Patients whose implantable cardioverter-defibrillators (ICDs) are implanted by nonelectrophysiologists are at increased risk of complications and are less likely to receive a specific type of ICD when clinically indicated, according to a new study.
Increases in the population of patients eligible for ICD (a device implanted in the body that converts abnormal heart rhythms back to normal by delivering an electrical shock to the heart) therapy have led to a controversy over which physicians should implant ICDs. Currently, physicians with different training implant ICDs. The training paths range from completion of an electrophysiology fellowship accredited by the American Board of Internal Medicine to industry-sponsored training programs, according to background information in the article. "Differences in training, experience, and technique may result in differences in rates of procedural complications," the authors write. However, it is not known whether outcomes of ICD implantation vary by physician specialty.
In addition, appropriate device selection is particularly important for patients who may benefit from an ICD that also is capable of providing cardiac resynchronization therapy (CRT-D), a device that may improve survival and quality of life in patients with certain heart abnormalities.
Jeptha P. Curtis, M.D., of Yale University School of Medicine, New Haven, Conn., and colleagues analyzed data from the ICD Registry, a national procedure-based registry of ICD implantations, to assess the association of physician certification with rates of ICD procedural complications and CRT-D implantation. Cases from the ICD Registry were grouped by the certification status of the implanting physician into mutually exclusive categories: electrophysiologists, nonelectrophysiologist cardiologists, thoracic surgeons, and other specialists.
Of 111,293 ICD implantations included in the analysis, the researchers found that the majority of implants were performed by electrophysiologists (70.9 percent), with about 29 percent performed by nonelectrophysiologists (nonelectrophysiologist cardiologists, 21.9 percent; thoracic surgeons, 1.7 percent; and other specialists, 5.5 percent). The rates of overall and major complications were 3.5 percent and 1.3 percent, respectively, among electrophysiologists, and 5.8 percent and 2.5 percent, respectively, among thoracic surgeons.
"The mechanisms underlying the observed differences in complication rates are not clear, but they may reflect differences in training, experience, and operative technique," the authors write.
Among 35,841 patients (32.2 percent) who met criteria for CRT-D, those whose ICD was implanted by physicians other than electrophysiologists were significantly less likely to receive a CRT-D device compared with patients whose ICD was implanted by an electrophysiologist.
"Given the substantial benefits associated with CRT-D both in terms of improved survival and quality of life, the decision not to implant a CRT-D device carries significant implications for patient care."
The researchers also found that the majority of ICD implantations performed by nonelectrophysiologists took place at or relatively near hospitals in which an electrophysiologist also implanted ICDs.
"If confirmed, these findings may warrant a reappraisal of the need for and methods of training nonelectrophysiologists to implant ICDs," the authors conclude.
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In an accompanying editorial, James Coromilas, M.D., of the Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, New Brunswick, comments on the findings of this study.
"Based on the thorough and insightful analysis by Curtis et al, a compelling argument can be made based on the outcome measure of procedural complications, whenever possible, a board-certified electrophysiologist should be implanting ICDs. Curtis et al found that access to electrophysiologists is not a major factor in the implantation of ICDs by nonelectrophysiologists because two-thirds of the implants by nonelectrophysiologists were performed in hospitals that had electrophysiologists on staff and the distance to a hospital with a board-certified electrophysiologist was only a factor in a small percentage of cases."
- Curtis et al. Association of Physician Certification and Outcomes Among Patients Receiving an Implantable Cardioverter-Defibrillator. JAMA The Journal of the American Medical Association, 2009; 301 (16): 1661 DOI: 10.1001/jama.2009.547
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