Do physicians' attitudes toward implantable cardioverter defibrillator therapy vary by patient age, gender, or race?

Racial and ethnic differences in implantable cardioverter-defibrillator patient selection, management, and outcomes

Racial and ethnic differences in treatment-cardiovascular and otherwise-have been documented in many aspects of the American health care system and can be seen in implantable cardioverter-defibrillator (ICD) patient selection, counseling, and management. ICDs have been demonstrated to be a powerful tool in the prevention of sudden cardiac death, yet uptake across all eligible patients has been modest. Although patients who do not identify as White are disproportionately eligible for ICDs in the United States, they are less likely to see specialists, be counseled on ICDs, and ultimately have an ICD implanted. This review explores racial and ethnic differences demonstrated in ICD patient selection, outcomes including shock effectiveness, and postimplantation monitoring for both primary and secondary prevention devices. It also highlights barriers for uptake at the health system, physician, and patient levels and suggests areas of further research needed to clarify the differences, illuminate the driving forces of these differences, and investigate strategies to address them.

Sex-Based Differences in Selected Cardiac Implantable Electronic Device Use: A 10-Year Statewide Patient Cohort

Background

Cardiac implantable electronic devices (CIEDs) include pacemakers, cardioverter defibrillators, and resynchronization therapy. This study aimed to assess CIED implantation and outcomes by sex and indication.

Methods and Results

This was a retrospective cohort study of adults with cardiovascular hospitalizations in New South Wales, Australia (2008 to 2018). CIED implantation in patients with arrhythmia, cardiomyopathy, and syncope were examined. Subcategories (complete heart block, atrial fibrillation/atrial flutter, ventricular tachycardia/ventricular fibrillation/cardiac arrest, sick sinus syndrome, and ischemic and nonischemic cardiomyopathy) were investigated. Primary outcome was implantation of CIEDs in men versus women adjusted for age and comorbidities. Secondary outcomes were trends over time, time to implant, length of stay, emergency status, and 30‐day survival. Of 1 291 258 patients with cardiovascular admissions, 287 563 had arrhythmia, cardiomyopathy, or syncope and 29 080 (2.3%) received a CIED (22 472 pacemakers, 6808 defibrillators, 3207 resynchronization therapy). Women with arrhythmia, cardiomyopathy, or syncope were less likely to have pacemakers (adjusted odds ratio [aOR], 0.78 [95% CI, 0.76–0.80]), defibrillators (aOR, 0.4, [95% CI, 0.40–0.45]) and resynchronization therapy (aOR, 0.66 [95% CI, 0.61–0.71]). Differences persisted across subcategories, including fewer pacemakers in complete heart block (aOR, 0.89 [95% CI, 0.80–0.98]) and syncope (aOR, 0.70 [95% CI, 0.63–0.79]); fewer defibrillators in ventricular tachycardia/ventricular fibrillation/cardiac arrest (aOR, 0.69 [95% CI, 0.61–0.77]); and less resynchronization therapy in cardiomyopathy (aOR, 0.62 [95% CI, 0.51–0.75]). Men and women receiving devices had higher 30‐day survival compared with those who did not receive a device, and 30‐day survival was similar between men and women receiving devices.

Conclusions

Lower CIED implantation was seen in women versus men, across nearly all indications, including complete heart block and ventricular tachycardia/ventricular fibrillation/cardiac arrest. The underuse of cardiac devices among women may arguably reflect a sex bias and requires further research.

Comparative effectiveness of CRT in older patients with heart failure: Systematic review and meta-analysis

OBJECTIVE

To perform meta-analyses comparing safety and effectiveness of cardiac resynchronization therapy (CRT) in older versus younger patients with heart failure with reduced ejection fraction (HFrEF).

BACKGROUND

Pivotal CRT trials enrolled patients with HFrEF significantly younger than the typical contemporary patient with HFrEF. Thus, risks and benefits in this older population with HFrEF are largely unknown.

METHODS

PubMed, The Cochrane Library, Scopus, and Web of Science were queried for comparative effectiveness studies of CRT in older HFrEF patients. Title, abstract, and full text screening was performed to identify studies comparing at least one pre-specified endpoint between older and younger adult patients with at least 50 participants. Random effects meta-analysis in LVEF mean difference (older minus younger) and relative risk (RR) of death, improvement in New York Heart Association (NYHA) class, and complications are reported along with estimates of heterogeneity.

