month.

Rationale

This recommendation focuses on modernising the MBS and is based on the following observation.

  • ΔAnalysis of the intervals between repeat studies (up to 18 months) showed that 4 per cent of repeat studies occurred within an interval of less than four weeks in FY 2014/15(9). However, there is a risk that future technologies that enable the live download of data from devices—some of which are already in use—may increase short interval repeat claiming. For this reason, it is recommended that claiming is restricted to once per month. It was agreed that this frequency is reasonable and will not have negative impacts on patient outcomes.

8.4.2 Item 38285

Current item descriptors and MBS data from FY 2014/15

Item 38285 – Schedule fee: $192.90
Services: 1,944  Total Benefits: $262,258  Average annual growth: 29.6%

Implantable ecg loop recorder, insertion of, for diagnosis of primary disorder in patients with recurrent unexplained syncope where: - a diagnosis has not been achieved through all other available cardiac investigations; and - a neurogenic cause is not suspected; and - it has been determined that the patient does not have structural heart disease associated with a high risk of sudden cardiac death. Including initial programming and testing, as an admitted patient in an approved hospital (Anaes.)

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

Recommendation 26
  • ΔAmend the descriptor of item 38285 as proposed below, removing “as an admitted patient in an approved hospital” if an exception is granted by the Prostheses List to allow for outpatient claiming.

Item 38285

Implantable ECG loop recorder, insertion by a specialist or consultant physician, for diagnosis of primary disorder in patients with recurrent unexplained syncope where:

  • – A diagnosis has not been achieved through all other available cardiac investigations; and
  • – A neurogenic cause is not suspected; and
  • – It has been determined that the patient does not have structural heart disease associated with a high risk of sudden cardiac death.

Including initial programming and testing, and documentation of the indication for the investigation in the procedure report. (Anaes.)

  • ΔReview the schedule fee for item 38285 in light of new technology.

Rationale

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

  • ΔThis item remains clinically valuable, and the Committee felt that the growth in service volumes reflects previously unmet need in the community.
  • ΔPreviously, the devices required operative insertion at the level of the pectoralis muscle, with closure in two layers. However, improvements in technology have enabled the safe and effective insertion of ILRs subcutaneously. As a result, requiring patient admission (“as an admitted patient”) now serves only to increase the overall financial cost to the health system and adds no clinical value. In order to address this, an exemption would need to be granted by the Prostheses List to allow ILRs to be claimed when not performed in hospital. Without this exception, a significant financial burden would be imposed on the patient or provider when IRLs were inserted as an outpatient service. It should be noted that paediatric patients often have these devices injected under general anaesthetic, and it is therefore recommended that anaesthetic approval be retained.
  • ΔIn light of the significantly reduced insertion time (a decrease from around one hour to routinely 5–10 minutes), the Committee agreed that the schedule fee for this item should be reviewed to reflect contemporary service requirements.
  • ΔThe Committee noted that this service is used to investigate neurocardiogenic syncope and agreed that this is likely to be clinically appropriate. The current descriptors and indication restrictions are new and are based on a recent review of the evidence conducted by the MSAC. Cryptogenic stroke is currently undergoing MSAC review, and consideration of this issue is therefore beyond the scope of the MBS Review. The Committee acknowledged that the current restriction on accessibility is partly due to the significant cost associated with inserting a new device, and that there is a need to restrict access to cases where there is high clinical value. This cost–benefit ratio may change over time as the cost of both the device and insertion decline.

8.4.3 Item 38286

Current item descriptors and MBS data from FY 2014/15

Item 38286 – Schedule fee: $173.75
Services: 573  Total Benefits: $52,095  Average annual growth: 14.2%

Implantable ecg loop recorder, removal of, as an admitted patient in an approved hospital (Anaes.)

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

Recommendation 27
  • ΔAmend the descriptor of item 38286 as proposed below, removing the following text: “as an admitted patient in an approved hospital.”

Item 38286

Implantable ECG loop recorder, removal of. (Anaes.)

  • ΔReview the schedule fee for this item in light of new technology.

Rationale

These recommendations focus on modernising the MBS and are based on the following observations.

  • ΔIt is now possible to safely remove devices that have been implanted subcutaneously in the outpatient setting for adult patients. Inpatient removal continues to be best practice for the removal of older devices, however, which are implanted at the level of the pectoralis muscle.
  • ΔAs with ILRs, the amount of time required to remove devices has decreased, although less markedly. The schedule fee for this item should therefore be reviewed to reflect contemporary service requirements.

