Questions to ask while selecting your EP and how to interpret their answers

There are several recent threads in our Phorum about how to select your EP and the questions to ask. While assembling those questions for myself I came across a website that has already prepared those questions in a PDF file. I should add that the website is marketing a book, but the questions are available to use directly from the website. The website that has the questions is a-fib.com and below is the link to the web page that discusses the EP questions.

Selecting your EP

Within that page is a link to the PDF file that allows you to print the page and use the questions in your discussion with EPs.

8 Specific questions to ask when selecting your EP

And what I think is the best information from this website are the possible answers from the EP and what they mean in making your decision. The possible answers/meanings to the questions can be found at the following link:

How to interpret your EP's answers



Edited 2 time(s). Last edit at 09/13/2018 10:58PM by JakeL.

Of all the questions to ask your EP, I would say the most important is "What is your Success Rate?". However, the definition of success can vary among EPs and the number of "touch up ablations" can also vary. We would all like an EP who performs "one and done". As the answer web page from the link indicates "If their success rate is 50% or less, you should probably look elsewhere".

As a proxy for success rate we could use "Number of ablations performed per year". George N made the following comment about about choosing an EP:
George's comment
You want a very high volume center, with a very high volume EP. Be certain he/she will do the ablation, not a fellow!!! If you are in the US my number one pick would be Andrea Natale in Austin - he's worth the travel! Second would be someone who trained under him.
Outside the US, I'd choose Jais or Hocini in Bordeaux Fr

Carey agreed with him:
Agree with George. The most important question you should ask is how many ablations do you perform per year, and for how many years? What you want to hear is at least hundreds per year and for 10 years or more. A total in the thousands is what you're looking for. Pass on anyone who can't meet those standards.

So, how do we find how many ablations your EP candidates have performed? In one of Carey's post he provides a link to Medicare payments for over one million medical providers from 2012 to 2015 (note: the data is dated to 2015) and compare that to their EP peers. While Medicare makes some payments to patients under the age of 65, I believe most patients are Medicare patients over the age of 64, which may or may not be an appropriate comparison for you. The link is below:
Medicare Billing History

Here are some recommendations for filling in the 4 requested fields for rating your EP. Start with the Physician's name, then enter City of practice, then enter State, and then enter Specialty. You can hit the Search button after entering any one of the 4 fields or combination of the fields. The advantage of entering fewer fields is that your doctor may be identified in a old location or another specialty. After you hit the Search button you may get the doctor you want, no doctor at all, or several possible doctors. If you see a list of doctors, find the one you want and click on it. Below is a description of what to enter in the 4 fields:

Physician or Provider: Enter the doctor's last name first and first name (without a separating comma) and middle initial, without a comma. As you are entering the last name, you may get a drop-down of several names that fit the pattern entered. If you find the exact doctor you want, then you do not have to enter any of the other 3 fields and just hit the search button.

Location: Enter the City where the doctor works, if needed

State (on the right of Location): Select state from the drop-down, if needed

Specialty (on the right of Physician name): Select the specialty from the drop-down, if needed. The specialty for EP is Cardiac Electrophysiology. However, when I selected this option it knocked out an EP that had a recorded specialty of Cardiology. If this happens then your EP likely has not done ablations to Medicare patients (but may have done so with other patients or just chosen to identify his or her specialty as Cardiology). So if you leave this field as "All Specialties", the search will provide more names to select from.

Once the doctor is selected then you can see the Total Payments made, Number of Patients, and Payments per Patient. Remember this is only for Medicare patients. The doctor's total numbers may be 1-3 times larger. However, you can use the numbers to compare doctors doing the same work on just Medicare patients.

In the Provider Comparison section the only year shown is 2015. There is a button for Nationally and Statewide. However, that button does not change the numbers but it does change their percentile.

