Low referral rates and treatment disparities lead to underuse of ICDs in indicated patients

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Principal investigator Anne Curtis

Implantable cardiac devices are underused, with widespread gender and race treatment disparities, and low referral rates to electrophysiologists, according to the findings from three studies presented at the Heart Rhythm Society’s 40th Annual Scientific Sessions (HRS 2019; 8–11 May, San Francisco, USA). The studies were based on analyses of electronic health records (EHR) datasets and algorithms.

Principal investigator Anne Curtis (University at Buffalo, New York, USA), said: “Device usage across both gender and race was strikingly low, despite medical records documenting patient eligibility for the therapy. The breadth of practice type, from academic medical centres to community hospitals, along with the sheer number of patients highlight the seriousness of the challenge.”

Implantable cardioverter defibrillators (ICD) and cardiac resynchronisation therapy (CRT) pacemakers (CRT-P) and defibrillators (CRT-D) are usually implanted by an electrophysiologist, following referral from a general practitioner or a general cardiologist. But an analysis of EHR data on referral and implant patterns among ICD-indicated patients demonstrated that only half (50.5%) of all patients medically indicated for a device were referred to an electrophysiologist. Of the patients who were referred to and seen by an electrophysiologist, 44.3% received a device, which was more likely to be an ICD. Only 8.8% of patients who did not see an electrophysiologist received a device.

In a separate, real-world analysis of disparities among people indicated for implantable cardiac devices, using EHR data from more than one million patients and based on medical society guidelines, devices were found to be implanted more frequently in indicated men than women (16.7% vs. 12.7%, respectively), but were significantly underused in all patient populations, and both women and men of colour and white women received devices at lower rates than white men. The assessment is consistent with previous research showing that black patients are considerably less likely to receive cardiac interventions.

A third analysis looked at the utilisation rates of device therapies in heart failure patients as defined by medical society (American College of Cardiology Foundation [ACCF]/American Heart Association [AHA]/Heart Rhythm Society [HRS]) guidelines. It showed that ICDs and CRT-Ds are substantially underused compared to other cardiovascular interventions, such as imaging, drug therapies and coronary procedures. Less than one-third (32.3%) of eligible patients received CRT, and 11% of eligible patients received ICDs. The analysis showed consistent underutilisation trends across five years (2012–2016) in >100,000 patients, adding to existing research which has previously highlighted treatment gaps. The impact of the 2012 guidelines (ACCF/AHA/HRS Focused Update for Device-based Therapies of Cardiac Rhythm Abnormalities) had not been thoroughly studied previously.

Curtis told Cardiac Rhythm News: “Cardiac implantable devices improve survival, important patient outcomes, and quality of life in appropriately selected patients. We need comprehensive quality improvement initiatives to identify patients who meet guideline indications for device therapy in order to get them the indicated treatment.”

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