October 5, 2016
Dr. Irfan Dhalla, Vice President
Evidence Development and Standards
Health Quality Ontario
130 Bloor Street West, 10th Floor
Toronto, ON M5S 1N5
Re: Draft Assessment on External Cardiac Loop Recorders
Dear Dr. Dhalla,
I am writing in response to your e-mail of September 15, 2016 which asks for feedback on a draft health technology assessment and recommendation on external cardiac loop recorders for detecting symptoms of cardiac arrhythmia. Specifically, based on Health Quality Ontario’s (HQO) findings, you have indicated that the Ontario Health Technology Advisory Committee (OHTAC) has recommended that publicly funding external cardiac loop recorders for detecting symptoms of cardiac arrhythmia be discontinued.
As Chair of the OMA Section on Cardiology and President of the Ontario Association of Cardiologists (OAC), I was very surprised to learn of this review and that only a few weeks have been given by HQO to provide input on this recommendation. It is extremely disappointing that the two largest organizations representing Ontario cardiologists, health care professionals who use of this technology for diagnosing and managing patients with life-threatening cardiac conditions, were not consulted or involved in this review from the outset.
Notwithstanding this, the OMA Section on Cardiology’s Executive Committee and the OAC’s Board of Directors have surveyed cardiologists on their views regarding the proposed recommendation. It is the collective view of the Section and the OAC that both long-term continuous ambulatory ECG monitors and external cardiac loop recorders continue to have merit in making the correct diagnosis for cardiac patients and each technology has merit in specific patients. Public funding for both technologies should be continued in the province of Ontario for the foreseeable future.
We base this opinion on the following factors:
- There is no clinical evidence that demonstrates the superiority of long-term continuous ambulatory ECG monitors over external cardiac loop recorders at diagnosing life-threatening cardiac arrhythmias.
- Clinical data on long-term continuous ambulatory ECG monitors, which is relatively new technology, is lacking and should not form the basis of a decision to discontinue public funding for external cardiac loop recorders.
- The two technologies are often used for different purposes.
- The external cardiac loop recorder is a simpler, less labour intensive technology when used for detecting certain cardiac conditions (e.g. paroxysmal atrial fibrillation).
- External cardiac loop recorders have a strong long track record of use and are widely available to patients across the province. Conversely, the availability of long-term continuous ambulatory ECG monitors is not as wide throughout the province. Cardiologists in rural and remote areas of the province rely on external cardiac loop recorders to provide patient care services closer to home. Discontinuing public funding for external cardiac loop recorders will lead to more patients travelling further distances to get the correct diagnosis and receive appropriate care.
- We note that a cost effectiveness analysis has not been conducted between the two technologies using currently available data. Conducting such an analysis, which would show at what cost long-term continuous ECG monitors detect arrhythmias compared to external cardiac loop recorders, is essential before a recommendation to discontinue public funding for external cardiac loop recorders can be accepted.
- Many cardiologists do not need the quantification that a long-term continuous ambulatory ECG monitor provides to identify the nature of a clinical event. They therefore use external cardiac loop recorders; however, discontinuing public funding for loop recorders will lead to increased utilization of long-term continuous ambulatory ECG monitors, which is more expensive technology.
- A committee of the Cardiac Care Network is currently examining the appropriate use of various ECG monitoring devices; we believe that before any recommendation to discontinue public funding for external cardiac loop recorders is made, the work and conclusions of this committee must be taken into account.
- The OAC recently identified and brought forward to the Auditor General of Ontario its concerns regarding overbilling of long-term continuous ambulatory ECG monitors. We believe correcting that situation will save significant dollars for the government of Ontario.
The OMA Section on Cardiology and the OAC appreciate the problem that the government of Ontario has identified regarding funding and changes in cardiac monitoring technology services in Ontario. The OAC and the Section on Cardiology have experts prepared to work with you to solve this problem so patient care will not suffer. We are prepared to meet with you now to make sure you understand our position clearly.
James Swan, M.D. F.R.C.P.(C) F.A.C.C.
President, Ontario Association of Cardiologists
Chair, OMA Section on Cardiology
34 Eglinton Ave. West
Toronto, ON M4R 2H6
E-mail: [email protected]