Abstract
Aims
Procurement of cardiac implantable electronic devices (CIEDs) across the European Union is shaped by diverse healthcare systems, reimbursement mechanisms and levels of clinician involvement. Despite a shared legal framework, limited comparative data are available on how procurement is implemented across countries.
Objective
The objectives of this study are to examine CIED procurement strategies in 22 European countries where public tendering is mandatory and to explore how clinical, economic and structural factors influence procurement processes.
Methods and results
We conducted 23 structured interviews with cardiologists and one industry expert across 22 European countries. A thematic analysis was used to synthesize procurement models, clinical involvement and reimbursement structures. No formal outcome or cost-effectiveness analysis was performed. Procurement models varied widely, encompassing centralized, decentralized and hybrid systems. Clinician involvement ranged from leading device selection based on clinical criteria to being excluded from decision-making in systems driven primarily by price. Reimbursement pathways also differed, with procedure tariffs for single-chamber pacemakers ranging from €1059 to €14 889. A single region in Finland had implemented a pilot value-based procurement model linking payment to patient outcomes.
Conclusion
Cardiac implantable electronic device procurement across Europe is heterogeneous and predominantly cost driven, with limited integration of clinical outcomes or value-based principles. While not designed to evaluate cost-effectiveness directly, this study identifies procurement structures that may support or hinder value-based decision-making. Further research is needed to assess how procurement impacts clinical outcomes, innovation adoption and system sustainability.
Keywords: Cardiac implantable devices, Public procurement, Value-based healthcare, Health economics, Reimbursement, Pacemakers, EU health systems
Graphical Abstract
Graphical Abstract.
Table of contents
Introduction
Methods
Participant selection and data collection
Reimbursement data sources
Ethical considerations
Results
Variations in procurement models across Europe
Role of cardiologists in procurement
Reimbursement differences
Discussion
Fragmentation in procurement models
Clinical involvement in procurement: scope and constraints
Reimbursement variability and implications for access
Value-based models: emerging but limited
Towards a more coherent European strategy
Limitations
Conclusion
Supplementary material
Acknowledgements
Funding
Data availability
Introduction
The European Union (EU) comprises 27 countries with distinct healthcare financing, governance, and procurement systems. This heterogeneity significantly limits the ability of EU institutions to harmonize health-related practices, particularly in the public procurement of medical technologies. Of the more than €2 trillion spent annually on public procurement across the EU, ∼70% is linked to the healthcare sector, encompassing everything from essential medicines to complex medical devices.1–3
Although EU procurement is regulated by directives such as 2004/18/EC and 2014/23/EU,3 implementation varies widely across Member States. National and regional authorities interpret and apply procurement rules differently, shaped by institutional frameworks, reimbursement models, and the level of clinical stakeholder engagement. As a result, public procurement for cardiac implantable electronic devices (CIEDs) differs not only between countries but also across regions and hospitals within them.4–7
Prior research has examined procurement innovations such as centralized purchasing and cross-border tenders.8–11 However, there remains limited empirical insight into how these mechanisms apply to CIEDs: a category of high-cost, high-impact technologies that require careful clinical selection and long-term patient matching.12
This study addresses that gap. Drawing on 23 semi-structured interviews with cardiologists and industry experts from 22 European countries, we map the current procurement and reimbursement landscape for CIEDs. We assess levels of clinical involvement, identify structural inefficiencies, and explore opportunities for value-based approaches. In doing so, we offer policy-relevant insights to support more equitable, efficient, and innovation-friendly procurement systems across Europe.13
Methods
This study was conducted under the auspices of the European Heart Rhythm Association (EHRA) between March and June 2025, with the aim of mapping procurement and reimbursement practices for CIEDs across Europe. The research design was descriptive and comparative, drawing on structured stakeholder interviews and documentary analysis. While interviews served as the primary data source, this was not a formal qualitative study, and no inferential coding or frequency analysis was performed.
Participant selection and data collection
Participants were purposively selected to ensure national coverage and included 22 cardiologists and one industry representative with regional procurement oversight. Each cardiologist had direct experience with device selection, procurement procedures, or reimbursement planning at the hospital or national level. Recruitment was conducted through EHRA-affiliated contacts, professional societies, and national networks, with a focus on identifying individuals with operational insight into procurement.
Structured interviews were conducted by a senior researcher (R.C.-A.) with the support of a junior analyst (L.O.). A standardized interview guide was used to ensure consistency across countries. Questions addressed procurement structures, clinician roles, reimbursement frameworks, and barriers to innovation. Interviews were conducted virtually in English, French, or Spanish, recorded with participant consent, and transcribed verbatim. Participants reviewed and corrected their transcripts for accuracy.
Reimbursement data sources
Information on device pricing and procedural reimbursement was collected through official national sources such as the French Assurance Maladie database, the German G-DRG catalogue, the Italian Ministry of Health tariff lists, and the UK NHS reference costs. Where multiple tariff schemes existed, the most widely used or nationally representative figures were selected. All figures reflect listed prices or reimbursement rates published as of 14 October 2025. Confidential discounts or negotiated transaction prices were not available.
Ethical considerations
All participants provided informed consent and were assured of confidentiality. No personal identifiers are disclosed in the manuscript. As the study did not involve patients, clinical data, or experimental interventions, it was exempt from formal ethics board review. The research adhered to the European Code of Conduct for Research Integrity and followed good practice standards for expert consultation in health policy research.
Results
Between September 2024 and May 2025, we conducted 23 interviews across 22 European countries with practicing cardiologists involved in CIED implantation or procurement (P1−P23, Supplementary material online, Appendix Table A1). The dataset spans a diverse range of public and private institutions including Austria, Belgium, Bulgaria, Denmark, Estonia, Finland, France, Germany, Iceland, Italy, Latvia, Lithuania, the Netherlands, Norway, Poland, Portugal, Romania, Serbia, Spain, Sweden, Switzerland and the UK (Figure 1). One industry representative participated, but their responses were excluded from this section to preserve clinical focus and neutrality as advised by peer review.
Figure 1.
Participants’ distribution by institution type.
Participants were asked to describe national and local procurement models, their individual roles in the process, criteria used to assess device quality and pricing, and how innovation is incorporated into public tenders. While findings are presented below under three thematic areas, strong interdependence was observed between procurement model type, reimbursement approach, and clinician involvement. Distinct differences emerged between centralized and decentralized procurement systems, with direct implications for supplier engagement, tender design, device selection, and access to new technologies. The timeline between tender publication and contract award varied widely, although a broad trend towards multi-supplier models was observed in an effort to ensure continuity of supply and mitigate product shortages. Most notably, regional differences in how health systems approach the introduction of new CIEDs highlighted the fragmented nature of procurement innovation across Europe.
