The Korean journal of internal medicine

The Korean Association of Internal Medicine (대한내과학회)
권호 표지
DOI QR코드

DOI QR Code

Impact of an expanded reimbursement policy on utilization of implantable loop recorders in patients with cryptogenic stroke in Korea

  • Hye Bin Gwag (Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine) ;
  • Nak Gyeong Ko (Department of Research and Support, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine) ;
  • Mihyeon Jin (Department of Research and Support, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine)
  • Received : 2023.11.06
  • Accepted : 2024.01.17
  • Published : 2024.05.01
Download PDF
⟨ Previous Next ⟩

Abstract

Background/Aims: The reimbursement policy for cryptogenic stroke (CS) was expanded in November 2018 from recurrent strokes to the first stroke episode. No reports have demonstrated whether this policy change has affected trends in implantable loop recorder (ILR) utilization. Methods: We identified patients who received an ILR implant using the Korea Health Insurance Review and Assessment Service database between July 2016 and October 2021. Patients meeting all the following criteria were considered to have CS indication: 1) prior stroke history, 2) no previous history of atrial fibrillation or flutter (AF/AFL), and 3) no maintenance of oral anticoagulant for ≥4 weeks within a year before ILR implant. AF/AFL diagnosed within 3 years after ILR implant or before ILR removal was considered ILR-driven. Results: Among 3,056 patients, 1,001 (32.8%) had CS indications. The total ILR implant number gradually increased for both CS and non-CS indications and the number of CS indication significantly increased after implementing the expanded reimbursement policy. The detection rate for AF/AFL was 26.3% in CS patients over 3 years, which was significantly higher in patients implanted with an ILR within 2 months after stroke than those implanted later. Conclusions: The expanded coverage policy for CS had a significant impact on the number of ILR implantation for CS indication. The diagnostic yield of ILR for AF/AFL detection seems better when ILR is implanted within 2 months than later. Further investigation is needed to demonstrate other clinical benefits and the optimal ILR implantation timing.

Keywords

Acknowledgement

The authors appreciate the Korean Health Insurance Review & Assessment Service for providing the data.

References

  1. Edvardsson N, Frykman V, van Mechelen R, et al. Use of an implantable loop recorder to increase the diagnostic yield in unexplained syncope: results from the PICTURE registry. Europace 2011;13:262-269. https://doi.org/10.1093/europace/euq418
  2. Lacunza-Ruiz FJ, Moya-Mitjans A, Martinez-Alday J, et al. Implantable loop recorder allows an etiologic diagnosis in one-third of patients. Results of the Spanish reveal registry. Circ J 2013;77:2535-2541. https://doi.org/10.1253/circj.CJ-13-0201
  3. Buck BH, Hill MD, Quinn FR, et al. Effect of implantable vs prolonged external electrocardiographic monitoring on atrial fibrillation detection in patients with ischemic stroke: the PER DIEM randomized clinical trial. JAMA 2021;325:2160-2168. https://doi.org/10.1001/jama.2021.6128
  4. Sanna T, Diener HC, Passman RS, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014;370:2478-2486. https://doi.org/10.1056/NEJMoa1313600
  5. Kim HK, Song SO, Noh J, Jeong IK, Lee BW. Data configuration and publication trends for the Korean National Health Insurance and Health Insurance Review & Assessment database. Diabetes Metab J 2020;44:671-678. https://doi.org/10.4093/dmj.2020.0207
  6. Tsivgoulis G, Katsanos AH, Grory BM, et al. Prolonged cardiac rhythm monitoring and secondary stroke prevention in patients with cryptogenic cerebral ischemia. Stroke 2019;50:2175-2180. https://doi.org/10.1161/STROKEAHA.119.025169
  7. Huang WY, Ovbiagele B, Hsieh CY, Lee M. Association between implantable loop recorder use and secondary stroke prevention: a meta-analysis. Open Heart 2022;9:e002034.
  8. Jiang H, Tan SY, Wang JK, et al. A meta-analysis of extended ECG monitoring in detection of atrial fibrillation in patients with cryptogenic stroke. Open Heart 2022;9:e002081.
  9. Skrebelyte-Strom L, Ronning OM, Dahl FA, Steine K, Kjekshus H. Prediction of occult atrial fibrillation in patients after cryptogenic stroke and transient ischaemic attack: PROACTIA. Europace 2022;24:1881-1888. https://doi.org/10.1093/europace/euac092
  10. Kim JG, Boo K, Kang CH, Kim HJ, Choi JC. Impact of neuroimaging patterns for the detection of atrial fibrillation by implantable loop recorders in patients with embolic stroke of undetermined source. Front Neurol 2022;13:905998.
  11. Ahluwalia N, Graham A, Honarbakhsh S, et al. Contemporary practice and optimising referral pathways for implantable cardiac monitoring for atrial fibrillation after cryptogenic stroke. J Stroke Cerebrovasc Dis 2022;31:106474.
  12. Samaan S, Kohli U, Nazeer B, et al. Detection of atrial fibrillation by implantable loop recorders following cryptogenic stroke: a retrospective study of predictive factors and outcomes. J Electrocardiol 2022;71:54-58. https://doi.org/10.1016/j.jelectrocard.2022.01.007
  13. Dulai R, Hunt J, Veasey RA, Biyanwila C, O'Neill B, Patel N. Immediate implantable loop recorder implantation for detecting atrial fibrillation in cryptogenic stroke. J Stroke Cerebrovasc Dis 2023;32:106988.
  14. Navi BB, Singer S, Merkler AE, et al. Cryptogenic subtype predicts reduced survival among cancer patients with ischemic stroke. Stroke 2014;45:2292-2297. https://doi.org/10.1161/STROKEAHA.114.005784
  15. Arboix A, Alio J. Cardioembolic stroke: clinical features, specific cardiac disorders and prognosis. Curr Cardiol Rev 2010;6:150-161. https://doi.org/10.2174/157340310791658730
  16. Stollberger C, Finsterer J. Detection of paroxysmal atrial fibrillation and patent foramen ovale in cryptogenic stroke. Eur J Neurol 2009;16:160-161. https://doi.org/10.1111/j.1468-1331.2008.02410.x
  17. Hart RG, Diener HC, Coutts SB, et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 2014;13:429-438. https://doi.org/10.1016/S1474-4422(13)70310-7
  18. Katsanos AH, Bhole R, Frogoudaki A, et al. The value of transesophageal echocardiography for embolic strokes of undetermined source. Neurology 2016;87:988-995. https://doi.org/10.1212/WNL.0000000000003063
  19. Bettin M, Dechering D, Kochhauser S, et al. Extended ECG monitoring with an implantable loop recorder in patients with cryptogenic stroke: time schedule, reasons for explantation and incidental findings (results from the TRACK-AF trial). Clin Res Cardiol 2019;108:309-314. https://doi.org/10.1007/s00392-018-1358-4