8.5 Cardiac resynchronisation device

Current item descriptors and MBS data from FY 2014/15

Item 38365 – Schedule fee: $255.45
Services: 401  Total Benefits: $33,080  Average annual growth: 11.4%

Permanent cardiac synchronisation device (including a cardiac synchronisation device that is capable of defibrillation), insertion, removal or replacement of, for a patient who: (a) has: (i) moderate to severe chronic heart failure (new york heart association (nyha) class iii or iv) despite optimised medical therapy; and (ii) sinus rhythm; and (iii) a left ventricular ejection fraction of less than or equal to 35%; and (iv) a qrs duration greater than or equal to 120 ms; or (b) satisfied the requirements mentioned in paragraph (a) immediately before the insertion of a cardiac resynchronisation therapy device and transvenous left ventricle electrode (Anaes.)

Item 38368 – Schedule fee: $1224.60
Services: 1,224  Total Benefits: $915,492  Average annual growth: 10.4%

Permanent transvenous left ventricular electrode, insertion, removal or replacement of through the coronary sinus, for the purpose of cardiac resynchronisation therapy, including right heart catheterisation and any associated venogram of left ventricular veins, other than a service associated with a service to which item 35200 or 38200 applies, for a patient who: (a) has: (i) moderate to severe chronic heart failure (new york heart association (nyha) class iii or iv) despite optimised medical therapy; and (ii) sinus rhythm; and (iii) a left ventricular ejection fraction of less than or equal to 35%; and(iv) a qrs duration greater than or equal to 120 ms; or (b) has: (i) mild chronic heart failure (new york heart association (nyha) class ii) despite optimised medical therapy; and (ii) sinus rhythm; and (iii) a left ventricular ejection fraction of less than or equal to 35%; and(iv) a qrs duration greater than or equal to 150 ms; or (c) satisfied the requirements mentioned in paragraph (a) or (b) immediately before the insertion of a cardiac resynchronisation therapy device and transvenous left ventricle electrode (Anaes.)

Item 38371 – Schedule fee: $287.85
Services: 1,125  Total Benefits: $95,066  Average annual growth: 11.4%

Permanent cardiac synchronisation device capable of defibrillation, insertion, removal or replacement of, for a patient who:(a) has:(i) moderate to severe chronic heart failure (new york heart association (nyha) class iii or iv) despite optimised medical therapy; and (ii) sinus rhythm; and (iii) a left ventricular ejection fraction of less than or equal to 35%; and (iv) a qrs duration greater than or equal to 120 ms; or (b) has:(i) mild chronic heart failure (new york heart association (nyha) class ii) despite optimised medical therapy; and (ii) sinus rhythm; and (iii) a left ventricular ejection fraction of less than or equal to 35%; and(iv) a qrs duration greater than or equal to 150 ms (Anaes.)

Item 38654 – Schedule fee: $1224.60
Services: 46  Total Benefits: $29,598  Average annual growth: -2.4%

Permanent left ventricular electrode, insertion, removal or replacement of via open thoracotomy, for the purpose of cardiac resynchronisation therapy, for a patient who:(a) has:(i) moderate to severe chronic heart failure (new york heart association (nyha) class iii or iv) despite optimised medical therapy; and (ii) sinus rhythm; and (iii) a left ventricular ejection fraction of less than or equal to 35%; and (iv) a qrs duration greater than or equal to 120 ms; or(b) has:(i) mild chronic heart failure (new york heart association (nyha) class ii) despite optimised medical therapy; and (ii) sinus rhythm; and (iii) a left ventricular ejection fraction of less than or equal to 35%; and (iv) a qrs duration greater than or equal to 150 ms; or (c) satisfied the requirements mentioned in paragraph (a) or (b) immediately before the insertion of a cardiac resynchronisation therapy device and transvenous left ventricle electrode (Anaes.) (Assist.)

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

Recommendation 28.1
  • ΔAllow items 38365 and 38368 to include an assistant.
Recommendation 28.2
  • ΔRemove “sinus rhythm” from the inclusion criteria for items 38365 and 38368; and
  • ΔAmend the descriptor for items 38365 and 38368 to read:

Item 38368

Permanent transvenous left ventricular electrode, insertion, removal or replacement of via the coronary sinus, including right heart catheterisation and any associated venograms, not associated with service to which item 35200, 38200 or 38212 applies, for a patient with:

  • ΔChronic heart failure of NYHA class III or IV (despite optimised medical therapy), LVEF less than 35% and QRS duration of greater than or equal to 130ms.
  • ΔChronic heart failure of NYHA class II (despite optimised medical therapy), LVEF less than 35% and QRS duration of greater than or equal to 150ms. (Anaes.) (Assist.)

Item 38365

  • ΔPermanent cardiac resynchronisation device, insertion, removal or replacement, not being a service for which item 38212 applies, for a patient with:
    • – Chronic heart failure of NYHA class III or IV (despite optimised medical therapy), LVEF less than 35% and QRS duration of greater than or equal to 130ms.
    • – Chronic heart failure of NYHA class II (despite optimised medical therapy), LVEF less than 35% and QRS duration of greater than or equal to 150ms. (Anaes.) (Assist.)
Recommendation 28.3
  • ΔRemove item 38371 from the MBS as the above changes render it redundant.
  • ΔConsolidate items 38654, 38470 and 38473 into a single item (detailed in surgical recommendation 52).