Variations in procurement models across Europe
Procurement structures for CIEDs vary considerably across Europe, shaped by differences in national healthcare governance, decentralization, and purchasing authority. Based on interviews conducted in 22 countries, three main procurement models emerged: centralized, decentralized, and hybrid, as outlined in Table 1 and Figure 2.
Table 1.
Overview of the procurement process for CIEDs per country
| Country | Healthcare system type | CIEDs’ procurement approach | Procurement based on quality vs. pricing | Procurement timelines | Innovation policy | Providers |
|---|---|---|---|---|---|---|
| Austria | Federal SHI, regionally administered | Public tenders: devices split across two suppliers per lot | 50% quality/specs, 50% pricing | Federal and regional level; varies locally | Active innovation procurement at the national level | Public and private mix with federal insurance |
| Belgium | Decentralized SHI system | Framework contracts by hospitals; central reimbursement | Quality-driven frameworks; pricing tied to volume thresholds | Depends on the hospital contract cycles | Hospital board reviews new tech requests | Framework contracts; reimbursement led |
| Bulgaria | Centralized SHI model | CIEDs: national tender for pacemakers; ICDs/CRTs handled locally | Minimum technical features; price driven | Centralized; NHIF cycles with local hospital input | Last in the EU innovation policy ranking | Predominantly public providers under NHIF |
| Denmark | Decentralized public system across three tiers | Hospital-specific tenders; regional discretion on pricing/quality mix | Mix varies; typically, price heavy in some hospitals | Undisclosed; generally 2–4 years | Allowed if justified; varies by centre | No required supplier number; varies regionally |
| Estonia | Centralized SHI via EHIF | National tenders: now moving to dual-supplier model | Price and quality split; flexible or fixed volume | Central EHIF tenders with periodic review | EHIF integrates new criteria in purchasing | EHIF contracts; providers mainly private law |
| Finland | Decentralized (WSCs), publicly funded + NHI | Innovative life-cycle mode in one region; hospital carries risk; risk-sharing agreements with companies | Innovative value-based procurement in one region; pricing over device lifetime | Decentralized (WSCs); negotiated life-cycle contracts | Anticipatory innovation governance model implemented | Municipal primary care, public specialized care |
| France | Mixed SHI and tax-funded system | Public hospitals: no tender for pacemakers; ICDs based on GDR | No tender for pacemakers; fixed reimbursement; price less decisive | Central with regional input; flexible cycles | National innovation procurement policy active | MoH as steward, broad hospital freedom |
| Germany | Federal SHI with corporatist self-governance | Hospital-led tenders; corporatist negotiation by groups or consortiums | Volume driven; quality must meet minimums; pricing drives choice | Varies by group; negotiated yearly or multi-year terms | Devices beyond DRG must be justified clinically | Clinicians define minimums; public/private procurement |
| Italy | Decentralized National Health Service with regional autonomy | National and regional tenders; split volume by provider | 50–55% pricing; technical/clinical form 45–50% | National, 2–4 years; regional, decided locally | Region-led HTAs; not publicly funded | 3–4 providers per tender; 70–20–10% splits |
| Latvia | Centralized, publicly funded, limited benefits package | Joint procurement with the Baltics, CIED tenders similar to Lithuania | Collaboratio driven; aims at better pricing through joint tenders | Joint Baltic procurements: national cycles | Joint Baltic strategy; national innovation support | Public + Baltic framework participation |
| Lithuania | Centralized, single-payer via NHIF | National volume-based tenders; recent tenders heavily skewed to one supplier | Publicly disclosed pricing; bureaucratic, volume driven | Centralized tenders; NHIF managed | National policy supports innovation procurement | Public hospitals under the NHIF contract system |
| Netherlands | Social Health Insurance with universal coverage | Varies by hospital; academic = public tender, regional = direct negotiation | Hospital-developed formula; pricing important, but quality considered | Decentralized; negotiated per hospital or insurer | MedMij framework for health data innovation | Private insurers and providers dominate |
| Norway | Semi-decentralized system via RHAs and municipalities | National-level tenders: 3–4 suppliers now | 50% quality/service and 50% pricing (point-based system) | Max 4 years with possible annual adjustments | Direct innovation testing allowed; must meet value criteria | 3–4 suppliers per tender, moving from a single-source model |
| Poland | Decentralized SHI system | Hospital-level procurement with cardiologist involvement | No universal standard; varies case by case (e.g. 60/40 or 40/60) | Annual budgets, tender cycles, irregular | Barriers from thresholds and budget caps | Clinician-led evaluation; some private group tenders |
| Portugal | National Health Service with integrated local units | Public hospitals: central platform with committee; private centres negotiate directly | Evaluation committees, clinical specs prioritized, pricing transparent | 3–4-year review cycles for public hospitals | Innovation within budgeted packages; test in high-volume centres | Public, central platform; private: direct supplier deals |
| Romania | Centralized, mandatory insurance via NHIF | National tenders; hospital-level allocation by volume and cost | Clinicians define minimums; the price cap drives selection | Annual tenders with several review meetings | Public approval and limited reimbursement; private flexibility | Multiple providers: Medtronic, Biotronik, Boston, etc. |
| Serbia | Centralized, universal with mandatory insurance via NHIF | Nationally managed by NHIF, hospitals choose among approved providers | Based on pricing, the technical specs set by clinicians | Recentralized in 2019, Ministry-led procurement | 2021–2025 national innovation strategy in development | Ministry of Health oversight; NHIF implements |
| Spain | decentralized SNS with autonomous communities | Regional-/hospital-level tenders; packages by technical specs | Must meet specs; lowest price used unless clinically justified otherwise | Regional agreements; durations vary per tender | Must improve outcomes; some direct tenders allowed | Multiple brands per lot; optional volume obligations |
| Sweden | Decentralized, universal, tax funded | Regional tenders with multiple suppliers; 2–4-year contracts | Point-based system; balanced price and clinical criteria | Decentralized, regional-level cycles | Active national framework for innovation procurement | Public providers under regional authority |
| Switzerland | Decentralized, insurancebased, federalist | Hospital managed, decentralized pricing negotiation | French cantons = clinical focus; German cantons = cost-efficiency | Decentralized; managed at cantonal and hospital levels | Four sectoral innovation policies (e.g. environment and energy) | Private providers, cantonal funding variations |
| UK | Decentralized NHS models across four nations | NHS trust-level procurement; integration of clinical input | Clinical specs with pricing balance; varies by region/trust | Trust-level schedules vary by region | Evaluated per trust; requires clinical justification | Open to multiple providers; volume sharing common |
Figure 2.
