Published: Oct. 2, 2007
Updated: Oct. 3, 2007
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By Duke Medicine News and Communications
DURHAM, NC – Many Americans hospitalized for heart failure are coming up short when it comes to getting the therapy they need – especially women and minorities, say researchers at Duke University Medical Center.
Researchers studied patterns of implantable cardioverter defibrillator (ICD) use for a two-year period among 13,034 patients hospitalized with heart failure in 217 hospitals participating in the American Heart Association's Get With The Guidelines - Heart Failure quality improvement program. They found that among those eligible for ICD therapy, only 35 percent actually had one of the devices in place or had plans for the therapy when they left the hospital.
An ICD is a three-inch device that constantly monitors heart rhythms and uses electrical shocks to help control erratic rhythms that could cause the heart to stop beating.
Dr. Adrian Hernandez, the lead author of the study and a cardiologist at the Duke Clinical Research Institute (DCRI), says they also found that white men are the most likely to get ICD therapy. Black men are 25 percent less like to receive an ICD than white men, and women – black or white – are 50 percent less likely to receive an ICD than white men.
The results appear in the October 3 issue of the Journal of the American Medical Association.
"Cardiovascular disease is the leading cause of death for women, and survival among women with heart failure has not improved substantially over the past 10 to 20 years," says Hernandez. "Increasing ICD use among eligible women with heart failure highlights one potential way that we could improve outcomes."
Practice guidelines recommend ICD use for patients who have heart failure who also have an ejection fraction of 30 percent or less. The ejection fraction is a measure of the heart's ability to pump. There are no studies suggesting that sex or race should be considered in prescribing ICDs, says Dr. Eric Peterson, the senior author of the paper and a member of the Get With The Guidelines – Heart Failure steering committee.
Peterson, who is also a cardiologist and member of the DCRI, says "the degree to which this technology is life-saving and not optional makes these findings all the more frightening."
The authors say it's not clear what accounts for the differences in ICD use – the study wasn't designed to detect that – but they note that when new technology is introduced, white men are usually the first to benefit. They say that patient preference may play a role, or perhaps physicians approach women and black patients with different assumptions regarding their health care needs or desires.
Given that the data on ICD use comes from hospitals voluntarily taking part in a quality improvement initiative, Peterson says the study's figures may underestimate the magnitude of the problem on a wider scale. "These hospitals are interested in doing the best they can do to comply with practice guidelines, and ICD use might be substantially lower in centers that are not participating."
Hernandez and Peterson say the Get With the Guidelines - Heart Failure program provides valuable feedback about physician and hospital performance and may help close the gap between evidence and practice.
Hernandez questions whether full compliance will come quickly, though, noting that ICDs cost anywhere from $30,000 to $40,000 thousand dollars. "At a time when our society is actively talking about health care reform and rationing resources, questions about who should get these devices and who should not are bound to come up, despite current practice guidelines. Still, there is no debate about their benefits, and some may feel that any costs are justifiable if ICDs save lives."
Support for the study came from the Get with the Guidelines - Heart Failure quality improvement program, sponsored by the American Heart Association, with funding from GlaxoSmithKline.
Hernandez and Peterson and several of the co-authors are supported through grants from pharmaceutical companies and medical device makers that produce products for heart failure care.
Co-authors include Gregg Fonarow from UCLA Medical Center; Li Liang, Sana Al-Khatib and Lesley Curtis, from Duke Clinical Research Institute; Clyde Yancy, from the Baylor Heart and Vascular Institute; and Nancy Albert, from Cleveland Clinic.
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