Rationale

These recommendations focus on simplifying the MBS and updating the indication criteria to align with contemporary clinical practice and international guidelines. They are based on the following observations.

  • ΔRemoving “sinus rhythm” from the inclusion criteria aligns with many international clinical guidelines.
  • ΔThe Committee agreed that the majority of patients who may not be in sinus rhythm would already receive this item, having been classified as having “paroxsymal AF.” There is good non-randomised evidence to support the use of cardiac resynchronisation devices in this population(62). The Committee noted that it was aware of patients who underwent direct-current (DC) cardioversion to regain sinus rhythm in order to meet the criteria for these items. It also noted that although 30 per cent of the target patient population has atrial fibrillation, many of these patients are already receiving these services. It would therefore be reasonable to expect that this change would increase volumes by 10 per cent to 20 per cent. It was noted that such a change may impact the cost-effectiveness of the service, and that this may not be acceptable.

    However, if the change improves the cost-effectiveness of the service, a specific note could be added specifying that AF was not an exclusion, instead of removing the sinus rhythm requirement. This would retain an exclusion for patients with other arrhythmias. The Committee felt that this change should be considered for an expedited MSAC review. During such a review, it may be worth considering the latest evidence on QRS duration, noting that new evidence has emerged supporting a higher requirement, as procedures in patients with a QRS of less 130 ms are potentially harmful (63).
  • ΔThe Committee agreed that items 38365 and 38368 are similar to or more complex than item 38654 and should be permitted to use an assistant.
  • ΔThe Committee agreed that the descriptor for item 38470 allows for all instances covered by item 38654, and that these items should be consolidated to simplify the MBS. Both procedures are performed almost entirely by cardiothoracic surgeons.

8.6 Electrophysiological studies

Current item descriptors and MBS data from FY 2014/15

Item 38209 – Schedule fee: $825.15
Services: 684  Total Benefits: $333,551  Average annual growth: 0.8%

Cardiac electrophysiological study up to and including 3 catheter investigation of any 1 or more of syncope, atrioventricular conduction, sinus node function or simple ventricular tachycardia studies, not being a service associated with a service to which item 38212 or 38213 applies (Anaes.)

Item 38212 – Schedule fee: $1372.45
Services: 10,685  Total Benefits: $7,956,396  Average annual growth: 8.1%

Cardiac electrophysiological study 4 or more catheter supraventricular tachycardia investigation; or complex tachycardia inductions, or multiple catheter mapping, or acute intravenous antiarrhythmic drug testing with pre and post drug inductions; or catheter ablation to intentionally induce complete AV block; or intraoperative mapping; or electrophysiological services during defibrillator implantation or testing not being a service associated with a service to which item 38209 or 38213 applies (Anaes.)

Item 38213 – Schedule fee: $408.70
Services: 90  Total Benefits: $27,524  Average annual growth: -24%

Cardiac electrophysiological study, for follow-up testing of implanted defibrillator - not being a service associated with a service to which item 38209 or 38212 applies (Anaes.)

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

Recommendation 29.1
  • ΔLeave item 38209 unchanged.
Recommendation 29.2
  • ΔAmend the descriptors of items 38212 and 38213 as described below:

Item 38212

Cardiac electrophysiological study involving 4 or more catheters for:

  1. (a) Supraventricular tachycardia investigation; or
  2. (b) Complex tachycardia inductions; or
  3. (c) Multiple catheter mapping, or
  4. (d) Acute intravenous antiarrhythmic drug testing with pre and post drug inductions; or
  5. (e) Catheter ablation to intentionally induce complete AV block; or
  6. (f) Intraoperative mapping.

Not being a service associated with a service to which item 38209 or 38213 applies. (Anaes.)

Item 38213

Cardiac electrophysiological study performed during the insertion of an implantable defibrillator or for defibrillation threshold testing at a time remote to implantation.

Not being a service associated with a service to which item 38209 or 38212 applies. (Anaes.)

Rationale

These recommendations focus on modernising the MBS and are based on the following observations.

  • ΔItem 38212 is clinically excessive for the purpose of defibrillator testing and has become significantly less common in contemporary practice. There was clinical consensus that the item is an historical legacy, and that this is now a very quick procedure that would be more appropriate under item 38213. Removal of this indication from item 38212 requires its addition to item 38213, in order to account for the instances where testing is still required. Testing at the time of insertion should be claimed as item 38213, when needed.
  • ΔThere is no expected change in the total number of services, but a small volume shift between items 38212 and 38213 is expected.
  • ΔService volumes for item 38212 have been growing at 8 per cent per year for the last five years. The Committee considered this data and felt that the population had been under-serviced historically, in which case this may be ‘catch-up’ growth. Access may also have improved in regional areas such as Far North Queensland (FNQ), further contributing to increased volumes.