Classification of public procurement models for CIEDs across 23 European countries. Centralized systems manage tenders at national level; decentralized systems devolve authority to regional or hospital levels; hybrid models combine national frameworks with local discretion.
Centralized procurement models were reported in countries such as Lithuania, Bulgaria, Romania, Latvia, and Estonia, where tenders are typically managed by national authorities, including Ministries of Health or central insurance funds. These systems aim to ensure administrative efficiency and standardized pricing. However, interviewees noted that such arrangements often constrain local hospital autonomy and limit clinician involvement in device selection.1,14–20
In contrast, decentralized procurement is characteristic of Germany, Spain, Italy, Switzerland, the Netherlands, Belgium, Portugal, and the UK, where authority rests with regional governments or individual hospitals. These models were praised for enabling alignment with clinical needs and providing flexibility for procurement at the point of care. However, they were also associated with pricing variation and lack of national standardization.1,21–29
Hybrid models, as observed in France, Austria, Sweden, Finland, Denmark, and Norway, combine national oversight, such as reference pricing or quality control frameworks with local-level tender execution. In these systems, hospitals typically select from approved supplier lists within national parameters, balancing clinical discretion with cost-efficiency.1,5,30–35
Tender structure further differentiates national approaches. In Bulgaria and pre-reform Estonia, single-winner tenders have led to supply concentration, occasionally resulting in monopolies or delays. In Bulgaria, the National Health Insurance Fund directly manages national pacemaker tenders, with hospitals acting as end users rather than buyers. Conversely, countries such as Austria, the UK, and post-reform Estonia utilize multi-supplier tenders, mandating a minimum number of suppliers per category. Interviewees in these systems reported improved resilience, clinical choice, and reduced supplier dependency.
Eastern and South-Eastern European countries, including Bulgaria, Romania, Poland, Lithuania, Latvia, Estonia, and Serbia, were reported to emphasize cost minimization as the primary tender criterion. While this achieved price reduction, clinicians frequently warned that excessive compression undermined device quality, limited innovation uptake, and exposed systems to supplier exits.
A notable example is Estonia’s reform of its procurement system in 2024–2025, transitioning from a single-vendor model to a multi-supplier framework. Interviewees highlighted that this change improved product availability and allowed greater alignment between device features and patient needs.
Cross-border and joint procurement efforts remain limited but promising. The Baltic countries, with occasional Nordic collaboration, have piloted joint tenders under the framework of EU Directive 2014/24/EU.36 While early stage, these initiatives suggest potential for improved purchasing power and shared evaluation processes.
Country-specific nuances also influence procurement processes. In the Netherlands, academic hospitals typically oversee their own tenders, while regional hospitals join consortia or use broader procurement frameworks. Respondents stressed that Dutch procurement practices maintain a strict separation between clinical decision-making and financial negotiations, supported by anti-corruption safeguards.
Finally, Finland presents a rare example of value-based procurement (VBP) in CIEDs. One regional authority implemented a model in which payment is tied to long-term outcomes over a follow-up period, rather than per procedure. Although limited in scope, this approach integrates cost and quality goals and is viewed as a model for future procurement innovation in Europe.37
Role of cardiologists in procurement
The role of cardiologists in procurement processes differs substantially across European health systems. In countries such as France, Poland, Romania, and Italy, clinicians are actively engaged in defining the technical and clinical criteria used in public tenders. Cardiologists in these systems often serve on procurement committees, helping to evaluate device specifications and ensure clinical appropriateness. For instance, in leading French university hospitals, interviewees described a weighted scoring system where technical, clinical, and economic factors are jointly assessed, and multiple suppliers are retained to preserve clinician choice and ensure flexibility at the point of care.
In Sweden, Austria, and Finland, cardiologists operate within multi-supplier procurement frameworks, which allow them to select the most appropriate device for each patient from a list of pre-approved vendors. This autonomy was seen by interviewees as crucial for aligning procurement with evidence-based, personalized care. In contrast, systems that rely predominantly on cost-based criteria, such as Bulgaria or the pre-reform model in Estonia, tend to limit clinician involvement to verifying basic device functionality, with little to no influence on supplier selection or pricing structures.
Several Western European countries, including the Netherlands and Belgium, have implemented strict safeguards to regulate interactions between clinicians and the medical device industry. These include mandatory declarations of financial interests, restrictions on participation in pricing discussions, and transparent governance mechanisms. Respondents in these countries highlighted that while these measures protect against conflicts of interest, they also necessitate clear communication between procurement teams and clinicians to maintain clinical relevance in tendering decisions.38
Reimbursement differences
Reimbursement models for CIEDs differ substantially across European countries, both in structure and in the levels of financial coverage provided.39 Two primary models are employed, as detailed in Table 2.40–50 In the device-based model, a fixed tariff is assigned to each device. As of October 2025, reimbursement rates for single-chamber pacemakers ranged from €1059 to €5448. In contrast, procedure-based models, most commonly using diagnosis-related group (DRG) codes, bundle all associated costs, including the device, surgical intervention, hospital stay, and perioperative care, into a single payment. Diagnosis-related group tariffs for single-chamber pacemaker procedures were found to vary widely, from €1798 to €14 889.
Table 2.
