This post is authored by Immediate Past-President Ralph Brindis, MD, MACC. 

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Health Affairs, along with co-sponsors the ABIM Foundation, the California HealthCare Foundation and the Foundation for Informed Medical Decision Making, hosted an event on Oct. 19 focused on discussions around Medicare savings ideas for the federal budget “Super Committee.”  Implantation of ICDs was one of the hot-topic areas in a session on Medicare coverage policy, with speakers highlighting overuse of the procedure among physicians as a major contributor to Medicare costs. Suggestions were made to require prior authorization as a means of reducing Medicare costs.  

It is important to note that the science surrounding ICD implantation is constantly evolving but guidelines and Medicare coverage policy take more time. That being said, it is true that recent studies have indicated a wide variation in ICD implantation. A study published earlier this year in the Journal of the American Medical Association (JAMA) found that ICD implantations were not in accordance with practice guidelines in 22.5% of patients, most commonly because of newly diagnosed heart failure (62%) or an MI within 40 days (37%). The risks of in-hospital death and complications were significantly lower when the ICD implant was consistent with practice guidelines (0.18% and 2.4%, respectively) than when it was not (0.57% and 3.2%, respectively). 

While these statistics are sobering, the ACC and the Heart Rhythm Society (HRS) already have programs and processes in place to turn the tide, so to speak, and ensure providers are appropriately using this procedure on the right patients. For one, the Centers for Medicare and Medicaid Services, has mandated that every U.S. hospital that implants ICDs for the purpose of primary prevention of sudden cardiac death participate in the ACC and HRS ICD Registry. Over the last year we have made great strides in enhancing this registry to allow for the connection of longitudinal Medicare administrative data of ICD patient outcomes -- such as mortality and repeat hospitalizations -- with our in-patient hospital registry data. This longitudinal follow-up assessment will extend our knowledge base substantially. In addition, the electrophysiology community is not only closely examining practice patterns but working more closely with staff responsible for entering ICD Registry data to ensure that the data quality is at the highest level. The ACC and HRS are also encouraging the practice of shared decision making, particularly in the elderly, for the use of ICD implants for prevention of sudden cardiac death. Recent studies actually show substantial underuse of ICD therapy for prevention of sudden cardiac death (SCD).  

Unlike prior authorization, which may reduce costs but not necessarily ensure appropriate patient care and/or change provider behavior, registry use can do all three by ensuring greater adherence to practice guidelines, providing insight into practice patterns and also extending overall physician knowledge and evidence base. At the end of the day, ICDs are effective in stopping life-threatening arrhythmias and enhancing survival and overall quality of care. We believe that we are moving in the right direction to ensure cost-savings in the Medicare system and welcome the discussion on how to do this even better.