Technology is expensive.
Technology saves lives.
Technology can bankrupt.
When there's no technology, are you a "bad" doctor for not following guidelines?
When technology's used, are you a "bad" doctor because the patient has multiple comorbidities and the benefit for the implanted technology is questionable?
It's become the yin and yang of medicine. An inconvenient truth.
Medicine's technology is incredibly expensive, but incredibly valuable.
But if the struggle isn't enough, along comes the press to skew the debate by "raising awareness" with our patients.
Doctor, you need to "Get with the Guidelines." The subtitle with such an industry-sponsored trial and press report should be, "Oh, and business is off."
The journal article at the heart of the Chicago Tribune piece (referenced below) suggests the underpenetrated market of defibrillators (ICDs) was partially caused by three factors:
Adjusted analyses revealed lack of adherence for ICD use most notably with advancing age (odds ratio: 0.87; 95% confidence interval: 0.82 to 0.93 per 10 years), black race (odds ratio: 0.75; 95% confidence interval: 0.60 to 0.94), and lack of insurance (odds ratio: 0.45; 95% confidence interval: 0.26 to 0.78).But other factors exist, they claim, like geography and available expertise:
Practices in the Northeast U.S. were more likely to adhere to guidelines (P <.001), as were those with a dedicated HF clinic (P = .004) and electrophysiologists on staff (P <.001).These data are indeed valuable, even for an industry-sponsored trial. But patients should be aware that six of these devices must be implanted to save one life in properly selected populations of patients. Not to say that the cost-effectiveness of this approach hasn't been extensively reviewed, it has. But referring doctors and patients have also been barraged with the problems with these technologies. No doubt the chart reviews in the study cited probably didn't account for the rash of recalls whose influence continues today.
We must also place a jaded eye at the manufacturer's earlier press release about this trial that 35,000 charts had been reviewed, rather than less than half of that (15,381). Small error? Not so much.
Medicine is a complicated, non-linear profession. But as patients continue to shoulder more of their health care bills, doctors are finding themselves in the increasingly difficult position of recommending very expensive life-saving technology that might bankrupt their patients. Unless industry acknowledges that very real price pressures are straining this doctor-patient relationship, there will remain a reluctance to completely "Get With the Guidelines" and implant the technology, even when doing so stands to benefit the doctor.
-Wes
Ref: Evidence of clinical practice heterogeneity in the use of implantable cardioverter-defibrillators in heart failure and post–myocardial infarction left ventricular dysfunction: Findings from IMPROVE HF. HeartRhythm Dec 2009, 6(12), Pp 1727-1734.