Reimbursement of CIEDs overview per device category and country. Currency exchange rate used: • 1 EUR = 0.87 GBP; 0.99 CHF; 4.46 PLN
| SINGLE-CHAMBER PACEMAKER | |||||
|---|---|---|---|---|---|
| Country | Physician fee | Procedure | Devicea | Total (or DRG) | Reimbursement source |
| Austria40 | – | €5.574,00 | Austria MoH | ||
| Belgium41 | €27 583 | €4.126,00 | €4.401,83 | INAMI | |
| France (private)42 | €27 919 | €1513.97 | €1.795,40 | €3.588,56 | Assurance Maladie |
| France (public)43 | €2.727,61 | €1.795,40 | €4.523,01 | Assurance Maladie | |
| Germany44 | €4.331,05 | €1.059,95 | €5.391,71 | G-DRG | |
| Italy45 | – | €4.756,00 | Italian MoH | ||
| Netherlands46 | €3.268,00 | €12.110,00 | Zorginstituut Nederland | ||
| Poland47 | – | €1.798,88 | NFZ Poland | ||
| Spain48 | – | – | – | – | Servicio Nacional de Salud |
| Switzerland49 | €9.309,13 | €5.580,72 | €14.889,85 | Swiss DRG | |
| UK50 | – | €2.858,66 | NHS England | ||
| DUAL-CHAMBER PACEMAKER | |||||
|---|---|---|---|---|---|
| Country | Physician fee | Procedure | Device | Total (or DRG) | Reimbursement source |
| Austria40 | – | €5.992,00 | Austria MoH | ||
| Belgium41 | €27 583 | €4.674,00 | €4.949,83 | INAMI | |
| France (private)42 | €27 919 | €1513.97 | €3.138,67 | €4.931,83 | Assurance Maladie |
| France (public)43 | €2.727,61 | €3.138,67 | €5.866,28 | Assurance Maladie | |
| Germany44 | €4.331,05 | €1.059,95 | €5.391,71 | G-DRG | |
| Italy45 | – | €4.756,00 | Italian MoH | ||
| Netherlands46 | €3.268,00 | €12.110,00 | Zorginstituut Nederland | ||
| Poland47 | – | €2.199,10 | NFZ Poland | ||
| Spain48 | – | – | – | – | Servicio Nacional de Salud |
| Switzerland49 | €9.251,56 | €6.630,95 | €15.882,51 | Swiss DRG | |
| UK50 | – | €3.545,62 | NHS England | ||
| CARDIAC RESYNCHRONIZATION THERAPY—PACEMAKER | |||||
|---|---|---|---|---|---|
| Country | Physician fee | Procedure | Device | Total (or DRG) | Reimbursement source |
| Austria1 | – | €9.587,00 | Austria MoH | ||
| Belgium41 | €27 583 | €7.329,34 | €7.605,17 | INAMI | |
| France (private)42 | €28 623 | €1513.97 | €5.317,15 | €8.044,76 | Assurance Maladie |
| France (public)43 | €2.727,61 | €5.317,15 | €7.117,35 | Assurance Maladie | |
| Germany44 | €5.241,89 | €3.687,17 | €8.929,06 | G-DRG | |
| Italy45 | – | €9.384,00 | Italian MoH | ||
| Netherlands46 | €3.268,00 | €16.445,00 | Zorginstituut Nederland | ||
| Poland47 | – | €4.063,52 | NFZ Poland | ||
| Spain48 | – | – | – | – | Servicio Nacional de Salud |
| Switzerland49 | €9.702,81 | €12.106,15 | €21.808,96 | Swiss DRG | |
| UK50 | – | €9.440,74 | NHS England | ||
| SINGLE CHAMBER ICD | |||||
|---|---|---|---|---|---|
| Country | Physician fee | Procedure | Device | Total (or DRG) | Reimbursement source |
| Austria40 | – | €13.148,00 | Austria MoH | ||
| Belgium41 | €27 583 | €14.520,53 | €14.796,36 | INAMI | |
| France (private)42 | €30 823 | – | €1.285,09 | €16.442,38 | Assurance Maladie |
| France (public)43 | – | €1.285,09 | €18.114,88 | Assurance Maladie | |
| Germany44 | €4.888,29 | €3.957,27 | €8.845,56 | G-DRG | |
| Italy45 | – | €16.573,00 | Italian MoH | ||
| Netherlands46 | €3.268,00 | €23.765,00 | Zorginstituut Nederland | ||
| Poland47 | – | €4.914,93 | NFZ Poland | ||
| Spain48 | – | – | – | – | Servicio Nacional de Salud |
| Switzerland49 | €9.064,40 | €17.118,15 | €26.182,55 | Swiss DRG | |
| UK50 | €5.262,43 | €5.262,43 | NHS England | ||
| DUAL-CHAMBER ICD | |||||
|---|---|---|---|---|---|
| Country | Physician fee | Procedure | Device | Total (or DRG) | Reimbursement source |
| Austria40 | – | €13.148,00 | Austria MoH | ||
| Belgium41 | €27 583 | €15.630,80 | €15.906,63 | INAMI | |
| France (private)42 | €31 452 | – | €2.570,18 | €16.442,38 | Assurance Maladie |
| France (public)43 | – | €2.570,18 | €18.114,88 | Assurance Maladie | |
| Germany44 | €5.796,76 | €4.582,39 | €10.379,15 | G-DRG | |
| Italy45 | – | €16.573,00 | Italian MoH | ||
| Netherlands46 | €3.268,00 | €23.765,00 | Zorginstituut Nederland | ||
| Poland47 | – | €4.914,93 | NFZ Poland | ||
| Spain48 | – | – | – | – | Servicio Nacional de Salud |
| Switzerland49 | €10.662,20 | €22.940,70 | €33.602,90 | Swiss DRG | |
| UK50 | €5.262,43 | €5.262,43 | NHS England | ||
| CARDIAC RESYNCHRONIZATION THERAPY–DEFIBRILLATOR | |||||
|---|---|---|---|---|---|
| Country | Physician fee | Procedure | Device | Total (or DRG) | Reimbursement source |
| Austria40 | – | €16.002,00 | Austria MoH | ||
| Belgium41 | €27 583 | €16.368,40 | €16.644,23 | INAMI | |
| France (private)42 | €32 201 | – | €3.855,27 | €16.442,38 | Assurance Maladie |
| France (public)43 | – | €3.855,27 | €18.114,88 | Assurance Maladie | |
| Germany44 | €5.801,75 | €7.169,99 | €12.971,74 | G-DRG | |
| Italy45 | – | €16.573,00 | Italian MoH | ||
| Netherlands46 | €3.268,00 | €24.602,00 | Zorginstituut Nederland | ||
| Poland47 | – | €7.821,32 | NFZ Poland | ||
| Spain48 | – | – | – | – | Servicio Nacional de Salud |
| Switzerland49 | €9.504,44 | €26.702,95 | €36.207,39 | Swiss DRG | |
| UK50 | €7.892,49 | €7.892,49 | NHS England | ||
| INSERTABLE CARDIAC MONITOR | |||||
|---|---|---|---|---|---|
| Country | Physician fee | Procedure | Device | Total (or DRG) | Reimbursement source |
| Austria40 | – | €7.162,00 | Austria MoH | ||
| Belgium41 | €2.122,65 | €2.122,65 | INAMI | ||
| France (private)42 | €5 716 | €43 258 | €1.408,77 | €1.898,18 | Assurance Maladie |
| France (public)43 | €75 658 | €1.408,77 | €2.165,35 | Assurance Maladie | |
| Germany44 | €4.331,05 | €1.059,95 | €5.391,71 | G-DRG | |
| Italy45 | – | €3.547,00 | Italian MoH | ||
| Netherlands46 | €1.634,00 | €4.095,00 | Zorginstituut Nederland | ||
| Poland47 | – | €83 277 | NFZ Poland | ||
| Spain48 | – | – | – | – | Servicio Nacional de Salud |
| Switzerland49 | €9.309,13 | €5.580,72 | €14.889,85 | Swiss DRG | |
| UK50 | — | €2.940,63 | NHS England | ||
| LEADLESS PACEMAKER | |||||
|---|---|---|---|---|---|
| Country | Physician fee | Procedure | Device | Total (or DRG) | Reimbursement source |
| Austria40 | – | €5.574,00 | Austria MoH | ||
| Belgium41 | €27 583 | €4.126,00 | €4.401,83 | INAMI | |
| France (private)42 | €77 200 | €1513.97 | €6.300,00 | €8.585,97 | Assurance Maladie |
| France (public)43 | €2.727,61 | €6.300,00 | €9.027,61 | Assurance Maladie | |
| Germany44 | €5.801,75 | €7.169,99 | €12.971,74 | G-DRG | |
| Italy45 | – | €4.756,00 | Italian MoH | ||
| Netherlands46 | €3.268,00 | €12.110,00 | Zorginstituut Nederland | ||
| Poland47 | – | €4.090,91 | NFZ Poland | ||
| Spain48 | – | – | – | – | Servicio Nacional de Salud |
| Switzerland49 | €9.702,81 | €12.106,15 | €21.808,96 | Swiss DRG | |
| UK50 | €2.858,66 | €2.858,66 | NHS England | ||
aThe German and Swiss device prices represent the retrospective national average implant costs associated with the relevant DRG, as reported in the DRG cost matrices. These costs may also include other devices that fall within the same DRG category. However, France and Belgium have a brand-specific device reimbursement catalogue. In UK (England), some devices may be paid separately outside of the tariff.
