Why Are Eligible Patients Not Receiving Lifesaving Devices?

Researchers have found that the cardiac arrest deaths of some patients may have been prevented. The Cedars-Sinai Heart Institute study is in the October 15, 2013 edition of Circulation, the American Heart Association journal. Researchers looked at the medical records of 2,093 patients who died of sudden cardiac arrest. They discovered that less than 20 percent of the patients were screened to see if they qualified for implantable cardiac defibrillators. More concerning, of the 92 screened patients found eligible, only 12 were actually given a defibrillator.  Lead researcher Sumeet Chugh, MD speculated about the reasons behind the lack of screening, including lack of health insurance and healthcare access, but acknowledged more research is necessary.

According to Janet Grace Attard, an expert witness and legal nurse consultant, the fact that less than 20 percent of the patients were screened “may have to do with the presence of additional factors when urgent cardiac treatment is the gold standard. Most pressing here is that only 12 of the eligible 92 patients received defibrillation, which may be related to misdiagnosis, delay in treatment, not listening to accurate and thorough symptomatology, failure to transfer to appropriate level of care, cost containment hospital specific budgets and insurance.”

Attard explains that similar restrictions are found in other specialty areas such as when an emergency NICU admission may be required to save a life or diminish complications. “Moreover, [because of] increased emphasis to mind financials, to limit admissions, gate keeping tactics are performed where the best and most advanced screening is set aside and symptoms are minimized. Unfortunately in the acute care setting, where a life can be saved, every symptom must be addressed, every hunch addressed, to provide optimal medical care. All 92 patients deserved prompt and accurate assessment and treatment. The difference between life and death demands this service, this skill, this excellent adherence to the Standard of Care to save a life.”

Lorick Fox, a physician assistant and expert on cardiology critical care, states,  “The decision to implant an automated implantable defibrillator is, and should be, complex. Screening for ejection fraction alone or sustained ventricular tachycardia, or previous cardiac arrest is not adequate, and to blindly implant without regard to patient desires, comorbidities and life expectancy would be unethical.”

He continues, “While in 33 years of practice, I have only seen one patient who clearly should have at least had the possibility of ICD discussed, but his cardiologist (unrelated to my practice) refused, I have no doubt that the described scenario (patient who meets criteria and at a major center would have routinely offered an implant) occurs. The fact these devices are exceptionally expensive may well drive some decisions, and are simply not an option for patients with no insurance unless they seek care at a facility which is, or feels, obligated to provide such care gratis.”

“That said,” concludes Fox, “Medicare will only pay implantation under very strict guidelines. The development of the Life Vest has provided a bridge for the usual 3 month waiting period and has resulted in MANY ‘saves’  but the manufacturer’s willingness to provide the Vest for patients with no insurance varies in case to case. We have found the Vest Trial (a randomized research trial) is a useful tool here because it provides 2/3 of eligible patients who sign up for the trial a Vest regardless of insurance.  Clearly part of the problem is that primary care providers (PCP’s) do NOT understand the criteria and fail to obtain cardiology assessment, or interpret echo, stress test or other evaluations of ejection fraction appropriately. A concentrated effort to educate at THIS level (i.e. AAFP, AAPA, AFPPA) may well be useful.”

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