Then to make sure the numbers are relevant you have to look at the procedures performed. Just looking at the descriptions I chose, the following codes as relevant to ablations, but you can choose a different subset:

CODE: 93656-F: Evaluation and insertion of catheters for recording, pacing, and treatment of abnormal heart rhythm
CODE: 93655-F: Insertion of catheters for treatment of abnormal heart rhythm
CODE: 93613-F: Insertion of catheters for 3D mapping of electrical impulses to heart muscles
CODE: 93657-F: Destruction of tissue of right or left upper heart chamber via catheter for treatment of abnormal heart rhythm
CODE: 93462-F: Insertion of catheter into left heart for diagnosis
CODE: 93621-F: Insertion of catheters for recording, pacing, and attempted induction of abnormal rhythm in left upper heart

If your EP does not show any activity for the above codes (or your own subset), then you may conclude that your EP does not do ablations or at least complicated ones, to at least over 10 Medicare patients in 2015.

See this Note on the web page: Category totals may not add up to a provider's total payments because information about a provider's specific services to fewer than 11 Medicare patients is suppressed by Medicare.

As a test of this system I check the numbers for NATALE ANDREA (AUSTIN, TEXAS), DI BIASE LUIGI (BRONX, N.Y), and CHINITZ LARRY A (NEW YORK, N.Y). These doctors have been mentioned on our Afibber's Forum.

For Doctor Natale I found that his specialty is Cardiac Electrophysiology and his codes are in the list above. The Number Performed for each code in 2015 for more than 10 Medicare patients is shown below, all are in the top 20% nationally.
CODE: 93656-F: 130
CODE: 93655-F: 159
CODE: 93613-F: 165
CODE: 93657-F: 101
CODE: 93462-F: 32
CODE: 93621-F: 32

For another doctor that I have seen recommended on this site, I will show the numbers for Doctor Luigi Di Biase. Note that we have been spelling the doctor's name incorrectly on our website, there is a space between Di and Biase. Also note that his specialty is Cardiology and not Cardiac Electrophysiology. Below are the The Number Performed for each code is shown below in 2015 for more than 10 Medicare patients. Perhaps I have the wrong doctor; but you can look him up.
CODE: 93656-F: 0
CODE: 93655-F: 0
CODE: 93613-F: 0
CODE: 93657-F: 0
CODE: 93462-F: 0
CODE: 93621-F: 0

Another name I have seen on this site is Doctor Larry A Chinitz. Note that his specialty is Cardiology and not Cardiac Electrophysiology. Below are the The Number Performed for each code in 2015 for more than 10 Medicare patients, all are in the top 20% nationally, except for the last code.
CODE: 93656-F: 162
CODE: 93655-F: 54
CODE: 93613-F: 229
CODE: 93657-F: 39
CODE: 93462-F: 41
CODE: 93621-F: 0

These numbers are close to Dr Natale's, some numbers higher and some lower. If you assume that code 93657-F is the primary ablation code then Dr Natale has done over twice as many ablations on Medicare patients in 2015.

The results for years 2012 to 2014 can be found by selecting the year in the drop-down field next to the doctor's name.



Edited 1 time(s). Last edit at 09/19/2018 10:05AM by JakeL.

While level of experience is important, I tend to place more importance on recommendations from former patients and those that know his/her work. Quality rules quantity. Looking at quantity numbers can lead you to ambitious, ego maniacal celebrity doctors...not really a great thing, unless you like being a number.

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JakeL
For another doctor that I have seen recommended on this site, I will show the numbers for Doctor Luigi Di Biase. Note that we have been spelling the doctor's name incorrectly on our website, there is a space between Di and Biase. Also note that his specialty is Cardiology and not Cardiac Electrophysiology. Below are the The Number Performed for each code is shown below in 2015 for more than 10 Medicare patients. Perhaps I have the wrong doctor; but you can look him up.
CODE: 93656-F: 0
CODE: 93655-F: 0
CODE: 93613-F: 0
CODE: 93657-F: 0
CODE: 93462-F: 0
CODE: 93621-F: 0

This highlights one of the limitations of that data. Some centers report procedures under the name of the head of the center rather than by the doctor who actually did them. Di Biase definitely does ablations and his experience is on par with Natale and other top EPs. In the same way that data underestimates Natale's experience. He's done over 10,000 ablations at this point but you wouldn't guess that from the Medicare data.