Further complexity arises in certain systems, such as Belgium and parts of France’s private sector, where physicians receive additional professional fees for each implantation. This layer of remuneration contributes to a fragmented landscape that complicates cross-country comparisons and may exacerbate inequities in access to advanced CIED technologies.
Securing reimbursement for new or high-cost devices, such as leadless pacemakers, remains a significant challenge. In countries including Italy, Lithuania, and Spain, central- or hospital-level approval is typically required before new technologies are included in tenders or reimbursed. This can result in delays in patient access. Conversely, France and Switzerland permit early-stage procurement of innovative devices at the hospital level, even in the absence of national reimbursement. While this facilitates early clinical use, it also creates financial strain and uncertainty if national approval is delayed.
Interviewees widely acknowledged that these variations in reimbursement mechanisms impact both access to innovation and long-term system sustainability. Fragmentation in funding strategies was cited as a barrier to equitable adoption of advanced technologies. Moreover, the disconnect between procurement decisions and reimbursement alignment often leads to inefficiencies and delays in patient care. As such, harmonizing payment pathways and incorporating clearer support for innovation were highlighted as priorities for policy reform.
Discussion
This study highlights the significant heterogeneity in the procurement and reimbursement of CIEDs across Europe. Despite shared regulatory underpinnings through EU directives, national implementation diverges sharply due to structural, legal, and institutional differences. These disparities influence not only procurement strategies but also clinician involvement, price transparency, and equitable access to innovation.
Fragmentation in procurement models
Cardiac implantable electronic device procurement frameworks are closely aligned with national health system structures. Centralized procurement, as seen in Bulgaria, Lithuania, and Romania, offers administrative efficiency and cost containment through national-level tenders but tends to limit clinical autonomy. By contrast, decentralized models, common in Germany, Italy, and the UK, allow procurement at the hospital or regional level, fostering responsiveness to clinical needs but potentially generating inconsistent pricing and supplier diversity.
Hybrid models, such as those in France, Sweden, and Austria, attempt to combine national oversight with local decision-making. However, the degree of clinical influence and standardization remains inconsistent. Early cross-border collaborations, such as those led by the Baltic states and Nordic countries under Directive 2014/24/EU,36 illustrate the feasibility of shared procurement for high-cost devices, though these initiatives remain nascent.
Clinical involvement in procurement: scope and constraints
The involvement of cardiologists in procurement varies substantially. In countries such as France, Poland, and Italy, cardiologists contribute to the drafting of technical specifications and serve on evaluation committees. These roles enable alignment of tenders with clinical needs and long-term outcomes. Conversely, in countries where procurement is primarily cost driven, such as Bulgaria or historically Estonia, clinicians have little input, often limited to verifying basic functionality.
Multi-supplier tenders, such as those now adopted in Austria and Estonia, offer clinicians more flexibility in matching devices to patient profiles. However, in systems with strict anti-corruption and transparency laws, such as Belgium and the Netherlands, physician involvement in financial negotiations is constrained. Interviewees emphasized that increased clinician engagement, balanced with appropriate governance and training, could improve alignment between procurement and care quality.
Reimbursement variability and implications for access
Substantial differences in reimbursement structures were observed, affecting both device-level and procedure-level funding. As outlined in Table 2,40–50 the tariffs for a single-chamber pacemaker vary more than three-fold across countries, with some nations reimbursing devices directly and others bundling costs through DRG-based systems. This inconsistency hinders cross-country comparison, creates disincentives for innovation, and may lead to inequitable access to new technologies.
In certain countries, such as Italy, Spain, and Lithuania, delays in reimbursement approval for advanced devices such as leadless pacemakers were noted. In contrast, hospitals in France and Switzerland may pilot new devices without initial national reimbursement, supporting early evaluation but raising sustainability concerns. The Spanish model, which integrates all CIED costs into public tenders, was cited as a potential example of equitable access.
Value-based models: emerging but limited
The introduction of a VBP pilot in one Finnish region offers an example of aligning payment with outcomes rather than volume. Under this model, reimbursement is tied to post-implantation clinical metrics over a defined follow-up period.37 However, VBP remains rare in Europe, and its implementation faces challenges, including limited access to outcome data, lack of standard performance indicators, and system fragmentation.51,52
Critically, the current study did not attempt to measure ‘value’ or ‘cost-effectiveness’ in economic terms. These concepts require outcomes data and comparative effectiveness analyses, which were outside the scope of this qualitative study. While some interviewees referenced VBP frameworks, their comments were observational and not systematically evaluated.
Towards a more coherent European strategy
While procurement policy remains a national competence, EU-level coordination could promote alignment in key areas such as transparency, data infrastructure, and innovation uptake, as outlined in Figure 3. Joint purchasing mechanisms, such as those developed during the SARS-CoV-2 virus pandemic, demonstrate the feasibility and value of shared strategies. A more cohesive approach could reduce fragmentation, empower smaller markets, and incentivize quality-based competition among suppliers.51,53
Figure 3.