8.7 Implantable cardiac defibrillator (ICD)

Current item descriptors and MBS data from FY 2014/15

Item 11725 – Schedule fee: $189.50
Services: None  Total Benefits: None  Average annual growth: N/A

Implanted defibrillator (including Cardiac Resynchronisation Defibrillator) remote monitoring involving reviews (without patient attendance) of arrhythmias, lead and device parameters, if at least 2 remote reviews are provided in a 12 month period. Payable only once in any 12 month period.

Item 11726 – Schedule fee: $94.75
Services: None  Total Benefits: None  Average annual growth: N/A

Implanted defibrillator testing with patient attendance following detection of abnormality by remote monitoring involving electrocardiography, measurement of rate, width and amplitude of stimulus, not being a service associated with a service to which item 11727 applies.

Item 11727 – Schedule fee: $94.75
Services: 49,842  Total Benefits: $4,017,423  Average annual growth: 11.2%

Implanted defibrillator testing involving electrocardiography, assessment of pacing and sensing thresholds for pacing and defibrillation electrodes, download and interpretation of stored events and electrograms, including programming when required, not being a service associated with a service to which item 11700, 11718, 11719, 11720, 11721, 11725 or 11726 applies

Item 38384 – Schedule fee: $1052.65
Services: 1,327  Total Benefits: $610,471  Average annual growth: 9.3%

Automatic defibrillator, insertion of patches for, or insertion of transvenous endocardial defibrillation electrodes for, primary prevention of sudden cardiac death in: - patients with a left ventricular ejection fraction of less than or equal to 30% at least one month after a myocardial infarct when the patient has received optimised medical therapy; or - patients with chronic heart failure associated with mild to moderate symptoms (nyha ii and iii) and a left ventricular ejection fraction less than or equal to 35% when the patient has received optimised medical therapy. Not being a service associated with a service to which item 38213 applies (Anaes.) (Assist.)

Item 38387 – Schedule fee: $287.85
Services: 916  Total Benefits: $90,551  Average annual growth: 8.4%

Automatic defibrillator generator, insertion or replacement of for, primary prevention of sudden cardiac death in: - patients with a left ventricular ejection fraction of less than or equal to 30% at least one month after a myocardial infarct when the patient has received optimised medical therapy; or - patients with chronic heart failure associated with mild to moderate symptoms (nyha ii and iii) and a left ventricular ejection fraction less than or equal to 35% when the patient has received optimised medical therapy. Not being a service associated with a service to which item 38213 applies, not for defibrillators capable of cardiac resynchronisation therapy (Anaes.) (Assist.)

Item 38390 – Schedule fee: $1052.65
Services: 975  Total Benefits: $494,751  Average annual growth: 4.9%

Automatic defibrillator, insertion of patches for, or insertion of transvenous endocardial defibrillation electrodes for - not for patients with heart failure or as primary prevention for tachycardia arrhythmias. Not being a service associated with a service to which item 38213 applies (Anaes.) (Assist.)

Item 38393 – Schedule fee: $287.85
Services: 1,272  Total Benefits: $132,218  Average annual growth: 2.7%

Automatic defibrillator generator, insertion or replacement of for - not for patients with heart failure or as primary prevention for tachycardia arrhythmias. Not being a service associated with a service to which item 38213 applies. (Anaes.) (Assist.)

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

Recommendation 30.1
  • ΔConsolidate items 38384 and 38390, using the following descriptor:

Item 38384X

Implantable defibrillator, insertion of patches for, insertion of transvenous endocardial or extravascular lead in patients with at least one of:

  1. A history of haemodynamically significant ventricular arrhythmias in the presence of structural heart disease; or
  2. Documented high-risk genetic cardiac disease; or
  3. Ischaemic heart disease, LVEF of less than 30% at least one month after myocardial infarction and on optimised medical therapy; or
  4. Patients with chronic NYHA class II or III heart failure, with LVEF less than 35% despite optimised medical therapy.

Not being a service to which item 38212 applies. (Anaes.) (Assist.)

Recommendation 30.2
  • ΔConsolidate items 38387 and 38393 with the following descriptor:

Item 38387X

Implantable defibrillator generator, insertion, replacement or removal, for patients with at least one of:

  1. A history of haemodynamically significant ventricular arrhythmias in the presence of structural heart disease; or
  2. Documented high-risk genetic cardiac disease; or
  3. Ischaemic heart disease, LVEF of less than 30%, at least one month after myocardial infarction and on optimised medical therapy; or
  4. Patients with chronic NYHA class II or III heart failure, with LVEF less than 35% despite optimised medical therapy.

