Improving same-day discharge after catheter ablation procedures: the Hawthorne effect or an epiphenomenon of the COVID-19 pandemic?

Same-day discharge may increase hospital bed capacity to facilitate additional procedural volume and also allow hospitals to realize cost-savings. Although same-day discharge after catheter ablation procedures is feasible and safe, it is underutilized. A European Heart Rhythm Association survey highlighted this with 50% of respondents in Spain and 0% in Italy and Germany using same-day discharge for electrophysiology procedures (1). Lack of supports and reimbursement have been reported as barriers to same-day discharge (2). To the best of our knowledge no study has evaluated approaches to increase the use of same-day discharge after catheter ablation procedures. Altering physician behaviors can be challenging but necessary to facilitate change. In this study we evaluated the impact of a simple intervention to influence physician use of same-day discharge after catheter ablation procedures.

This prospective observational quality improvement study was undertaken at Sunnybrook Health Sciences Center, a regional cardiac center located in Toronto, Ontario, Canada. The study was approved by the Sunnybrook Research Ethics Board (study approval number 3296). Patient consent was not required however a patient information form describing the study was provided to patients.

Discharge after catheter ablation procedures at Sunnybrook Health Sciences Center is at the discretion of the procedural physician. As currently no publication evaluating approaches to increase same-day-discharge after cardiac interventions exist, the purpose of this study was to evaluate the benefit of a simple intervention to increase the rate of same-day-discharge after SVT catheter ablation procedures at Sunnybrook Health Sciences Center. The study period was between April 2018 and June 2023 with the intervention period being between November 2019 and June 2023. During the intervention period monthly emails summarizing the institution’s current and prior months use of same-day discharge after catheter ablation procedures for supraventricular tachycardias (SVT; atrio-ventricular node reentrant tachycardia, atrio-ventricular tachycardia, atrial tachycardia, and atrial flutter) was provided to all physicians (n=9 during the study period) performing catheter ablation procedures. In addition, a patient information form was attached to a traditional procedure consent form for patients undergoing SVT ablation procedures. This served the purpose of providing an additional reminder to the physician prior to performing the procedure to consider same-day discharge after the procedure. The monthly rate of patients undergoing same-day discharge for SVT ablation procedures was then determined.

To assess the specificity of our intervention we evaluated the proportion of patients undergoing same-day discharge after catheter ablation procedures for AF. AF ablation was selected as a comparator as it is a common procedure with additional procedural complexity when compared to SVT ablation procedures. Feedback or reminders for same-day discharge with AF ablation procedures were not provided during the study period.

The study was designed and study periods defined prior to the onset of the coronavirus disease 2019 (COVID-19) pandemic which coincidentally occurred shortly after our study commenced. In Ontario, Canada a state of emergency with a lockdown or “stay-at-home” period implemented between March 2020 and July 2020. A second wave of COVID-19 infections occurred in the fall of 2020 with a second lockdown or “stay-at-home” period put in place between November 2020 and June 2021. During these periods hospitals attempted to minimize elective and unnecessary admissions to allow for bed availability for patients with COVID-19 infections. In May 2022 all COVID-19 public-health restrictions were removed in Ontario, Canada. Thus, the study was initiated approximately 5 months prior to the onset of the COVID-19 pandemic, and approximately half of the intervention period occurred during periods of COVID-19 public health restrictions being in place in Ontario, Canada.

All consecutive patients undergoing a catheter ablation at Sunnybrook Health Sciences Center between April 1^st 2018 and June 20^th 2023 were included in this study. During this time 2,636 patients underwent any SVT or AF catheter ablation procedure at Sunnybrook Health Sciences Center during the study period, with 1,814 occurring during the intervention period. The monthly procedure volume and proportion of patients discharged same-day for 20 months prior and 44 months during the intervention period for SVT (Figure 1A,1B) and AF ablation (Figure 1C,1D) procedures is summarized in the Figure 1 with a trendline calculated (Microsoft Excel 2019, Redmond, WA, USA) to estimate the trend in same-day discharge during the entire study period. A correlation coefficient (R²) was determined to describe the “goodness-of-fit” of the trendline to the raw data, with a value of 1 indicating a perfect fit (Microsoft Excel 2019).

Figure 1 Same-day discharge for catheter ablation procedures. (A) Monthly SVT ablation procedure volume—orange indicates admitted patients and blue indicates same-day discharge patients. (B) Percentage of SVT ablation patients with same-day discharge. (C) Monthly AF ablation procedure volume—orange indicates admitted patients and blue indicates same-day discharge patients. (D) Percentage of AF ablation patients with same-day discharge. Red dotted line indicated start of study period (November 2019). AF, atrial fibrillation; SVT, supraventricular tachycardia.

