It took over a week to finish writing about some of the major news concerning defibrillators (ICDs) from the Heart Rhythm Society sessions this month.
As therapies go, the ICD could not be much more complicated. These expensive devices are often implanted in patients at risk for–but not yet had–sudden death. The stats in this regard suggest we implant 15-20 useless ICDs for every one that saves a life. Unfortunately, we cannot know which patient will get a life-saving shock and which will be one of 20 who do not. We try our best to risk stratify patients before implant, but this is not an exact science.
Predicting the need for the device is only one of the complicated aspects of the ICD. Others include the risk of the device: surgical mishaps, infection, inappropriate painful shocks and now, device recalls. Another risk less mentioned is the chance that a shock from an ICD may only change a person’s mode of death from painless and quick to painful and drawn out.
And there’s more complexity. An ICD can be easily implanted and is well-re-reimbursed. These two facts have led some to believe doctors are apt to over-utilize ICDs. Now, two branches of government are investigating ICD use. Scrutiny from the CMS and the Department of Justice has had a chilling effect on ICD use. Even nuanced implanters who have long advocated restraint in implanting ICDs have garnered no good-will capital. We are just as guilty as any other implanting ICD doctor. (Yes…you are reading between the lines correctly…it is frustrating.)
My post on theHeart.org is titled Part 1 of my favorite ICD-related stories from HRS 2012 (Part 2 is coming soon.)
I try to accurately represent the many sides of the ICD debate. I highlight a striking abstract that showed patients who were implanted with non-evidence based ICDs (and so would be called inappropriate by federal regulators) had the same outcomes as those who had evidence-based devices. In other words, maybe some inappropriate ICDs are not so inappropriate.
If so inclined head over to Trials and Fibrillations.
JMM
One reply on “New ICD post on Trials and Fibrillations”
Your world is similar to the world of most other medical providers with 2 big differences … : i) You are reimbursed better than most (especially compared to medical providers) when you implant a device; and ii) ICD implantation is not uncommonly a life-or-death-determining decision … Because of this – your field is subject to that-much-closer scrutiny …
It isn’t easy. It is definitely “no fun” being scrutinized by pencil pushers (who have never seen a patient) when you are soul-searchingly trying to do the right thing.