Incidence of Unwarranted Implantation of Permanent Cardiac Pacemakers in a Large Medical Population

Abstract

Because of allegations that the implantation of many permanent cardiac pacemakers has been unjustified, we reviewed the indications for all new pacemakers implanted at 30 hospitals in Philadelphia County between January 1 and June 30, 1983, and paid for by Medicare. Complete chart data were evaluated for 382 implants. We determined whether the indications for implantation were appropriate and adequately documented on the basis of standard clinical practice. Implants were classified as possibly indicated primarily because of inadequate diagnostic evaluation (63 percent) or inadequate documentation of an accepted indication (36 percent). Implants were classified as not indicated primarily because a rhythm abnormality was incorrectly identified as a justifiable indication (84 percent). We found that 168 implants (44 percent) were definitely indicated, 137 (36 percent) possibly indicated, and 77 (20 percent) not indicated. Unwarranted implantation was both prevalent (73 percent of hospitals had an incidence of 10 percent or more) and independent of the type of hospital (university teaching, university-affiliated, and community hospitals). The additional tests most often required to clarify the need for a pacemaker in inadequately evaluated cases included electrophysiologic studies (37 percent) and ambulatory monitoring (31 percent). We conclude that in a large medical population in 1983, the indications for a considerable number of permanent pacemakers were inadequate or incompletely documented.

American College of Cardiology/American Heart Association Clinical Practice Guidelines: Part I

“…This led to the formulation of the first writing committee for an ACC/AHA clinical practice guideline, which was chaired by Dr Robert Frye from the Mayo Clinic. 2 Several years later, data were published 3 showing that definite justification for permanent pacemaker implantation was present in medical records Ͻ50% of the time, and justification was totally inadequate about 20% of the time. Although the actual magnitude of the problem may be overstated because of inadequate record keeping, these data demonstrated the need for the development of guidelines that would detail appropriate indications.…”

Managing The Physician: Rules Versus Incentives

“…4 Payers who issue such rules can withhold payment if physicians fail to comply. Since few patients or physicians can afford to forfeit insurance payment, this sanction is usually effective.…”

Patient, provider and hospital characteristics associated with inappropriate hospitalization.

“…Recent studies have documented substantial inappropriate hospital use for adults, as well as children. [1][2][3][4][5] In the RAND Health Insurance Experiment, we reported previously that 23 percent of the admissions made inappropriate use of the acute hospital setting or level of care, while an additional 17 percent of admissions were avoidable by use of ambulatory surgery. 2 In this report, we examined the effect of patient, physician, and hospital variables on inappropriate hospitalizations and days.…”