The practice of medicine is glorious, and I love it, but cynicism must be overcome.
What cynicism?
A far more established and connected blogger, Dr Wes, writes of the way technology strains the doctor-patient relationship. It involves a piece in the Chicago Tribune in which a study published in a major journal outlined doctors lack of adherence to guidelines in the implantation of ICDs. The scientific article cited showed there were three primary predictors of lack of guideline adherence for ICD implantation: increased age, black race and lack of insurance. Factors that increased the chances of getting an ICD included practicing in the Northeast, having a “heart failure” clinic and an electrophysiologist on site. Obvious conclusions they are.
A Johns Hopkins professor who I am sure (from personal experiences with him) means well, is saying we need to get with it and implant more devices.
Oh my…
Where would one who is trained in science, but who practices in the “real” (non-academic) world start? Additionally, having a wife who practices in palliative care has further illuminated the carte blanche with which the “guidelines” have enabled the inappropriate use of ICDs in the real world of ‘fee for service’ medicine.
To start, the cited study which concluded not enough ICDs are implanted was funded by Medtronic, an ICD manufacturer. No accusations here, (Medtronic is one of my preferred device companies) just statement of facts.
When originally published years ago, the vagueness in the guidelines of ICD implantation prompted the explosion of non-electrophysiologists who were hurriedly trained, often by industry, to handle the massive numbers of people who “needed” ICDs. A non-academic EP doctor witnessed this expansion of “installers” live in real time. ICDs implanted for low EF’s in patients with end-stage disease, scooter chairs, with dementia and in those with rapidly conducting atrial fibrillation whose EF would normalize with treatment of the tachycardia are just a few of the examples of ICD misuse that continue even in the present day.
Would the academic guideline writers know of the patients whose ICDs deliver inappropriate shocks as they are programmed nominally by the industry “rep” who helps the marginally trainer doctor “install” the device? Would they know of the misinformed patient who comes to me after their primary prevention ICD implanted elsewhere failed to help their class IV heart failure symptoms?
Do the professors know that in the real world many ICDs are implanted in patients (with insurance) who profess to do nothing for their health? Would they still recommend an ICD for the patient who will not take medicine and not stop smoking? How do the guidelines address this patient in whom an ICD will only change the mode of death?
Why do the academics, who write the guidelines or tout the underuse of the ICD, only infrequently quote the recent NEJM study which notes the median survival of 200 days after any shock from a device? To the patient with multiple medical problems whom an ICD is only for treatment of a possible painless death; might he/she choose not to have an implanted ICD if they knew the median increase in survival after a 750 volt shock is only 200 days and the device will not improve any of their symptoms?
Would the press be interested in this study and could their take be: here is a device that has multiple potential complications, easy to implant but complicated to program, well reimbursed and for 40,000 dollars only extends life on average 7 months in many a patient cohort? Could an argument be made that a fee for service model, that favors the installing of ICDs, does little to encourage the judicious application of science in this emotionally charged treatment, which prevents sudden cardiac death?
Do not misunderstand, the ICD is a remarkable device that has important uses and I am a believer and active “installer.” However, recommending an ICD has pre-requisites; these include a thorough evaluation of the patient including co-morbidities, a frank discussion with the patient about goals and expectations, an assessment of a patient’s compliance, an intelligence of programming after implantation and a commitment to follow-up. Further, it is clearly true that in most cases, ICD misuse stems not from overt malfeasance, but rather misinformation.
So as to not just complain and sound cynical, some suggestions are offered:
To the professors: When new guidelines are written there should be clarity on the importance of applying science to the ICD implant and that patients meet with an electrophysiologist before surgery to clarify the role of the ICD in their overall care.
Doctors who implant a device designed to lower mortality should be encouraged to ask the question: how similar their patient is to the patient cohorts in the primary prevention trials.
The guideline writers might also seek opinion from those who practice outside the university.
To patients: Seek out an electrophysiologist who discusses the ICD in its entirety and beware of the words, “you need an ICD.” Also, beware of the words, “an ICD is like an insurance policy;” as unlike a policy holder an ICD carries significant inherent risk.
JMM
5 replies on “A note to the professors, from the “real†world, on the use of ICDs in a fee for service community…”
Thank you for a very interesting post.
I was the second member of my family to have an ICD implanted; there are now four of us. It was a difficult decision. My EP suggested it, but left the final choice up to me. After some research, some long telephone conversations with my EP and a lot of thought, I decided to get the device.
I'm glad I did, but it's certainly not the easiest thing in the world to live with. If I was 75 or 80, or had other serious health issues, I might have chosen very differently.
John, I'm coming to see you when I think I might need an ICD for myself.
I wonder how many devices are installed because the guideline says to do it, but it's against the better judgement of the installer? After, you might get sued for withholding therapy.
-Steve
Helen,
ICDs are most appropriate for young patients with high risk Hypertrophic CM.
Thanks, Steve. When "experts" write guidelines they are often interpreted as mandates set in stone. This makes many doctors uneasy about not recommending an ICD out of fear. Additionally, the guidelines were vague and soon morphed into: low EF=ICD, which is incorrect. Then, there is favorable reimbursement; all form a perfect storm for overuse in the private world.
JMM
Microvolt T-Wave Alternans seems to have also been hammered by Medtronic for an obvious reason…jus sayin…98% negative predictive value….of course if it could have helped them sell more icds, they were all for it….Including St Jude…Funny though when they figured it would eliminat the low hanging fruit they decided to kill it…..http://www.nytimes.com/2007/05/16/business/smallbusiness/16heart.html
MTWA in risk stratification of CDM patients: can it help to better select candidates for ICD implantation? First experience of a single Belgian Center (Belgium Congress of Cardiology 2010)
Conclusion: MTWA ia an accurate NON-INVASIVE test to select ICD patients for primary prevention of arrhythmic events and sudden cardiac death. Even in our small cohort, a normal TWA test clearly identifies patients at low risk who have a good prognosis and are unlikely to benefit from primary prevention ICD implantationin in a long term follow-up…