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ICD nonuse in eligible patients may be lower than previously estimated

LaPointe N. Circ Cardiovasc Qual Outcomes. 2011;4:146-151.

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Detailed analysis showed that rates of underutilization of implantable cardioverter defibrillators among eligible patients decreased from 41% to 13%, according to newly published data.

“To date, several analyses of claims or registry data have indicated high rates of underutilization of this evidence-based therapy in clinical practice, as well as age, sex and racial disparities in ICD use,” the researchers wrote. “Although we initially identified similar rates of ICD underutilization and disparities within our health care system, after detailed medical record abstraction, we discovered that a majority of those not receiving an ICD had an identified contraindication or patient refusal.”

Their analysis included patients (n=542) with a diagnosis of HF and left ventricular ejection fraction of no more than 30% at a tertiary care center from Jan. 1, 2007, to Aug. 30, 2007. With the use of medical records, researchers determined reasons for nonuse among patients without an ICD.

Overall, 224 eligible patients (41%) did not receive an ICD. Adjusted analysis comparing all ICD recipients with all nonrecipients revealed absence of ventricular arrhythmia or cardiac arrest (OR=3.17; 95% CI, 2.14-4.68), index hospitalization on a noncardiology service (OR=2.64; 95% CI, 1.65-4.21) and female sex (OR=1.90; 95% CI, 1.28-2.81) as being the factors most associated with nonuse.

After performing a detailed chart review on the eligible patients, researchers observed that 117 patients (52%) were ineligible for the device and 38 (17%) refused it, leading to only 69 (13%) patients eligible for an ICD who failed to receive one.

Furthermore, analysis comparing all ICD recipients with nonrecipients without contraindications indicated the following characteristics of nonuse: absence of ventricular arrhythmias (OR=4.93; 95% CI, 2.56-9.5), noncardiology hospital service (OR=3.73; 95% CI, 1.98-7.04) and no health insurance (OR=3.10; 95% CI, 1.48-6.46).

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