MONDAY, June 18, 2007 (HealthDay News) -- Implantable cardioverter-defibrillators (ICDs) can save heart patients' lives, but certain patients -- older people, or those with lung disease, kidney disease or heart failure -- are less likely to benefit from them than others, a new Canadian study shows.
The findings could help doctors make better decisions about who should get these costly devices, experts say.
ICDs cost around $30,000 each, plus hospital and doctor costs, according to data from the Connecticut Hospital Association. In addition, follow-up care and replacement of ICD components, can cost between $44,000 and $144,000 for each year of additional life.
But it takes the implantation of 15 defibrillators in as many patients to save one life, noted Dr. Sumeet S. Chugh, from the cardiac division of Oregon Health and Science University, Portland.
"These are quite expensive," said Chugh, who authored an editorial on the study in the June 19 online edition of the Journal of the American College of Cardiology. "An important role for the people who implant these is to figure out who are the people that will benefit the most."
Chugh believes that, to cut costs, that 1-in-15 ratio should be cut in half to 1-in-7. "The way we do that is to improve the way we predict people who are at high risk," he said. Imposing an age cutoff for ICD use, and limiting their use in people with certain medical conditions, might help, he said.
It is essential to cut costs to be able to continue to provide ICDs, Chugh said, since they already make up a significant slice of Medicare expenditure, he noted.
"We have to get the best bang for the buck," Chugh said. "These are tough decisions, but they have to be made. It will evolve over time, but it will become a reality."
In the study, lead researcher Dr. Douglas S. Lee, from the Institute for Clinical Evaluative Sciences, Toronto, and colleagues gathered data on deaths among almost 2,500 people who received ICDs.
Among these patients, more than 46 percent had heart failure, and when these patients were elderly, they had a 72 percent increased risk of dying compared with younger patients who didn't have heart failure, Lee's team found.
Moreover, those with more than one preexisting medical condition were almost three times more likely to die after receiving an ICD than less-sick patients.
"If we want to improve our outcomes in defibrillator patients, the heart failure aspect of their management has to be vigilantly treated," Lee said.
Lee said he does not want this study to influence who does and does not get an ICD right now. "Many of these factors, like heart failure, are modifiable," he said. "This study could be used as information for future studies, which could be used to identify who might benefit most from a defibrillator," he said.
He does agree that there's an economic downside to making ICDs available to anyone who needs one, however.
"Unlimited access to a defibrillator could have major implications in terms of health care budgets," he said. "From a policy perspective, you could argue that access to these devices should be limited if you are not going to benefit from them," he added.
Another expert disagrees that patient access to ICDs should or can be limited.
"It is not surprising that people who are sicker and older are more likely to die, and implanting ICDs in these people may not be cost-effective," said Dr. Paul Chan, a fellow in cardiovascular medicine at the University of Michigan.
However, Chan believes doctors still don't fully understand the full benefit of ICDs in older, sicker patients. "There is very limited data in the benefit of ICDs in people over 75," he said.
Heart failure patients probably can benefit from ICDs, Chan said. "Heart failure by itself should not be an exclusion factor for giving an ICD," he said.
ICDs are expensive and barely cost-effective, Chan said. In addition, only about 25 percent of the people who are eligible for an ICD are referred by their cardiologist to get one, he noted.
"The problem in the United States is that since we have broadened the indications for everyone to be covered who meet basic criteria, it's really hard to pull back coverage, especially when electrophysiologists' livelihood depends, partly, on implanting these devices," Chan said.
More information
Visit the U.S. Food and Drug Administration for more on implantable defibrillators.