Not being a service to which item 38212 applies. (Anaes.) (Assist.)

Recommendation 30.3
  • ΔAmend the descriptor for item 11727 to specify that it can only be claimed when the doctor is immediately available, and can directly review the patient and can have an impact on patient outcomes.

Item 11727

Implanted defibrillator testing involving electrocardiography, assessment of pacing and sensing thresholds for pacing and defibrillation electrodes, download and interpretation of stored events and electrograms, including programming when required. Performed where a medical practitioner is immediately available to attend the patient and where such testing is clinically indicated.

Not being a service associated with a service to which item 11700, 11718, 11719, 11720, 11721, 11725 or 11726 applies.

Recommendation 30.4
  • ΔItems 11725 and 11726 for remote monitoring were recently added to the MBS and were therefore agreed to be beyond the scope of this review.

Rationale

These recommendations focus on simplifying the MBS and aligning descriptors with contemporary clinical practice. They are based on the following observations.

  • ΔAdding “high-risk genetic cardiac disease” to the scope of these items is recommended to align the descriptors with contemporary practice. Class 2A or class 1 recommendations exist for this, as reflected in the current CSANZ guidelines (64,65). As new risk markers develop every few years, overly prescriptive descriptors may rapidly become obsolete. The proposed wording allows for future flexibility. The Committee felt that the small number of patients in this category are already being billed under current MBS items, and that budgetary impacts would be minimal as a result.
  • ΔThe Committee discussed the role of subcutaneous/extravascular lead insertion in relation to items 38384 and 38390. This issue has been recently reviewed by the MSAC, and the original applicants are required to resubmit a new application to the MSAC if new data becomes available to support the service. In light of the recent MSAC review, the Committee agreed that further recommendations on this topic were beyond the scope of the MBS Review.
  • ΔThe Committee agreed that in the public health system, it is already standard practice for a doctor to be immediately available during the provision of implanted cardiac defibrillator testing. It agreed that this is appropriate to carry across to private practice.

8.8 Ablation of accessory pathways

Current item descriptors and MBS data from FY 2014/15

Item 38287 – Schedule fee: $2098.45
Services: 4,183  Total Benefits: $6,821,196  Average annual growth: 6.8%

Ablation of arrhythmia circuit or focus or isolation procedure involving 1 atrial chamber (Anaes.) (Assist.)

Item 38290 – Schedule fee: $2671.95
Services: 3,072  Total Benefits: $6,149,831  Average annual growth: 15.1%

Ablation of arrhythmia circuits or foci, or isolation procedure involving both atrial chambers and including curative procedures for atrial fibrillation (Anaes.) (Assist.)

Item 38293 – Schedule fee: $2868.05
Services: 450  Total Benefits: $981,898  Average annual growth: 16.5%

Ventricular arrhythmia with mapping and ablation, including all associated electrophysiological studies performed on the same day (Anaes.) (Assist.)

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

Recommendation 31
  • ΔLeave items 38287, 38290 and 38293 unchanged.

Rationale

These recommendations focus on ensuring the MBS is in line with contemporary practice and are based on the following observations.

  • ΔThe Committee agreed that atrial flutter is one of the supraventricular tachycardia (SVT) indications for item 38287 and clinically does not warrant a unique item number. Although some ablations for flutter are simple, some single-chamber ablations are more complicated. However, it was felt that the brevity of flutter ablations is balanced by more complex single-chamber ablations, and that there is no evidence of any issue that necessitates a review of the item.
  • ΔThe Committee felt that the considerable growth in use of these items (Figure 23) reflected (i) the increasing number of electrophysiologists, which is improving access to services; and (ii) a change in clinical guidelines, which now identify ablation as a first-line treatment for a number of arrhythmias.
  • ΔAlthough there has been considerable growth in use of item 38293, this is a significant procedure and there was clinical consensus that no one would perform it unnecessarily. Furthermore, changes in clinical guidelines mean that ablation is now a first-line treatment, and it is likely that this is driving increased use of this item.
  • ΔThe AECG and Electrophysiology Working Group considered the items for division of accessory pathways however surgeons account for 90 per cent of claims for items 38512 and 38515. For this reason, these items were referred to the Cardiac Surgical Working Group for consideration and are discussed in Section 9.5.4. Item 38518 only had 2 services in 2014/15 and was thought to be potentially obsolete, however was also referred to the Cardiac Surgical Working Group for review and retained as outlined in Section 9.5.4.

Figure 23: Growth of ablation services over five years (includes items 38387, 38290, 38293)


Figure 23 is an area chart for growth of ablation services over 5 years. The y-axis is for the number of services by thousands and the x-axis is for the financial year commencing 2009/10 to 2014/15. The number of services has increased at an average of 10% per year. Highest increase is for the ablation of the ventricle at 16% growth over 5 years though this is the lowest volume with less than 500 services. Ablation of both atrial chambers at 15% growth has increased from around 30% to around 40%. Ablation of single atrial chamber has grown at 7% per year from around 3,000 to 4,000 services per year.

