Article

Evidence-Based Medicine And Policy: The Case Of The Implantable Cardioverter Defibrillator

Duke University, Durham, North Carolina, United States
Health Affairs (Impact Factor: 4.97). 01/2005; 24(1):42-51. DOI: 10.1377/hlthaff.24.1.42
Source: PubMed

ABSTRACT

The implantable cardioverter defibrillator (ICD) is a costly new treatment for patients at high risk of sudden cardiac death. Randomized trials of the ICD showed it to be effective in some groups of patients but not in others. While new trials testing the ICD were ongoing to clarify the evidence, policymakers faced immediate decisions about providing insurance coverage for the device. The high cost of ICDs, the large population of patients potentially eligible to receive them, the potential to reduce preventable deaths, and the unsettled state of the medical evidence provided a challenge to evidence-based medicine and to policymakers.

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    • "Given the expanding indications for ICD implantation,1–4,9,10 the issue of device deactivation will become more relevant as the population ages. Under current Medicare criteria, approximately 3–4 million patients are currently eligible to receive this device.4,11–13 Ultimately, all patients with an ICD will die, and therefore, it seems prudent to better understand their wishes with respect to the role the device will play in their future lives. "
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    ABSTRACT: To understand potential patient barriers to discussions about implantable cardioverter defibrillator (ICD) deactivation in patients with advanced illness. Qualitative focus groups. Fifteen community-dwelling, ambulatory patients with ICDs assigned to focus groups based on duration of time since implantation and whether they had ever received a shock from their device. A physician and a social worker used a predetermined discussion guide to moderate the groups, and each session was audiotaped and subsequently transcribed. Transcripts were analyzed using the method of constant comparison. No participant had ever discussed deactivation with their physician nor knew that deactivation was an option. Patients expressed a great deal of anxiety about receiving shocks from their device. Participants discussed why they needed the device and expressed desire for more information about the device; however, they would not engage in conversations about deactivating the ICD. One patient described deactivation "like an act of suicide" and all patients believed that the device was exclusively beneficial. Patients also expressed a desire to have their physician make the decision about deactivation. None of the patients in our study knew that they might need to deactivate their ICD as their health worsens. These community-dwelling outpatients were not willing to discuss the issue of ICD deactivation and their attitudes about deactivation might impede patients from engaging in these conversations. These findings are in contrast to findings in other advance care planning research and may be related to the unique nature of the ICD.
    Full-text · Article · Feb 2008 · Journal of General Internal Medicine
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    • "Given the expanding indications for ICD implantation,1–4,9,10 the issue of device deactivation will become more relevant as the population ages. Under current Medicare criteria, approximately 3–4 million patients are currently eligible to receive these devices, with 400,000 new patients eligible each year.3,11–13 Prior research has suggested that patients prefer physicians to initiate discussions about treatment options at the end of life. "
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    ABSTRACT: To understand potential barriers to physician-initiated discussions about Implantable Cardioverter Defibrillator (ICD) deactivation in patients with advanced illness. Qualitative one-on-one interviews. Four electrophysiologists, 4 cardiologists, and 4 generalists (internists and geriatricians) from 3 states. Clinicians were interviewed using open-ended questions to elicit their past experiences with discussing deactivating ICDs and to determine what barriers might impede these discussions. Transcripts of these interviews were analyzed using the qualitative method of constant comparison. Although many physicians believed that conversations about deactivating ICDs should be included in advance care planning discussions, they acknowledged that they rarely did this. Physicians indicated that there was something intrinsic to the nature of these devices that makes it inherently difficult to think of them in the same context as other management decisions at the end of a patient's life. Other explanations physicians gave as to why they did not engage in conversations included: the small internal nature of these devices and hence absence of a physical reminder to discuss the ICD, the absence of an established relationship with the patient, and their own general concerns relating to withdrawing care. Whereas some of the barriers to discussing ICD deactivation are common to all forms of advance care planning, ICDs have unique characteristics that make these conversations more difficult. Future educational interventions will need to be designed to teach physicians how to improve communication with patients about the management of ICDs at the end of life.
    Full-text · Article · Feb 2008 · Journal of General Internal Medicine
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