The proportion of SVT patients discharged same-day in the 6 months prior to the study initiation was 64%. This increased to 91% within the last 6 months of the study period. The overall rate of growth of same-day discharge using a trendline was near linear pre- and post-intervention (R²=0.5).

For patients undergoing AF ablation, 9% were discharged same-day during the 6 months prior to the study initiation. This increased to an average of 91% within the last 6 months of the study period. A non-linear change in the rate of same-day discharge after AF ablation procedures was observed during the study period compared to prior to the study period (R²=0.8).

Additional analyses were undertaken during various time periods in an attempt to understand the contribution of our intervention on the growth of same-day discharge relative to the potential contribution of changes in care-pattern with the COVID-19 pandemic. The rate of change in same-day discharge was evaluated in four discrete periods—Period 1: April 2018 to October 2019 which was the pre-intervention and pre-COVID-19 period; Period 2: November 2019 to March 2020 which was the post-intervention and pre-COVID-19 period; Period 3: April 2020 to May 2022 which was the ongoing intervention period encompassing all waves of the COVID-19 pandemic in Ontario, Canada where public-health restrictions were in place; and Period 4: May 2022 to June 2023 which was the post COVID-19 pandemic period, ongoing intervention period.

For SVT procedures the rate of change in same-day discharge was greatest in Period 2 (% change in discharge rate—Period 1: 0.006%/month; Period 2: 0.17%/month; Period 3: 0.006%/month; Period 4: 0.01%/month). For AF ablation the rate of change in same-day discharge was greatest in Period 3 (% change in discharge rate—Period 1: −0.002%/month; Period 2: −0.03%/month; Period 3: 0.1%/month; Period 4: 0.06%/month).

In this study we attempted to evaluate the benefit of a simple intervention, that is a monthly email summarizing performance feedback and daily pre-procedure reminders, on increasing the use of same-day discharge after catheter ablation procedures. Our work is important given the absence of publications evaluating approaches to improve same-day discharge after cardiovascular interventions. Our approach of sending a group email providing awareness of same-day discharge performance can be considered a “nudge”—a non-punitive hands-off intervention that preserves physician choice (3). This approach is reasonable when the behavior being influenced does not result in patient harm. This approach has been shown to increase the likelihood of successful physician change (4). Evaluating the effectiveness of this intervention was confounded by the presence of the COVID-19 pandemic which also has its impact on physician and patient behaviors. Specifically, we initially hypothesized that the dramatic and unintended increase in same-day discharge for AF ablation was due to a Hawthorne-like effect whereby physicians changed behavior during this observation period (5,6).

While suspicious, it is more plausible that our findings were due to change in physician practice related to the COVID-19 pandemic which occurred approximately 4 months after the initiation of the study. Indeed, the greatest growth in the rate of same-day-discharge for AF ablation occurred during the time of the COVID-19 pandemic with lockdown interventions in Ontario, Canada. We suspect changes in delivery of care during the COVID-19 pandemic was a dominant driver in the use of same-day-discharge in general.

It is also possible that increases in same-day-discharge for AF ablation may also be related to evolution of physician practice and the availability of publications of clinical studies highlighting the safety of same-day discharge for AF ablation during the study period (7,8). These alternative explanations would add support to work of social scientists who suggest the Hawthorne effect is not real but rather other factors account for changes in individual behavior when this phenomenon is raised (9). Despite the impact of the COVID-19 pandemic, there may be some value to providing physicians reminders and access to dashboards summarizing group performance. The growth in the rate of same-day-discharge for SVT ablation occurring immediately after our intervention was implemented, and independent of the COVID-19 pandemic, suggest some benefit of an intervention of this nature. Though the change was small, it was positive, measurable and likely to have larger benefits when scaled to a population level.

In conclusion, multiple factors may influence the use of same-day-discharge after catheter ablation procedures. Our work demonstrates one approach to improve same-day discharge of catheter ablation procedures. We highlight the impact the of the COVID-19 pandemic on this practice, which may provide additional support debunking the phenomenon of a Hawthorne effect.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-142/prf

Funding: This project was supported by the Sunnybrook Alternative Funding Plan (AFP) association through the Innovation Fund of the Alternative Funding Plan from the Academic Health Sciences Centres of Ontario.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-142/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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