1 Compound annual growth over 5 years. Data is by date of service. Unpublished data from 2009-15 using claims processed between 1 July 2014 – 30 April 2016 (Department of Health).

8.9 Pacemaker insertion

Current item descriptors and MBS data from FY 2014/15

Item 38350 – Schedule fee: $638.65
Services: 2,796  Total Benefits: $1,002,970  Average annual growth: 6.9%

Single chamber permanent transvenous electrode, insertion, removal or replacement of, including cardiac electrophysiological services where used for pacemaker implantation (Anaes.)

Item 38353 – Schedule fee: $255.45
Services: 9,871  Total Benefits: $1,117,848  Average annual growth: 5.8%

Permanent cardiac pacemaker, insertion, removal or replacement of, not for cardiac resynchronisation therapy, including cardiac electrophysiological services where used for pacemaker implantation (Anaes.)

Item 38356 – Schedule fee: $837.35
Services: 6,625  Total Benefits: $4,082,981  Average annual growth: 7.3%

Dual chamber permanent transvenous electrodes, insertion, removal or replacement of, including cardiac electrophysiological services where used for pacemaker implantation (Anaes.)

Item 11718 – Schedule fee: $34.75
Services: 11,549  Total Benefits: $341,826  Average annual growth: 7.3%

Implanted pacemaker testing involving electrocardiography, measurement of rate, width and amplitude of stimulus, including reprogramming when required, not being a service associated with a service to which item 11700, 11719, 11720, 11721, 11725 or 11726 applies

Item 11719 – Schedule fee: $66.85
Services: None  Total Benefits: None  Average annual growth: N/A

Implanted pacemaker (including cardiac resynchronisation pacemaker) remote monitoring involving reviews (without patient attendance) or arrhythmias, lead and device parameters, if at least one remote review is provided in a 12 month period. Payable only once in any 12 month period

Item 11720 – Schedule fee: $66.85
Services: None  Total Benefits: None  Average annual growth: N/A

Implanted pacemaker testing, with patient attendance, following detection of abnormality by remote monitoring involving electrocardiography, measurement of rate, width and amplitude of stimulus including reprogramming when required, not being a service associated with a service to which item 11718 or 11721 applies.

Item 11721 – Schedule fee: $69.75
Services: 140,527  Total Benefits: $8,348,467  Average annual growth: 8.3%

Implanted pacemaker testing of atrioventricular (AV) sequential, rate responsive, or antitachycardia pacemakers, including reprogramming when required, not being a service associated with a service to which item 11700, 11718 11719, 11720, 11725 or 11726 applies

Item 38256 – Schedule fee: $267.25
Services: 791  Total Benefits: $86,109  Average annual growth: 7.2%

Temporary transvenous pacemaking electrode, insertion of (Anaes.)

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

Recommendation 32.1
  • ΔLeave items 11719, 11720, 38256, 38350, 38353 and 38356 unchanged. The first two items have only recently been added to the MBS.
Recommendation 32.2
  • ΔRemove item 11718 from the MBS. The consensus was that this item is obsolete as devices for which this is appropriate are no longer in use.
Recommendation 32.3
  • ΔAmend the descriptor for item 11721 to specify that it can only be claimed when the doctor is immediately available, can directly review the patient and can have an impact on patient outcomes.

Item 11721

Implanted pacemaker testing of atrioventricular (AV) sequential, rate responsive, or antitachycardia pacemakers, including reprogramming when required. Performed where a medical practitioner is immediately available to attend the patient and where such testing is clinically indicated.

Not being a service associated with a service to which item 11700, 11718 11719, 11720, 11725 or 11726 applies.

Rationale

These recommendations focus on modernising the MBS and supporting best practice care and are based on the following observations.

  • ΔRegarding item 11721, the Committee agreed that industry representatives perform many of these tests and then pass the information on to clinicians. Although there are benefits to this system, it was agreed that this is not the intent of the item. Specifically, it was felt that the spirit of the item is to cover all the costs of running a pacemaker clinic. The Committee further agreed that it is not good practice to have a device checked without clinician involvement. As a result, the clinical consensus was that the descriptor should be amended to ensure that the item is only claimed when the doctor is immediately available, can review the patient and can directly affect patient outcomes. It felt that this requirement would help to restrict low-value services and reduce the 7 per cent annual growth seen in recent years. Growth should be monitored to ensure that it remains in line with pacemaker prevalence.