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jpeters
While level of experience is important, I tend to place more importance on recommendations from former patients and those that know his/her work. Quality rules quantity. Looking at quantity numbers can lead you to ambitious, ego maniacal celebrity doctors...not really a great thing, unless you like being a number.

With doctors who do invasive procedures such as surgeons and interventional cardiologists, experience is everything. Reputation and patient opinions are fine and all, but they're important only after experience levels have been ascertained. I don't care what an EP's patients think of him if he has relatively little experience. A good example would be my first EP, who managed to botch three ablations on me. My PCP recommended him, he's got great credentials and reputation, and he gets glowing reviews from his patients on healthgrades.com. Nevertheless, he absolutely, positively does not know how to do an ablation. Despite three tries my second EP found no evidence I'd ever had an ablation at all. My PVs were fully connected and I had three, possibly four separate flutter circuits. That's the only thing he accomplished -- creating a mess of flutter circuits in my heart. So that's what credentials, professional reputation, and patient opinions got me. I've seen that same scenario play out time and again on afib forums. They go to that guy at a mid-sized hospital with great credentials and great references who does maybe a dozen or two ablations per year, and they end up here after three failed ablations wondering why.

Ablations are a fine mix of art, science and manual dexterity. You simply can't maintain high skill levels if you don't do it frequently, and you can't be familiar with all the possible corner cases, odd situations and unusual anatomies if you haven't done thousands of procedures. Assess experience first, ignore any EP who hasn't done many hundreds, preferably thousands, and THEN ask about reputation and patient opinions.

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Carey
My PCP recommended him, he's got great credentials and reputation, and he gets glowing reviews from his patients on healthgrades.com. Nevertheless, he absolutely, positively does not know how to do an ablation.

Think you missed my point...Expertise yes, but simply quantity no. In fact, after establishing high level of expertise, I would prefer an EP that is not overloaded with daily procedures. My local EP was impressed by the amount of work Hongo did on my ablation, and said it must have taken a long time. It was complex, and he took all the time necessary. I wonder if that would have happened if he had three other procedures to get done that day. The other factor is money, not a small incentive, and I think Medicare pays by the procedure, not how long it took.

Re Healthgrades"

"Healthgrades determines Top Care Area rankings by comparing nationally the number of times a given provider performs a procedure or treats a condition against all providers nationally who perform the same procedure or treat the same condition."



Edited 1 time(s). Last edit at 09/19/2018 10:29PM by jpeters.

I'd like to know how they define their success rate without being able to cheat a little or more...

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jpeters
Expertise yes, but simply quantity no. In fact, after establishing high level of expertise, I would prefer an EP that is not overloaded with daily procedures.

In the EP world, quantity and quality go hand in hand. You literally can't have quality without quantity. Aside from the technical proficiency that comes with doing a lot of procedures, there's also the simple fact that most EPs don't draw enough patients to be overloaded. The typical EP does maybe 3-4 ablations per week, whereas someone like Natale often does that many in a single day. Is that overloaded? Apparently not for him. So I'm not sure what constitutes overloaded in your mind, but I've never encountered an EP I think that description applies to.

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Carey

Expertise yes, but simply quantity no. In fact, after establishing high level of expertise, I would prefer an EP that is not overloaded with daily procedures.

In the EP world, quantity and quality go hand in hand. You literally can't have quality without quantity. Aside from the technical proficiency that comes with doing a lot of procedures, there's also the simple fact that most EPs don't draw enough patients to be overloaded. The typical EP does maybe 3-4 ablations per week, whereas someone like Natale often does that many in a single day. Is that overloaded? Apparently not for him. So I'm not sure what constitutes overloaded in your mind, but I've never encountered an EP I think that description applies to.

I'm not convinced elite doctors have a straight line that goes up and up until they finally retire. I think it's more like a bell curve, with overwork facilitating a decline. More isn't better.

Just heard a discussion about Tiger Woods, where someone pointed out that even if his body is in excellent shape, the mind loses it's edge with age (he's now 42).



Edited 1 time(s). Last edit at 09/20/2018 05:43PM by jpeters.