RESULTS

In 7 studies, there was similar LVEF improvement between groups [mean difference 1.14; 95% CI -0.04 - 2.32, p=0.06, I 2 =53%]. Older patients were equally likely as younger patients to see an improvement in NYHA class of at least 1 in 6 studies [RR 0.99; 95% CI, 0.93 - 1.06; p=0.76; I 2 =25%]. No significant differences in the incidence of hematoma, pneumothorax, lead dislodgment, cardiac perforation, or infection requiring explant was observed. RR of mortality in 11 studies demonstrated higher risk of all-cause mortality in older patients [RR 1.05; 95% CI, 1.03 - 1.08, p<0.01, I 2 =0%].

CONCLUSIONS

Compared with younger patients, older patients receiving CRT were equally likely to experience improvement in LVEF, LVEDD, and NYHA class. There was no difference in procedural complications. The higher rate of all-cause mortality in older patients likely reflects a greater underlying risk of death from competing causes.

Decision-making regarding primary prevention implantable cardioverter-defibrillators among older adults

Most implantable cardioverter defibrillators (ICDs) are implanted for the purpose of primary prevention of sudden cardiac death among older patients with heart failure with reduced ejection fraction. Shared decision‐making prior to device implantation is guideline‐recommended and payer‐mandated. This article summarizes patient and provider attitudes toward device placement, device efficacy and effectiveness, potential periprocedural complications, long‐term events such as shocks, quality of life, costs, and shared decision‐making principles and recommendations. Most patients eligible for an ICD anticipate more than 10 years of survival. Physicians are less likely to offer an ICD to patients ≥80 years of age given a perceived lack of benefit. There is a dearth of data from randomized clinical trials addressing device efficacy among older patients; there is a need for more research in this area. However, currently available data support the use of ICDs irrespective of age provided life expectancy exceeds 1 year. Advanced age is independently associated with complications at the time of device placement but not the risk of device infection. The risk of inappropriate shock may be comparable or lower than that of younger patients. While quality of life is generally not adversely impacted by an ICD, a subset of patients experience post‐traumatic stress disorder. ICDs are cost‐effective from societal and health care sector perspectives; however, out‐of‐pocket costs vary according to insurance type and level. Shared decision‐making encounters may be incremental and iterative in nature. Providers are encouraged to partner with their patients, providing them counsel tailored to their values, preferences, and clinical presentation inclusive of age.

Sex and Race/Ethnicity Differences in Implantable Cardioverter-Defibrillator Counseling and Use Among Patients Hospitalized With Heart Failure: Findings from the Get With The Guidelines-Heart Failure Program

BACKGROUND

Previous studies have found that women and black patients eligible for a primary prevention implantable cardioverter-defibrillator (ICD) are less likely than men or white patients to receive one.

METHODS

We performed an observational analysis of the Get With The Guidelines-Heart Failure Program from January 1, 2011, to March 21, 2014. Patients admitted with heart failure and an ejection fraction ≤35% without an ICD were included. Rates of ICD counseling among eligible patients and ICD receipt among counseled patients were examined by sex and race/ethnicity.

RESULTS

Among 21 059 patients from 236 sites, 4755 (22.6%) received predischarge ICD counseling. Women were counseled less frequently than men (19.3% versus 24.6%, P<0.001, adjusted odds ratio [OR], 0.84; 95% confidence interval [CI], 0.78-0.91). Racial and ethnic minorities were less likely to receive counseling than white patients (black 22.6%, Hispanic 18.6%, other race/ethnic group 14.4% versus white 24.3%, P<0.001 for each): adjusted OR versus white, 0.69; 95% CI, 0.63 to 0.76 for black patients; adjusted OR, 0.62; 95% CI, 0.55 to 0.70 for Hispanic patients; adjusted OR, 0.53; 95% CI, 0.43 to 0.65 for other patients. Among the 4755 counseled patients, 2977 (62.6%) received an ICD or had one planned for placement after hospital stay. Among those counseled, women and men were similarly likely to receive an ICD (adjusted OR, 1.13; 95% CI, 0.99-1.29). However, black (adjusted OR, 0.70; 95% CI, 0.56-0.88) and Hispanic patients (adjusted OR, 0.68; 95% CI, 0.46-1.01) were less likely to receive an ICD.