8.10 Extraction of chronically implanted lead

Current item descriptors and MBS data from FY 2014/15

Item 38358 – Schedule fee: $2868.05
Services: 99  Total Benefits: $213,072  Average annual growth: 2.2%

Extraction of chronically implanted transvenous pacing or defibrillator lead or leads, by percutaneous method where the leads have been in situ for greater than six months and require removal with locking stylets, snares and/or extraction sheaths in a facility where cardiac surgery is available, in association with item 61109 or 60509 (Anaes.) (Assist.)

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

Recommendation 33
  • ΔUpdate the descriptor and explanatory notes for item 38358 as proposed below.

Item 38358A

Extraction of chronically implanted transvenous pacing or defibrillator lead or leads, by percutaneous method where the leads have been in situ for greater than six months and require removal with locking stylets, snares and/or extraction sheaths.

Performed:

  1. By an appropriately trained provider; and
  2. With a cardiac surgeon present during lead extraction; and
  3. In a suitable environment in which a thoracotomy can be performed immediately and without transfer.

Claimable in association with item 61109 or 60509. (Anaes.) (Assist.)

Explanatory notes: International guidelines state that delays from injury to open access to the heart of more than 5–10 minutes are often associated with a fatal outcome. Preparations for this procedure should provide for this rare but life threatening circumstance.

  • ΔSplit item 38358 into one item for extraction (as above) and one item for a cardiac surgeon to be present and on standby during lead extraction, in a cost-neutral manner.

Item 38358B

Extraction of chronically implanted transvenous pacing or defibrillator lead or leads. Claimable by a cardiac surgeon providing surgical backup for a provider who is not a cardiac surgeon. Present for the full duration of lead extraction, excluding low risk pre and post extraction phases, and able to immediately scrub and perform a thoracotomy if major complications should occur.

Claimed in association with item 38358. (Anaes.)

Rationale

These recommendations focus on modernising the MBS to reflect contemporary practice and are based on the following observations.

  • ΔThe Committee noted that although this is a small item in terms of absolute volume and benefits, it is a high-risk procedure and is significant for the patients who require it. The Committee felt that this item is one of the most highly regulated items on the MBS, performed by only nine providers in Australia. Major complications including death occur in 1 to 2 per cent of cases.
  • ΔThe descriptor currently requires the procedure to be performed “in a facility where cardiac surgery is available,” but the Committee felt that this does not sufficiently comply with Australian and international guidelines on the performance of this procedure (66,67). The Committee also heard that there have been a number of recent adverse events, including deaths, and it noted that a recent coronial inquest into one such death commented on the lack of clarity around requirements for the safe performance of this procedure (68). From a consumer perspective, the Committee felt that it was imperative to address any significant safety concerns, and that consumers would be very supportive of recommendations that ensure best-practice safety standards are met.
  • ΔIf a cardiologist performs the procedure, the Committee agreed that it is accepted best practice to have a cardiac surgeon immediately available to assist in the event of complications. International guidelines developed in 2009 noted that in “the external review of fatal cases around the world, it was the strong consensus that when the superior vena cava was torn or perforated, delays from the injury to having open access to the heart of more than 5–10 minutes were often associated with a fatal outcome. Rescue efforts initiated within this time period have been usually successful.”(66) For this reason, the Committee recommended updating the descriptor so that it requires a cardiac surgeon to be present during the lead extraction phase of all procedures. The surgeon does not need to be present during lower risk preparation and post-extraction phases. The surgeon does not need to be scrubbed while on standby, but open access to the heart is required in less than 5-10 minutes and adequate preparations must be in place to ensure this is possible.
  • ΔThe Committee noted that the role of a surgeon who is physically present and on standby for the procedure is not the same as the role of an assistant (although it is similar). It was also noted that when a cardiac surgeon performs the procedure, a standby surgeon is not required. The Committee considered two options for the remuneration of standby surgeons. The first option was to create a new item for surgeon standby. It was noted that this sets a precedent, however, due to the strict requirement of physical attendance, and it was felt that this would have limited application beyond this procedure. The second option was to continue allowing the surgeon and proceduralist to negotiate an acceptable arrangement, as is the current practice. Current guidelines require a surgeon to be present, and the Committee agreed that this is often the case, although they are generally unpaid for this service. The current MBS descriptor does not require physical attendance, and the Committee felt that altering this would constitute a material change in the requirements. The Committee was concerned that providers billing each other to meet an MBS-mandated requirement could foster perverse relationships, with either party making unreasonable demands of the other. In light of this, the Committee recommended the creation of the specific item, noting that it would be claimed fewer than 100 times per year.
  • ΔThe Committee discussed, with some contention, whether the item should be created in a cost-neutral way. Some members cited the current high rebate, and the likelihood that it was originally created with a team-supported procedure in mind, as a reason for a cost-neutral approach. However, others felt that this rebate was necessarily high to incentivise providers to up skill in this area, as it has significant accreditation requirements and is only performed by a small number of providers in low volumes. It was also suggested that when the item was originally created, there was no expectation in the guidelines for surgical backup to be present for the procedure, and that this would therefore be a new requirement and should be funded incrementally. Other members suggested that the item was always intended to include surgical backup with fee splitting. Ultimately, the Committee remained divided, but the majority felt that a fee increase was unlikely to be accepted and that a cost-neutral approach should be taken due to the high rebate.
  • ΔIn addition to the presence of a surgeon, Australian and international guidelines state that the procedure should be performed in an environment where an emergency thoracotomy can be performed.(66,67) Although a cardiac catheterisation suite (cath lab) is not as ideal a setting as a purpose-built hybrid operating theatre, it was agreed that it is an appropriate environment for the procedure if an emergency thoracotomy can be performed there. It was noted that the current CSANZ guidelines state that this “requirement [for a suitable environment] needs to be balanced against the need for high quality fluoroscopy.”(67) The Committee agreed that procedures would not be performed without high-quality fluoroscopy, and that these requirements were not mutually exclusive. For this reason, the Committee has not recommended compromising access to emergency thoracotomy for improved fluoroscopy. It was agreed that transfer to an operating theatre and achieving open access to the heart within 5–10 minutes would not be achievable in this scenario, and the recommendation therefore does not allow for this.

