Access and reimbursement of ambulatory cardiac monitoring across Europe

Ambulatory cardiac monitoring (ACM) allows long-term electrocardiogram (ECG) monitoring to detect arrhythmias with different modalities, ranging from short-term Holter monitoring (up to 48 h) to long-term continuous patch ECG monitors (up to 14 days), external event recorders (up to 30 days), and implantable loop recorders (ILRs). Access and reimbursement for ACM across Europe are not well understood. We performed a systematic review and analysis to understand ACM reimbursement across Europe, including a review of the reimbursement systems in each country and a detailed inspection of clinical coding and provider reimbursement. Level of reimbursement is dependent on many factors, including clinical setting (inpatient, outpatient, and day case), hospital length of stay, diagnosis, complications/severity, geographical location, hospital type, and device model and manufacturer. In most countries, reimbursement is performed for the monitoring procedure itself, without considering the time extension of monitoring and the specific type of device used for monitoring. The monetary value of reimbursement varies by country for both ACM and ILR [for Holter from €17.49 to €939.78 and for ILR from €416.14 (provider reimbursement only) to €18,718 (provider reimbursement bundled with ILR device)]. Holter and ILR are universally reimbursed, but newer ACM technologies with extended duration of monitoring, including long-term continuous monitoring and event recorders, are not. Across Europe, we found large variation in monetary values for reimbursement for ACM and ILR. We also found limited reimbursement and access to longer-duration ACM technologies. These findings suggest heterogeneous and problematic access to evidence-based tools for longer-duration monitoring.