Hospital utilisation and the costs associated with complications of ICD implantation in a contemporary primary prevention cohort

Changes in numbers needed to treat and hospital care expenditures of optimized indications for primary prevention implantable cardioverter defibrillators: a scenario analysis

AIM

A strong need exists to better select patients with reduced left ventricular ejection fraction for primary prevention of sudden cardiac death by ICD implantation. This paper reports on the expected clinical and economic benefits of stricter indication scenarios based on minimum probabilities for patients of experiencing appropriate ICD-therapy and/or maximum risks of dying during the first 2 years following ICD implantation.

METHODS

Data on clinical events and hospital care expenditures were gathered for patients in the Dutch DO-IT registry. Registry-based prediction models were used to derive individual prior probabilities. Realistic assumptions were made concerning short-term disease courses and related hospital care in absence of ICD implantation. The potential impact of stricter indication scenarios was assessed with changes in numbers needed to treat (NNT) in subpopulations with (NNT-yes) or without (NNT-no) indication for ICD implantation and with changes in the yearly incidence-based national hospital care budget for ICD-based primary prevention.

RESULTS

The NNT-yes under the existing guidelines equalled 42. Not indicating ICD implantation if prior probabilities of receiving appropriate therapy within 2-year post-implant are < 5% seems a promising cutoff with an NNT-yes of 33, an NNT-no of 246 and a national annual reduction in hospital expenditures for ICD-based primary prevention of €11 million (16.7%).

CONCLUSIONS

Stricter indication criteria for primary prevention ICD implantation enable the selection of patient subpopulations with high numbers needed to treat, in which unnecessary harm can be forgone and substantial savings can be accomplished. The scenario analysis facilitates rationing of indication policies for ICD implantations.

Surgical skill simulation training to proficiency reduces procedural errors among novice cardiac device implanters: a randomized study

AIMS

In cardiac device implantation, having both surgical skills and ability to manipulate catheter/lead/wire is crucial. Few cardiologists, however, receive formal surgical training prior to implanting. Skills are mostly acquired directly on-the-job and surgical technique varies across institutions; suboptimal approaches may increase complications. We investigated how novel proficiency-based progression (PBP) simulation training impacts the surgical quality of implantations, compared to traditional simulation (SIM) training.

METHODS AND RESULTS

In this international prospective study, novice implanters were randomized (blinded) 1:1 to participate in a simulation-based procedure training curriculum, with proficiency demonstration requirements for advancing (PBP approach) or without (SIM). Ultimately, trainees performed the surgical tasks of an implant on a porcine tissue that was video-recorded and then scored by two independent assessors (blinded to group), using previously validated performance metrics. Primary outcomes were the number of procedural Steps Completed, Critical Errors, Errors (non-critical), and All Errors Combined. Thirty novice implanters from 10 countries participated. Baseline experiences were similar between groups. Compared to SIM-trained, the PBP-trained group completed on average 11% more procedural Steps (P < 0.001) and made 61.2% fewer Critical Errors (P < 0.001), 57.1% fewer Errors (P = 0.140), and 60.7% fewer All Errors Combined (P = 0.001); 11/15 (73%) PBP trainees demonstrated the predefined target performance level vs. 3/15 SIM trainees (20%) in the video-recorded performance.

CONCLUSION

Proficiency-based progression training produces superior objectively assessed novice operators' surgical performance in device implantation compared with traditional (simulation) training. Systematic PBP incorporation into formal academic surgical skills training is recommended before in vivo device practice. Future studies will quantify PBP training's effect on surgery-related device complications.