8.11 Cardioversion

Current item descriptors and MBS data from FY 2014/15

Item 13400 – Schedule fee: $96.80
Services: 10,205  Total Benefits: $746,932  Average annual growth: 8.7%

Restoration of cardiac rhythm by electrical stimulation (cardioversion), other than in the course of cardiac surgery (Anaes.)

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

Recommendation 34
  • ΔRestrict item 13400 to a hospital or equivalent setting.

Rationale

This recommendation focuses on ensuring best practice care and is based on the following observations.

  • ΔA safety concern was raised regarding the 8 per cent of services that are provided in an outpatient setting. It was suggested that this percentage could reflect the item being claimed when electrical overdrive is performed in a provider’s rooms. The Committee agreed that the service described by this item is serious in nature and that performing it outside a hospital or equivalent setting may compromise patient safety.
  • ΔThere was clinical consensus that growth in the use of this item reflects the increasing burden of AF in the population.

8.12 Signal-averaged ECG

Current item descriptors and MBS data from FY 2014/15

Item 11713 – Schedule fee: $69.75
Services: 5,425  Total Benefits: $315,978  Average annual growth: 57%

Signal averaged ECG recording involving not more than 300 beats, using at least 3 leads with data acquisition at not less than 1000Hz of at least 100 QRS complexes, including analysis, interpretation and report of recording by a specialist physician or consultant physician

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

Recommendation 35
  • ΔObsolete – remove item 11713 from the MBS.

Rationale

This recommendation focuses on modernising the MBS and is based on the following observations.

  • ΔThere is no evidence for use of this service beyond investigating arrhythmogenic right ventricular dysplasia (ARVD), which is a rare condition. Although the guidelines support investigation for this condition, the Committee agreed that removing the item would not affect patient outcomes. Should the item be retained, access to the item should be significantly restricted.
  • ΔIt was noted that a small number of providers in Western Australia provide more than half of all services. It was suggested that this is related to an ongoing clinical trial. The Committee agreed that the MBS is not intended to cover services for clinical trials, and that this trial does not justify retaining the item.

8.13 Tilt-table testing

Current item descriptors and MBS data from FY 2014/15

Item 11724 – Schedule fee: $168.90
Services: 1,753  Total Benefits: $261,922  Average annual growth: -2.7%

Up-right tilt table testing for the investigation of syncope of suspected cardiothoracic origin, including blood pressure monitoring, continuous ECG monitoring and the recording of the parameters, and involving an established intravenous line and the continuous attendance of a specialist or consultant physician — on premises equipped with a mechanical respirator and defibrillator

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

Recommendation 36
  • ΔLeave item 11724 unchanged.

Rationale

This recommendation is based on the following observations.

  • ΔThe Committee agreed that this item is the subject of clinical debate but felt that the test could be valuable if performed by a clinician with a specific interest and expertise in administering the test.
  • ΔThe test takes a significant amount of time and the fee is relatively small, which means that there are no perverse incentives for administering the test.

8.14 Blood dye – dilution indicator testing

Current item descriptors and MBS data from FY 2014/15

Item 11715 – Schedule fee: $120.75
Services: 16  Total Benefits: $1,480  Average annual growth: -21.6%

Blood dye — dilution indicator test

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

Recommendation 37
  • ΔObsolete – remove item 11715 from the MBS.

Rationale

This recommendation focuses on modernising the MBS and is based on the following observations.

  • ΔThere is no accepted role for this service in contemporary practice, and the item should be removed to prevent any patients being exposed to this clinically unnecessary test.
  • ΔThe Committee felt that services claimed under this item number may represent coding errors.


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