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Physician certification associated with differing outcomes for ICD implantation
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Patients who have an implantable cardioverter defibrillator implanted by a physician other than an electrophysiologist are at an increased risk for developing complications, study results suggested.
Researchers retrospectively analyzed registry data from 111,293 ICD implantations performed between 2006 and 2007. A total of 2,128 physicians (1,303 electrophysiologists, 614 nonelectrophysiologist cardiologists, 66 thoracic surgeons and 145 other specialists) who had performed at least 10 ICD implantations were included in the analysis. Board-certified electrophysiologists implanted 78,857 (70.9%) of the devices; 24,399 (21.9%) were implanted by nonelectrophysiologist cardiologists; 1,862 (1.7%) by thoracic surgeons; 6,175 (5.5%) by other specialists.
According to the study results, overall complication rates (3.5%) and major complication rates (1.3%) were lowest among patients who had their ICDs implanted by an electrophysiologist. The overall and major complication rates were highest among thoracic surgeons (5.8% and 2.5%, respectively). The researchers reported differences in complication rates of dual-chambered ICDs and cardiac resynchronization therapy devices across all physician categories (P<.001 for interaction).
In addition, the researchers reported that 34,841 (32.2%) of the patients in the study met the criteria for receiving a CRT-D. A multivariable, adjusted analysis suggested that patients were less likely to receive CRT-D devices if their ICDs were implanted by thoracic surgeons (RR=0.81; 95% CI, 0.74-0.88), nonelectrophysiologist cardiologists (RR=0.93; 95% CI, 0.91-0.95) and other specialists (RR=0.97; 95% CI, 0.94-0.99).
“Patients whose ICDs are implanted by nonelectrophysiologists are at an increased risk for developing procedural complications and are less likely to receive CRT-D when eligible compared with those whose devices are implanted by electrophysiologists,” the researchers concluded. “If confirmed, these findings may warrant a reappraisal of the need for and methods of training nonelectrophysiologists to implant ICDs.” – by Eric Raible
Curtis J. JAMA. 2009;301:1661-1670.
Numerous studies support the conclusion that highly trained physicians who perform more of a particular procedure obtain better results than less-trained physicians. The results from this study are no different: The highly trained physicians (ie, electrophysiologists) perform ICD implantations with fewer complications than nonelectrophysiologist physicians. Furthermore, the electrophysiologists were more likely to implant a CRT-D device in appropriate patients; the inference being that maneuvering a pacing wire in the coronary sinus vasculature was more likely to be done by electrophysiologists.
The implications are twofold. First, similar to many surgeons having to make public their operative mortality figures, these results should be made available to patients. That way they can “vote with their feet” as to who they wish to have implant their ICD or CRT-D. Second, the Heart Rhythm Society and American College of Cardiology might revisit the ICD implantation credentialing criteria to consider setting the bar higher.
– Douglas P. Zipes, MD
Cardiology Today Section Editor