Key policy recommendations to enhance CIED procurement systems in Europe. Thematic priorities identified include improving transparency in public tendering, promoting balanced supplier competition, enhancing cardiologist involvement with appropriate safeguards, and integrating patient perspectives into procurement design.
To that end, professional societies such as EHRA could lead efforts to define minimum clinical criteria for device selection and establish procurement evaluation standards. Supporting clinicians with training in procurement processes, health economics, and ethical governance may also improve their contribution while safeguarding against conflicts of interest.
Limitations
This study has several limitations that should be acknowledged. Although participants were purposively selected to ensure national coverage and to capture both clinical and procurement perspectives, the inclusion of a single representative per country may not fully reflect regional or institutional variations. Health systems such as those of Spain, Italy, and the UK encompass multiple procurement structures and reimbursement mechanisms, and these intra-country differences may therefore be underrepresented.
While all participants reviewed their interview transcripts and provided corrections to ensure accuracy, qualitative interviews are inherently interpretative and may include subjective perceptions influenced by local experience. Some inconsistencies in interpretation or emphasis across countries are therefore possible. Moreover, given the limited number of respondents and the lack of Delphi methodology or structured quantitative analysis, the thematic findings should be interpreted as exploratory insights rather than definitive patterns.
Reimbursement data were collected from official national databases and publicly available sources; however, these figures represent listed tariffs or reimbursement benchmarks, not the confidential net prices negotiated between hospitals and suppliers. As such, they should be interpreted as indicative rather than actual transaction values. Professional fee structures were available only for selected countries and may not capture broader variation in physician reimbursement across systems.
Additionally, potential conflicts of interest among participants, particularly in relation to clinical or commercial roles, were not formally audited or declared beyond verbal confirmation of independence. This limitation may affect the objectivity of some perspectives.
Finally, procurement and reimbursement frameworks are dynamic and may have evolved since data collection. Despite these limitations, this study provides a unique comparative overview of CIED procurement practices across Europe, identifying key structural and policy differences that can inform future reforms.
Conclusion
This study provides a comparative overview of CIED procurement practices across 22 European countries, identifying wide variation in purchasing structures, clinician involvement, and reimbursement mechanisms. While centralized models offer cost control, decentralized and hybrid approaches better support clinical autonomy and device personalization. Reimbursement frameworks, including both device-specific tariffs and bundled payments, exhibit substantial variability in value and transparency, complicating cross-country comparisons. Only a few regions, such as in Finland, have begun to explore structured value-based procurement models. The findings underscore the lack of harmonized procurement governance across the EU and highlight the potential benefits of increasing clinical input, improving transparency, and encouraging outcome-linked reimbursement to promote access, quality, and innovation in device therapy.
Supplementary Material
Acknowledgements
We extend our sincere gratitude to all contributors who supported the development of this manuscript. In particular, we would like to thank Mr. Mika Mustonen, General Manager for the Nordic and Baltic region at Abbott Laboratories, for his valuable insights and expertise, which greatly enriched the analysis of procurement practices across Northern Europe.
Contributor Information
Lucía Osoro, Department of Cardiology, H.U.B.-Hôpital Erasme, Université Libre de Bruxelles, Brussels 1070, Belgium; EHRA Advocacy, Quality Improvement, and Health Economics Committee (European Heart Rhythm Association), Sophia Antipolis, France; Centro Universitario HM Hospitales de Ciencias de la Salud (CUHMED), Universidad Camilo José Cela. Madrid, Spain.
Elena Arbelo, EHRA Advocacy, Quality Improvement, and Health Economics Committee (European Heart Rhythm Association), Sophia Antipolis, France; Department of Cardiology, Hospital Clinic, Barcelona, Spain.
Nikola Kozhuharov, EHRA Advocacy, Quality Improvement, and Health Economics Committee (European Heart Rhythm Association), Sophia Antipolis, France; Department of Cardiology, University Hospital Bern—Inselspital, Freiburgstrasse 20, Bern 3010, Switzerland.
Runa Landen, EHRA Advocacy, Quality Improvement, and Health Economics Committee (European Heart Rhythm Association), Sophia Antipolis, France; Institute of Medicine—Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
Martin Martinek, Department of Cardiology, Ordensklinikum Linz Elisabethinen, Linz, Austria.
Christophe Leclerq, Department of Cardiology, CHU Rennes—Hôpital Pontchaillou, Rennes, France.
Laurent Fauchier, Department of Cardiology, Hôpital Trousseau, CHRU de Tours, Tours, France.
Jean-Claude De Haro, Assistance Publique − Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, Marseille, France; Faculty of Medicine, Aix Marseille Université, C2VN, Marseille, France.
Serge Boveda, Cardiac Arrhythmia Department, Clinique Pasteur, Toulouse, France.
Philipp Sommer, Heart and Diabetes Center North Rhine-Westphalia, University Clinic of Bochum, Bad Oeynhausen, Germany.
Michiel Rienstra, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
Piotr Szymański, Clinical Cardiology Department, National Institute of Medicine MSWiA, Warszawa, Poland.
Michal Farkowski, Arrhythmia Unit, Ministry of Interior and Administration National Medical Institute, Warsaw, Poland.
Anastasia Egorova, Cardiology Department, Leiden University Medical Center, Leiden, The Netherlands.
Francisco Moscoso Costa, Cardiology Department, Hospital da Luz, SA, Lisbon, Portugal.
Diana Tint, Faculty of Medicine, Transilvania University of Brasov, Brasov, Romania.
Stefan Simovic, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia.
Krasimir Dzhinsov, Electrophysiology Unit, University Hospital ‘Sveti Georgi’, Plovdiv, Bulgaria.
Francisco Leyva, Medical Research Department, Aston University, Birmingham, United Kingdom of Great Britain & Northern Ireland.
Giuseppe Boriani, Department of Cardiology, Policlinico di Modena, Italy.
Josep Figueras, European Health Observatory on Health Systems and Policies, Brussels, Belgium.
Zenichi Ihara, Health Economics and Reimbursement, Abbott, Zaventem, Belgium.
Jose Luis Merino, Cardiac Robotic Unit, La Paz University Hospital, Madrid, Spain.
Haran Burri, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland.
Helmut Pürerfellner, Institute of Medicine—Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
Rubén Casado-Arroyo, Department of Cardiology, H.U.B.-Hôpital Erasme, Université Libre de Bruxelles, Brussels 1070, Belgium; EHRA Advocacy, Quality Improvement, and Health Economics Committee (European Heart Rhythm Association), Sophia Antipolis, France.
