The Belgian system to control indications for the implantable defibrillator: a model for other European countries?

The purpose of this study was to assess the value of the Belgium system to control the indications for the implantable defibrillator.

We reviewed the answers of our official organization (Riijksinstituut voor Ziekte en Invaliditeitsverzekering-RIZIV) to our requests of implantable defibrillators in 49 patients in 1990, 1991 and the first months of 1992. In 1988 and in agreement with the RIZIV, 15 implants per year were allowed, but this number had been extended to 100 in 1992.

There was an increasing first refusal rate from 1990 (0%) to 1991 (25%) and 1992 (42%), which was caused by: a) Difficulties to deal with indications for unusual diseases, particularly young patients with cardiac arrest and a structural normal heart; b) Possible distrust by the RIZIV towards the physician when the number of requests increases over time. However, all patients for whom a defibrillator was requested ultimately had it implanted.

In the most ideal type of cooperation between official organisms and implanting physicians, such as the Belgian system, the official organization has to realize that uncommon patients with disputable indications exist. To avoid refusal of reimbursement in these cases, the decision taken by the treating physician can be accepted only on condition that the mutual relationship between both parties is based on open communication, mutual respect, and trust. The Belgian system provides care to all patients requiring a defibrillator with costs to society which are very acceptable. The Belgian system may be an excellent model for countries without clear regulations for reimbursement of implantable defibrillators.