LaPointe Nancy M Allen, Al-Khatib Sana M, Piccini Jonathan P, Atwater Brett D, Honeycutt Emily, Thomas Kevin, Shah Bimal R, Zimmer Louise O, Sanders Gillian, Peterson Eric D
Duke University Medical Center, Duke Clinical Research Institute, Durham, NC 27705, USA.
Circ Cardiovasc Qual Outcomes. 2011 Mar;4(2):146-51. doi: 10.1161/CIRCOUTCOMES.110.958603. Epub 2011 Feb 8.
Several studies that used claims and registry data have reported that 40% to 80% of patients eligible for an implantable cardioverter defibrillator (ICD) fail to receive one in clinical practice, and the rates are especially high among women and blacks. The extent and documented reasons for nonuse of ICDs among patients with left ventricular systolic dysfunction are unknown.
Using hospital claims and clinical data, we identified patients hospitalized with a heart failure diagnosis and left ventricular ejection fraction ≤30% between January 1, 2007, and August 30, 2007, at a tertiary-care center. Using claims data, we determined placement of an ICD or cardiac resynchronization therapy with defibrillation device at any time up to 1 year after hospitalization. Medical records for patients without an ICD were abstracted to determine reasons for nonuse. Patients with an ICD were compared with patients without an ICD and also with patients without an ICD who did not have any contraindication for an ICD as identified through chart abstraction. Of the 542 potentially eligible patients identified, 224 (41%) did not have an ICD. In the initial adjusted analysis, female sex (odds ratio=1.90; 95% CI, 1.28 to 2.81) and increasing age (odds ratio=1.07; 95% CI, 1.04 to 1.11) were associated with a higher likelihood of not having an ICD. After detailed chart review, of the 224 patients without an ICD, 117 (52%) were ineligible for the device and 38 (17%) patients refused the device, resulting in only 69 (13%) patients eligible for an ICD who failed to receive one. In this subsequent adjusted analysis, remaining factors associated with a higher likelihood of not having an ICD were absence of ventricular arrhythmias (odds ratio=4.93; 95% CI, 2.56 to 9.50), noncardiology hospital service (odds ratio=3.73; 95% CI, 1.98 to 7.04), and lack of health insurance (odds ratio=3.10; 95% CI, 1.48 to 6.46).
On the basis of a detailed chart review, the true rate of ICD underuse may be substantially lower than previous estimates. In addition, after accounting for ICD eligibility criteria, patient sex and age disparities in ICD therapy were no longer present.
多项使用理赔和登记数据的研究报告称，在临床实践中，符合植入式心脏复律除颤器（ICD）植入条件的患者中有40%至80%未接受该治疗，且女性和黑人的未接受率尤其高。左心室收缩功能障碍患者未使用ICD的程度及记录在案的原因尚不清楚。
利用医院理赔和临床数据，我们确定了2007年1月1日至2007年8月30日期间在一家三级医疗中心因心力衰竭诊断住院且左心室射血分数≤30%的患者。利用理赔数据，我们确定了患者在住院后长达1年的任何时间是否植入了ICD或心脏再同步化治疗除颤装置。对未植入ICD的患者的病历进行摘要分析以确定未使用的原因。将植入ICD的患者与未植入ICD的患者进行比较，并与通过病历摘要确定无ICD植入禁忌证但未植入ICD的患者进行比较。在确定的542名潜在符合条件的患者中，224名（41%）未植入ICD。在初始校正分析中，女性（比值比=1.90；95%可信区间，1.28至2.81）和年龄增加（比值比=1.07；95%可信区间，1.04至1.11）与未植入ICD的可能性较高相关。在详细查阅病历后，在224名未植入ICD的患者中，117名（52%）不符合植入该装置的条件，38名（17%）患者拒绝植入该装置，结果只有69名（13%）符合ICD植入条件的患者未接受植入。在随后的校正分析中，与未植入ICD可能性较高相关的其他因素包括无室性心律失常（比值比=4.93；95%可信区间，2.56至9.50）、非心内科住院服务（比值比=3.73；95%可信区间，1.98至7.04）和缺乏医疗保险（比值比=3.10；95%可信区间，1.48至6.46）。
基于详细的病历查阅，ICD使用不足的实际发生率可能远低于先前的估计。此外，在考虑ICD适用标准后，ICD治疗中患者的性别和年龄差异不再存在。
