Geographic Differences in Implantable Cardioverter Defibrillator Usage

Abstract

Geographic Differences in ICD Usage. Despite the demonstrated efficacy of implantable cardioverter defibrillators (ICDs) in reducing sudden and total mortality in selected patients, their implantation rates vary greatly among countries. In the United States, the implantation rate is 185 implants per million inhabitants compared with only 31 implants per million in western Europe. The differences in ICD use may be explained by the following factors: manner in which sudden cardiac death is perceived by politicians and physicians (sudden cardiac death is perceived as a “nice way of dying”); differences in indications; physicians' information; prevalence of coronary artery disease; sudden cardiac death survival rates; perceived reliability of alternative treatment (namely, antiarrhythmics including amiodarone); economic backgrounds; and health care politics. Furthermore, the cost of this treatment strategy must be considered. This issue has been raised because generalization of ICD use in patients matching clinical characteristics of patients enrolled in the primary prevention trials may represent a significant economic burden to be added to the already overloaded health care system. This low acceptance may not be entirely related to budget constraint but also to the perceived efficacy of ICDs by physicians and health authorities.

Utilization of implantable cardioverter-defibrillators in survivors of cardiac arrest in the United States from 1996 to 2001

“…There may be a general reluctance within the medical community to implant defibrillators in survivors of CA who have significant comorbidities and limited life-expectancy. Finally, health care providers' perception of CA as a painless way of dying may provide a barrier to appropriate ICD utilization (16).…”

ICD Therapy: What Have We Learned From the Clinical Trials?

“…In the United States 185 ICDs are implanted/million population; In Western Europe and Japan this figure is 31 and 8 per million, respectively. 61 Based on MADIT II, COMPANION, DEFINITE, and SCD-HeFT trials, most candidates for CRT will likely receive CRT + ICD and this will further accelerates the growth rate of ICD implantation. All these factors will substantially increase the cost burden of health care.…”

The patient with an implantable cardioverter defibrillator

“…The researchers concluded that the ICD is underused, and many people who could benefit from this technology were not receiving it. It is of interest that the implant rate in European countries is one fifth of that in the United States, 8 with cost a likely factor in the difference between implant rates.…”