Study: Hospitals are underusing cardiac devices
NEW YORK - Fewer than half of eligible patients in the United States received medical devices to shock their faulty hearts back into rhythm, though the products can cut death rates by more than one-third, a study found.
Hospitals implanted the $33,000 cardiac resynchronization therapy devices in 12.4 percent of heart failure patients, according to a survey of 34,000 cases published online in the journal Circulation.
Previous studies suggest 30 to 50 percent of heart failure patients have conditions that make them best suited for the pacemakers, said Jonathan Piccini, a Duke University cardiologist who cowrote the paper.
Cost is a factor at some hospitals, as is the lack of trained specialists to implant the devices and physicians' reluctance to embrace the relatively new technology, Piccini said. Almost 5 million Americans suffer from heart failure, a weakening of the organ that can cause fatigue, physical limitations, and ultimately death, according to the St. Paul-based Heart Failure Society of America.
"There is a fine balance between appropriate restraint and timely and efficient utilization of new technologies," Piccini said. "In the case of cardiac resynchronization therapy, there is an abundance of clinical trial data that shows it helps patients."
The $5 billion-a-year market for heart-rhythm devices is led by Boston Scientific Corp. of Natick, Mass.; Medtronic Inc. of Minneapolis; and St. Jude Medical Inc. of St. Paul, each of which makes a version of the pager-sized resynchronization products, known as CRTs.
Similar to pacemakers and implantable defibrillators, the devices use electrical impulses to zap the heart's pumping back into rhythm, improving the flow of oxygen-rich blood to the rest of the body. Studies have shown the therapy, used with medication and other steps, can cut hospitalizations for heart-failure patients by 50 percent and deaths by 36 percent, said Adrian Hernandez, a Duke cardiologist who worked on the paper.
"There are a lot of patients who potentially could benefit from the device who aren't receiving it," Hernandez said in a statement released by the American Heart Association, which publishes the journal.
The latest study looked at patients treated at 228 hospitals from January 2005, when the heart association issued guidelines for resynchronization therapy, to September 2007.
Those guidelines recommended the devices for heart-failure sufferers with a left ventricular ejection fraction, a measure of the heart's pumping strength, of 35 percent or less. While fewer than half of these patients received the devices, 10 percent of patients with stronger hearts got the pacemakers and were likely "over treated," Hernandez said.
The Duke team's results are "discouraging," said Eric Prystowsky, a past president of the Heart Rhythm Society, a doctor's association. CRT devices have been widely available since early this decade, he said.
"Imagine another area of medicine where people would not be up in arms" when only 15 percent of patients were getting proper care, he said.
Similarly low rates plague the use of defibrillators, said Prystowsky, whose Indianapolis practice has implanted more than 500 CRTs.
"There are people who have blind spots," he said. "They're not necessarily bad doctors. They may simply not understand CRT technology and how it may help their patients."
The study's authors also found the devices used less often in blacks, older people, and those in the Northeast. Black patients were 55 percent less likely than whites to get the CRTs. Heart failure sufferers in the Northeast were half as likely to receive the products as those elsewhere in the country, and the use of the technology fell the older a patient was above 70, the study said.
Hernandez' group said more study is needed to explain the discrepancies among demographic groups.
"The study sends a clear message that hospitals need to have systematic practices" in treating heart failure, the heart association statement said. Patients need to explore options and "be their own advocate to get optimal care," it said. 