Supplementary material
Supplementary material is available at Europace online.
Funding
None.
Data availability
The datasets generated and analysed during the current study are not publicly available due to confidentiality agreements and the qualitative nature of the data, which include personal professional opinions expressed during interviews. To protect participant anonymity, full transcripts and audio recordings cannot be shared. Summarized or aggregated data supporting the findings of this study are available from the corresponding author upon reasonable request.
References
- 1. OECD/European Observatory on Health Systems and Policies . OECD: Health at a Glance: Europe 2022. Available from: https://www.oecd.org/en/topics/health.html (21 September 2025, date last accessed).
- 2. Bax H, Koettlitz S. Value-based Procurement. Medtech Europe: from diagnosis to cure. Accessed 2024 Apr 17. Available from: https://www.medtecheurope.org/access-to-medical-technology/value-based-procurement/
- 3. European Commission . Directorate General for Health and Food Safety. Expert Panel on effective ways of investing in Health (EXPH) :opinion on public procurement in healthcare system : the EXPH adopted this opinion at the plenary meeting on 28 April 2021 after public hearing on 3 February 2021. LU: Publications Office; 2021. Accessed 2024 Sept 17. Available from: https://data.europa.eu/doi/10.2875/782344
- 4. Boriani G, Imberti JF, Leyva F, Casado-Arroyo R, Chun J, Braunschweig F et al. Length of hospital stay for elective electrophysiological procedures: a survey from the European Heart Rhythm Association. Europace 2023;25:euad297. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Farkowski MM, Scherr D, Boriani G, Kazakiewicz D, Haim M, Huculeci R et al. Arrhythmia care in ESC member countries: the 2025 ESC-EHRA atlas on heart rhythm disorders. Europace 2025;27:euaf124. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Boriani G, Svennberg E, Guerra F, Linz D, Casado-Arroyo R, Malaczynska-Rajpold K et al. Reimbursement practices for use of digital devices in atrial fibrillation and other arrhythmias: a European Heart Rhythm Association survey. Europace 2022;24:1834–43. [DOI] [PubMed] [Google Scholar]
- 7. Timmis A, Aboyans V, Vardas P, Townsend N, Torbica A, Kavousi M et al. European Society of Cardiology: the 2023 Atlas of Cardiovascular Disease Statistics. Eur Heart J 2024;45:4019–62. [DOI] [PubMed] [Google Scholar]
- 8. Sorenson C, Kanavos P. Medical technology procurement in Europe: a cross-country comparison of current practice and policy. Health Policy 2011;100:43–50. [DOI] [PubMed] [Google Scholar]
- 9. Frausing MHJP, Nielsen JC, Westergaard CL, Gerdes C, Kjellberg J, Boriani G et al. Economic analyses in cardiac electrophysiology: from clinical efficacy to cost utility. Europace 2024;26:euae031. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Osoro L, Zylla M, Braunschweig F, Leyva F, Figueras J, Pürerfellner H et al. Challenging the status quo: a scoping review of value-based care models in cardiology and electrophysiology. Europace 2024;26:euae210. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Mei DA, Imberti JF, Vitolo M, Bonini N, Casali E, Osoro L et al. Economic evaluations in electrophysiology in the last 15 years: a systematic review of the literature. Rev Cardiovasc Med 2025;26:36206. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Jimenez-Candil J, Hernandez Hernandez J, Cruz Galban A, Blanco F, Moriñigo JL, Sanchez García M et al. Clinical and economic outcomes of a systematic same-day discharge programme after pulmonary vein isolation: comparison between cryoballoon vs. radiofrequency ablation. Europace 2023;25:euad265. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Gottschalk S, Kany S, König HH, Crijns HJ, Vardas P, Camm AJ et al. Cost-effectiveness of early rhythm control vs. usual care in atrial fibrillation care: an analysis based on data from the EAST-AFNET 4 trial. Europace 2023;25:euad051. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. OECD, European Observatory on Health Systems and Policies, Lithuania: Country Health Profile 2023. Paris: OECD Publishing; 2023. 1 p. (State of Health in the EU). [Google Scholar]
- 15. OECD . OECD Reviews of Health Systems: Lithuania 2018. Organisation for Economic Co-operation and Development; 2018. Accessed 8 May 2025. (OECD Reviews of Health Systems). Available from: https://www.oecd.org/en/publications/lithuania_9789264300873-en.html
- 16. Dimova A, Rohova M, Polin K. Bulgaria: health system summary 2024. Copenhagen: European Observatory on Health Systems and Policies, WHO Regional Office for Europe; 2024. [Google Scholar]
- 17. OECD/European Observatory on Health Systems and Policies . Romania: Health System and Policy Monitor. 2021. Available from: eurohealthobservatory.who.int
- 18. Behmane D, Dudele A, Villerusa A, Misins J, Kļaviņa K, Mozgis D, Scarpetti G. Latvia: Health System Summary, 2024. Copenhagen: European Observatory on Health Systems and Policies, WHO Regional Office for Europe; 2024. [Google Scholar]
- 19. OECD, European Observatory on Health Systems and Policies, editors. Latvia: Country Health Profile 2023. Paris: OECD Publishing; 2023. 1 p. (State of Health in the EU). [Google Scholar]
- 20. Kasekamp K, Habicht T, Võrk A, Köhler K, Reinap M, Kahur K, Laarmann H, Litvinova Y. Estonia: Health System Summary, 2024. Copenhagen: European Observatory on Health Systems and Policies, WHO Regional Office for Europe; 2025.
- 21. Busse R, Blümel M. Germany: health system review. Health Syst Transit 2014;16:1–296. [Google Scholar]
- 22. OECD, European Observatory on Health Systems and Policies, editors. Spain: Country Health Profile 2023. Paris: OECD Publishing; 2023. 1 p. (State of Health in the EU). [Google Scholar]
- 23. Bernal-Delgado E, Angulo-Pueyo E, Ridao-López M, Urbanos-Garrido RM, Oliva-Moreno J, García-Abiétar D et al. Spain: Health system review. Health Systems in Transition. WHO Regional Office for Europe; 2024. Accessed 27 December 2024. Available from: https://eurohealthobservatory.who.int/publications/i/spain-health-system-review-2024
- 24. de Belvis AG, Meregaglia M, Morsella A, Adduci A, Perilli A, Cascini F et al. Italy: Health system review. Health Syst Transit 2022;24:pp.i–203.
- 25. De Pietro C, Camenzind P, Sturny I, Crivelli L, Edwards-Caravoglia S, Spanger A et al. Switzerland: Health system review. Health Syst Transit 2015;17:1–288.