CONCLUSIONS

Up to 4 of 5 hospitalized patients with heart failure eligible for ICD counseling did not receive it, particularly women and minority patients. Among counseled patients, ICD use differences by race and ethnicity persisted.

Future Research Prioritization: Implantable Cardioverter-Defibrillator Therapy in Older Patients

BACKGROUND

Although the implantable cardioverter-defibrillator (ICD) is highly effective therapy for preventing sudden cardiac death, there is considerable uncertainty about its benefits and harms in older patients, especially in the presence of factors, other than old age, that increase the risk of death.

OBJECTIVE

To develop a prioritized research agenda for the Patient-Centered Outcomes Research Institute as informed by a diverse group of stakeholders on the use and outcomes of the ICD in older patients.

DESIGN

The existing literature was reviewed to identify evidence gaps, which were then refined by engaged stakeholders. Using a forced-ranking prioritization method, the stakeholders ranked evidence gaps by importance. For the highest-ranked evidence gaps, relevant recent studies were identified using PubMed, and relevant ongoing trials were identified using ClinicalTrials.gov.

PARTICIPANTS

Eighteen stakeholders, including clinical experts and researchers in the prevention of sudden cardiac death and ICD therapy, representatives from federal and non-governmental funding agencies, representatives from relevant professional societies, health care decision-makers and policymakers, and representatives from related consumer and patient advocacy groups

KEY RESULTS

The top 12 evidence gaps prioritized by stakeholders were related to the safety and effectiveness of ICDs in older patient subgroups not well represented in clinical trials, predictors of SCD, the impact of the ICD on quality of life, the use of shared decision-making, disparities in ICD use, risk stratification strategies, patient preferences, and distribution of modes of death in older patients.

CONCLUSIONS

In this paper, we identify evidence gaps of high priority for current and future investigations of ICD therapy. Addressing these gaps will likely resolve many of the uncertainties surrounding the use and outcomes of the ICD in older patients seen in clinical practice.

A systematic review of the extent and measurement of healthcare provider racism

BACKGROUND

Although considered a key driver of racial disparities in healthcare, relatively little is known about the extent of interpersonal racism perpetrated by healthcare providers, nor is there a good understanding of how best to measure such racism.

OBJECTIVES

This paper reviews worldwide evidence (from 1995 onwards) for racism among healthcare providers; as well as comparing existing measurement approaches to emerging best practice, it focuses on the assessment of interpersonal racism, rather than internalized or systemic/institutional racism.

METHODS

The following databases and electronic journal collections were searched for articles published between 1995 and 2012: Medline, CINAHL, PsycInfo, Sociological Abstracts. Included studies were published empirical studies of any design measuring and/or reporting on healthcare provider racism in the English language. Data on study design and objectives; method of measurement, constructs measured, type of tool; study population and healthcare setting; country and language of study; and study outcomes were extracted from each study.

RESULTS

The 37 studies included in this review were almost solely conducted in the U.S. and with physicians. Statistically significant evidence of racist beliefs, emotions or practices among healthcare providers in relation to minority groups was evident in 26 of these studies. Although a number of measurement approaches were utilized, a limited range of constructs was assessed.

CONCLUSION

Despite burgeoning interest in racism as a contributor to racial disparities in healthcare, we still know little about the extent of healthcare provider racism or how best to measure it. Studies using more sophisticated approaches to assess healthcare provider racism are required to inform interventions aimed at reducing racial disparities in health.

Ventricular arrhythmias: device therapy and ablation

There are few randomized, well-controlled studies to guide decision making with respect to the treatment of ventricular arrhythmias in the elderly treated with either device implantation or catheter ablation. Although some data are conflicting, the elderly appear to have a greater degree of risk related to treatment compared with younger ones; however, this increased risk is in part a consequence of age itself and comorbid conditions. Conversely, in terms of benefit, although the data may again be mixed, there is ample information indicating that age should not contraindicate aggressive treatment when accepted indications for intervention exist.