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Published on: February 28, 2012
Regional variations in physicians' attitudes and recommendations surrounding implantable cardioverter-defibrillators
Dan D Matlock1, Jean S Kutner, Caroline B Emsermann
1Division of General InternalMedicine, University of Colorado, Denver School of Medicine, 12631 E. 17th Ave., Aurora, CO 80045, USA. daniel.matlock@ucdenver.edu
Insights
Physician recommendations for implantable cardioverter-defibrillators (ICDs) vary by region, not by physician attitude. High-use regions recommend ICDs more often, even for patients with limited benefit.
Area of Science:
- Cardiology
- Health Services Research
Background:
- Physician attitudes and recommendations regarding implantable cardioverter-defibrillators (ICDs) may influence their utilization.
- Regional variations in ICD use suggest potential disparities in care.
Purpose of the Study:
- To investigate the association between physicians' attitudes, recommendations, and regional variations in ICD use.
- To determine if physician recommendations align with established guidelines across different regions.
Main Methods:
- A national survey of 9969 American College of Cardiology members was conducted.
- Survey responses were linked with ICD implantation rates from the National Cardiovascular Data Registry.
- Multivariable regression analysis assessed trends between regional ICD use and physician responses.
Main Results:
- Physicians demonstrated consistent recommendations for ICDs in male/female patients with ischemic or non-ischemic cardiomyopathy across all regions.
- Recommendations for ICD therapy increased significantly for "frail" patients (21% to 32%) or those with <1 year life expectancy (5% to 10%).
- These recommendation trends were not associated with physicians' attitudes toward ICDs.
Conclusions:
- Physicians in low ICD use regions adhere to guidelines for recommending ICDs in appropriate cases.
- Physicians in high ICD use regions are more likely to recommend ICDs for patients who may derive limited benefit.
- Regional variations in ICD use are not explained by differences in physician attitudes or recommendations for guideline-supported indications.
Introduction:
This study was designed to determine if physicians' attitudes and recommendations surrounding implantable cardioverter-defibrillators (ICDs) are regionally associated with ICD use.
Methods And Results:
A national sample of 9969 members of the American College of Cardiology was surveyed electronically. Responses were merged with rates of ICD implantation from the National Cardiovascular Data Registry. Multivariable regression was used to assess trends between regional use and responses. We received 1210 responses (12%) and used 1124 after exclusions. Across regions, physicians were equally likely to recommend ICDs to males or females with ischemic (∼99% for both; P = NS) or nonischemic cardiomyopathy (85 vs. 88% P = 0.85). Significant increasing trends in the probability recommending ICD therapy were found when the patient was "frail" (21% to 32%; P = .03) or had a life expectancy <1 year (5% to 10%; P = .05). These differences were not associated with attitudes toward ICDs.
Conclusions:
Independent of variations in physicians' attitudes towards ICDs, physicians in regions of low ICD use are not less likely to recommend ICDs in situations clearly supported by guidelines while those in regions of high ICD use are more likely to recommend ICDs to patients who might have limited benefit.
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