Higher Risk of Complications Tied to Defibrillators Implanted by Non-Specialist Physicians
Non-specialist physicians who inserted implantable cardioverter-defibrillators (ICDs) had higher rates of complications in their patients than electrophysiologists, who are specially trained to implant the devices. These findings are reported by Yale School of Medicine researchers in the April 22/29 issue of Journal of the American Medical Association.
The Yale team analyzed data from the ICD registry, a large national registry with information from all hospitals that implant these devices. They found that non-specialist now perform about 29 percent of ICD procedures. They then assessed the link between physician certification with rates of ICD complications and CRT-D implantation.
“In the overall group of patients with ICDs, we found that acute complication rates, such as cardiac arrest, cardiac perforation and hematomas, were higher among patients who had their ICDs put in place by non-specialists,” said lead author Jeptha Curtis, M.D., assistant professor of internal medicine at Yale School of Medicine. “The differences were particularly striking among thoracic surgeons.”
ICDs are implanted for patients to treat potentially lethal heart rhythms, such as ventricular fibrillation and tachycardia. The defibrillator monitors the heart rhythm and if it senses a problem, it shocks the heart or paces the patient out of the arrhythmia. Over the last 10 years, the use of ICDs has expanded dramatically and they are currently implanted by physicians with different levels of training, ranging from those who completed dedicated fellowships in electrophysiology to those with less formal training.
Curtis and colleagues also identified differences in the use of cardiac resynchronization therapy (CRT-D) across physician categories. Patients with severe heart failure may benefit from this special type of ICD, which has been shown to improve symptoms and survival.
Thoracic surgeons missed one CRT-D opportunity for every six eligible patients. Other types of non-specialist physicians missed this opportunity in one out of every 17 patients. Curtis said it is unclear whether these physicians were less aware of the criteria or whether they did not have the technical skills needed to implant this specialized device.
Curtis and his colleagues found that the majority of implantations done by non-electrophysiologists occurred at hospitals that had an electrophysiologist available on staff.
Curtis said the next step is to confirm the findings and to study whether extra training for non-specialist physicians would improve outcomes. He said the Heart Rhythm Society has proposed an alternative training pathway for non-electrophysiologists.
Other authors on the study included Jeffrey Luebbert, M.D., Yongfei Wang, Saif Rathore, Jersey Chen, M.D., Paul Heidenreich, M.D., Stephen Hammill, M.D., Rachel Lampert, M.D. and Harlan Krumholz, M.D.
Citation: JAMA, 301 (16) 1661-1670 (April 22/29, 2009)