JAMA: Patients have better outcomes when electrophysiologists implant ICDs

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Patients whose implantable cardioverter-defibrillators (ICDs) are implanted by non-electrophysiologists are at increased risk of complications and are less likely to receive a specific type of ICD when clinically indicated, according to a study in the April 22/29 issue of the Journal of the American Medical Association.

"Differences in training, experience, and technique may result in differences in rates of procedural complications," the authors wrote. However, they noted that it is not known whether outcomes of ICD implantation vary by physician specialty. Also, appropriate device selection is particularly important for patients who may benefit from an ICD that also is capable of providing cardiac resynchronization therapy (CRT-D).

Jeptha P. Curtis, MD, of Yale University School of Medicine in New Haven, Conn., and colleagues analyzed data from the ICD Registry, a U.S. procedure-based registry of ICD implantations, to assess the association of physician certification with rates of ICD procedural complications and CRT-D implantation. They grouped cases from the ICD Registry by the certification status of the implanting physician into mutually exclusive categories: electrophysiologists, non-electrophysiologist cardiologists, thoracic surgeons and other specialists.

Of 111,293 ICD implantations included in the analysis, the researchers found that the majority of implants were performed by electrophysiologists (70.9 percent), with about 29 percent performed by non-electrophysiologists (non-electrophysiologist cardiologists, 21.9 percent; thoracic surgeons, 1.7 percent; and other specialists, 5.5 percent).

Curtis and colleagues found that rates of overall and major complications were 3.5 percent and 1.3 percent, respectively, among electrophysiologists, and 5.8 percent and 2.5 percent, respectively, among thoracic surgeons.

"The mechanisms underlying the observed differences in complication rates are not clear, but they may reflect differences in training, experience, and operative technique," the authors wrote.

Among 35,841 patients who met criteria for CRT-D, those whose ICD was implanted by physicians other than electrophysiologists were significantly less likely to receive a CRT-D device compared with patients whose ICD was implanted by an electrophysiologist.

"Given the substantial benefits associated with CRT-D both in terms of improved survival and quality of life, the decision not to implant a CRT-D device carries significant implications for patient care," the researchers said.

The researchers also found that the majority of ICD implantations performed by non-electrophysiologists took place at or relatively near hospitals in which an electrophysiologist also implanted ICDs.

"If confirmed, these findings may warrant a reappraisal of the need for and methods of training non-electrophysiologists to implant ICDs," the authors concluded.

In an accompanying editorial, James Coromilas, MD, of the Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey in New Brunswick, commented that an argument can be made based on the outcome measure of procedural complications that, whenever possible, a board-certified electrophysiologist should be implanting ICDs.

"Curtis et al found that access to electrophysiologists is not a major factor in the implantation of ICDs by non-electrophysiologists because two-thirds of the implants by non-electrophysiologists were performed in hospitals that had electrophysiologists on staff and the distance to a hospital with a board-certified electrophysiologist was only a factor in a small percentage of cases," Coromilas wrote.