- 26. Kroneman M, Boerma W, Van den Berg M, Groenewegen P, De Jong JJ, Van Ginneken E. The Netherlands: health system review. Health Syst Transit 2016;18:1–239. [Google Scholar]
- 27. OECD, European Observatory on Health Systems and Policies, editors. Belgium: Country Health Profile 2023. Paris: OECD Publishing; 2023. 1 p. (State of Health in the EU). [Google Scholar]
- 28. Serviço Nacional de Saude de Portugal . Serviço Nacional de Saúde (SNS). Accessed 5 June 2025. Available from: https://www.sns.gov.pt/
- 29. Anderson M, Pitchforth E, Edwards N, Alderwick H, McGuire A, Mossialos E. The United Kingdom: Health system review. Health Syst Transit 2022;24:i–192. [Google Scholar]
- 30. Or Z, Gandré C, Seppänen AV, Hernández-Quevedo C, Michel M, Chevreul K. France: Health System Summary, 2024. Copenhagen: European Observatory on Health Systems and Policies, WHO Regional Office for Europe; 2025.
- 31. Bachner F, Bobek J, Habimana K, Ladurner J, Lepuschütz L, Osterman H et al. Austria: Health system review. Health Syst Transit 2018;20:1–256. [Google Scholar]
- 32. Janlov N, Blume S, Glenngard AH, Hanspers K, Anell A, Merkur S. Sweden: Health system review. Health Syst Transit 2023;25:i–198. [Google Scholar]
- 33. Karanikolos M, Tynkkynen L, Keskimäki I. Finland: Health System Summary, 2024. Copenhagen: European Observatory on Health Systems and Policies, WHO Regional Office for Europe; 2024. [Google Scholar]
- 34. OECD, European Observatory on Health Systems and Policies . Denmark: Country Health Profile 2023. OECD; 2023 Accessed 7 May 2025. (State of Health in the EU). Available from: https://www.oecd.org/en/publications/denmark-country-health-profile-2023_e4f0bee3-en.html
- 35.OECD, European Observatory on Health Systems and Policies. Norway: Country Health Profile 2023. OECD; 2023 [cited 2025 May 7]. (State of Health in the EU). Available from: https://www.oecd.org/en/publications/norway-country-health-profile-2023_256fd7cf-en.html
- 36. Vogler S, Haasis M, van den Ham R, Humbert T, Garner S, Suleman F. European collaborations on medicine and vaccine procurement. Bull World Health Organ 2021;99:715–21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37. NMG2 project . Value-Based Procurement: Knowledge, Guide, and Support for All in the Value Chain of Medical Technology. Nordic MedTech; 2017. [Google Scholar]
- 38. Ministry of Economic Affairs and Climate Policy . Public Procurement Monitoring Report of the Netherlands. The Hague The Netherlands: Ministry of Economic Affairs and Climate Policy; 2021. Available from: https://www.tenderned.nl/cms/en/english/tenderned-dutch-governments-online-tendering-system
- 39. Boriani G, Burri H, Mantovani LG, Maniadakis N, Leyva F, Kautzner J et al. Device therapy and hospital reimbursement practices across European countries: a heterogeneous scenario. Europace 2011;13:ii59–65. [DOI] [PubMed] [Google Scholar]
- 40.Bundesministerium Arbeit, Soziales, Gesundheit, Pflege und Konsumentenschutz Krankenanstalten. Available from: https://www.sozialministerium.gv.at/Themen/Gesundheit/Gesundheitssystem/Krankenanstalten/ (1 September 2025, date last accessed).
- 41. INAMI, Institut national d'assurance maladie-invalidité, Accueil | INAMI . Available from: https://www.inami.fgov.be/fr/recherche?q=appareils+m%C3%A9dicaux+r%C3%A9pertori%C3%A9s (15 August 2025, date last accessed).
- 42.L’assurance maladie. Available from: https://www.ameli.fr/infirmier (20 August 2025, date last accessed).
- 43.ATIH. Agence Technique de l’Information sur l’Hospitalisation. Available from: https://www.atih.sante.fr/ (20 August 2025, date last accessed).
- 44. German Institute for the Hospital Remuneration System . Available from: https://www.iges.com/sites/igesgroup/iges.de/myzms/content/e29564/e30170/bitem30173/AiM_Reimbursement_of_Medical_Devices_in_Germany_2023_2024_eng.pdf (1 August 2025, date last accessed).
- 45.Orazio Schillaci. Ministro della Salute Sen. Roberto Calderoli Ministro per gli Affari Regionali e le Autonomie Presidente della Conferenza Stato-Regioni. 2024. Available from: https://www.quotidianosanita.it/allegati/allegato1720682871.pdf (1 August 2025, date last accessed).
- 46. Dutch Healthcare Authority . Available from: https://www.nza.nl/english (15 July 2025, date last accessed).
- 47. Narodowy Fundusz Zdrowia . Available from: https://www.nfz.gov.pl/o-nfz/informator-o-zawartych-umowach/ (18 July 2025, date last accessed).
- 48. Ministerio de la presidencia, justicia y relaciones con las cortes. Agencia Estatal Boletin Oficial de Estado . Available from: https://www.boe.es/ (15 June 2025, date last accessed)
- 49. Swiss Confederation. Federal Office of Public Health . Available from: https://www.bag.admin.ch/de (16 January 2025, date last accessed).
- 50. National Health System (NHS) . National tariff payment system documents, annexes and supporting documents. Available from: https://www.england.nhs.uk/?s=tariffs (24 February 2025, date last accessed).
- 51. Kanavos P, Wouters OJ. Competition Issues in the Distribution of Pharmaceuticals. Brussels: OECD Publishing, Paris/European Observatory on Health Systems and Policies; 2014. [Google Scholar]
- 52. Kanavos P, Ferrario A, Nicod E, Sandberg D. Tender Systems for Outpatient Pharmaceuticals in the European Union: Evidence from the Netherlands and Germany. London: London School of Economics; 2012. [Google Scholar]
- 53. König S, Wohlrab L, Leiner J, Pellissier V, Nitsche A, Darma A et al. Patient perspectives on same-day discharge following catheter ablation for atrial fibrillation: results from a patient survey as part of the monocentric FAST AFA trial. Europace 2023;25:euad262. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated and analysed during the current study are not publicly available due to confidentiality agreements and the qualitative nature of the data, which include personal professional opinions expressed during interviews. To protect participant anonymity, full transcripts and audio recordings cannot be shared. Summarized or aggregated data supporting the findings of this study are available from the corresponding author upon reasonable request.