How to improve quality of care in electrophysiology in Europe

Jose L Merino
Jose L Merino

By Jose L Merino

Invasive management of heart rhythm disorders by catheter ablation and device implantation has been established as the therapy of choice for most arrhythmias and the number of patients and complex procedures has increased dramatically. In addition, these procedures have a risk of serious complications and require fluoroscopy, which entails additional risks for both the patient and the operating personnel. All these considerations justify the implementation of actions to guarantee quality and qualification to practice these techniques. Attempts at quality improvement of European electrophysiology should undergo a systematic approach with different actions.


Setting-up guidelines and recommendations of clinical practice is the first and most obvious action. Much work has been done in this field by several scientific organizations. However, some surveys have suggested a limited impact of these official recommendations in clinical practice. According to some, only 30% of the physicians follow these recommendations and many others are more likely to trust key opinion leaders’ recommendations or personal opinions. Therefore, understanding the real scenario is highly important. Daily practice is generally influenced by many factors different to those strictly scientific, such as funding, national cost-effectiveness analysis, resources constrains, habits, and country/local differences in medical practice. Registries and surveys have been proposed as means to get such information. Several registries have been published about pacemakers, implantable defibrillators, and catheter ablation especially for southern European countries. One of the most important surveys is the Euroheart survey, which provides relevant information about atrial fibrillation management in Europe. Finally, the European Heart Rhythm Association (EHRA) white book is probably the best available picture that can be obtained about electrophysiology resources and manpower in the different countries of Europe. It was developed by as a survey conducted among the national societies of each European country.


Other pivotal aspect to improve quality of care in electrophysiology is education. At present time there are many excellent educational activities across Europe. However, most of them are limited in time, not comprehensive and mainly theoretical with little training of practical skills. There are training programmes in some European countries, but coordination at a European level is needed. The EHRA developed a core curriculum for the European heart rhythm specialist which represents a harmonised and uniform way to ensure high standards of excellence. This core curriculum is a formal education plan that establishes specific learning objectives and requirements for trainees, trainers and training centres. It also provides a syllabus of the subspecialty, which is a listing of subject matters that are covered in the training programme. Finally, the document details the minimum number of procedures recommended to be performed by the trainee.


Assessment of the trainee and the training programmes is essential, both to guarantee a minimum level of knowledge and practical competence of the trainee and to promote continuous improvement of the training programmes. This assessment process should result in a certification or accreditation system, which could play an important role as an informative element when taking decisions in the case of health authorities as well as service professionals and users. However, until recently and with few exceptions (Spain, France, etc), there have not been electrophysiology accreditation systems in Europe. In 2005 the EHRA initiated accreditation of professionals by verifying the candidates’ credentials, log books and merits, and holding accreditation examinations. Two accreditation processes were implemented, invasive EP and implantable cardiac rhythm devices (pacemakers and ICDs). The candidates were asked to be cardiologists, to provide a log book with a minimum number of procedures and to pass an exam.


Research is critical because promotes healthcare professionals to be motivated, active in the field and updated. Research on EP in Europe has increased in recent years and funding is more available than ever. The European Union’s Framework Programme for research and technological development has to be mentioned as a important initiative in this field.


Finally, an important way to promote quality in EP is by increasing public awareness about the importance of heart rhythm disorders. This in turns often results in increasing public resources to decrease the impact of these diseases on society. The role of public foundations, such as the British and Spanish Heart Foundations, is very important supporting informative and educational programmes for the general population. In addition, some patient associations have been recently created in the field of EP, such as the international Arrhythmia Alliance, which organise informative campaigns for the public.


Jose L Merino is director of the Arrhythmia Research Unit, Hospital Universitario La Paz, Madrid, Spain