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Published on: February 28, 2012
Assessing physician knowledge regarding indications for a primary prevention implantable defibrillator and potential
Rochelle Bernier1, Satish R Raj2, Dat Tran3
1Mazankowski Alberta Heart Institute, Division of Cardiology, University of Alberta, Alberta, Canada.
Insights
Physician knowledge of primary prevention implantable cardioverter-defibrillators (ICDs) is limited, impacting utilization. Addressing knowledge gaps and specific barriers among internists, cardiologists, and residents can improve appropriate ICD use in high-risk patients.
Area of Science:
- Cardiology
- Medical Device Technology
- Clinical Practice Guidelines
Background:
- Primary prevention implantable cardioverter-defibrillators (ICDs) are proven to reduce mortality in high-risk individuals.
- Despite evidence, ICD utilization remains suboptimal, suggesting potential barriers in physician referral practices.
- Limited data exist on referring physicians' understanding of ICD guidelines and their attitudes toward device implantation.
Purpose of the Study:
- To assess referring physicians' knowledge of primary prevention ICD indications.
- To identify barriers influencing physician decisions for ICD referral.
- To inform the development of strategies for improving appropriate ICD utilization.
Main Methods:
- A web-based survey was developed by the Alberta Cardiovascular and Stroke Strategic Clinical Network's Arrhythmia Working Group.
- The survey included case scenarios on primary prevention ICD indications and referral barriers.
- 109 physicians (internists, cardiologists, cardiology residents) completed the survey, yielding a 14% response rate.
Main Results:
- Only 34% of physicians provided complete guideline-concordant answers regarding ICD indications.
- Cardiologists (OR 5.9) and cardiology residents (OR 6.7) were more likely to demonstrate guideline concordance.
- Barriers varied: internists lacked knowledge confidence, cardiologists cited cost-effectiveness, and residents worried about inappropriate shocks.
Conclusions:
- Physician knowledge of primary prevention ICD indications is limited and inconsistent across specialties.
- Referral barriers differ significantly among internists, cardiologists, and cardiology residents.
- Targeted interventions addressing specific knowledge deficits and barriers are crucial for enhancing appropriate ICD use.
Background:
Although there is clear evidence to demonstrate that primary prevention implantable defibrillators (ICDs) reduce mortality in high-risk patients, ICDs are underutilized. Limited data exist assessing referring physicians' knowledge about guideline indications and attitudes towards ICDs, which may influence decision for referral.
Methods And Results:
The Arrhythmia Working Group from the Alberta Cardiovascular and Stroke Strategic Clinical Network developed a web-based survey consisting of case scenarios regarding primary prevention ICD indications and a list of barriers for referral to aid in the design of a complex device care pathway. We invited referring physicians to participate in the survey including internists and cardiologists and cardiology residents. The survey was completed by 109 of 799 (response rate = 14%) of physicians. Of those, 55% were internists, 32% cardiologists, and 13% cardiology residents. The majority of physicians were male (62%), practicing in a university hospital (66%). Overall, complete guideline-concordant answers were provided by 34% of physicians. In multivariable analysis, predictors of complete guideline concordance were being a cardiologist (odd ratio [OR] 5.9, confidence interval [CI] 2.1-16.4, P = 0.001) and cardiology resident (OR 6.7, CI 1.7-27.3, P = 0.007). The most common barrier for referral for internists was lack of confidence in knowledge of guideline recommendations; while cardiologists reported concerns about cost-effectiveness and cardiology residents were most concerned with inappropriate shocks.
Conclusion:
Knowledge regarding indications for primary prevention ICD is limited and varies significantly among referring physicians. The barriers for referral differ among physician groups and addressing these identified barriers may help to improve appropriate ICD utilization.
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