Tuesday, December 22, 2009

Elderly, uninsured and African Americans less likely to receive heart devices

A new study of some 15,000 patients with heart rhythm disorders in 167 cardiology clinics across the US has found that even when they meet the clinical criteria to receive implanted cardiac defibrillators, patients who are elderly, uninsured or African American are less likely to receive them. Men were also more likely to receive them than women.

Funded by Medtronic, the major manufacturer of the heart devices, the study found that overall only about half of patients who were clinical candidates for the devices actually receive them. The devices are designed to provide a corrective jolt of electricity to the heart’s electrical system in people suffering from heart rhythm abnormalities. Uncorrected, such disorders can have severe consequences, including stroke and death. The implanted devices essentially monitor the heart’s electrical pulses, and only take action when they detect the need. The study’s lead author reports that of every 14 patients who receives an implant, one will suffer an event that triggers the device within 2 years. The cost of the device and implantation is about $50,000. (That high cost has led some to suggest that we recycle these devices. )

The authors did not hazard to guess what is motivating this disparity in care, but there are obviously many possible explanations. Docs could shy away from recommending expensive treatment options the uninsured who are unlikely to be able to afford the care (even if it could likely save their life.) Elderly patients are often viewed as too frail for surgical procedures, even in cases where the evidence suggests they are perfectly suitable candidates. Or it’s possible that elderly patients themselves may be more likely to decline to undergo the implantation procedure even if their surgeon recommends it. And there is also a relatively robust body of research showing that African American’s receive substandard care compared to whites, including less effective treatment for pain. In a specialty dominated by white practitioners in a society with a deep racial divide, subtle racism cannot be ruled out.

Finally, as with any study funded by a manufacturer of a product being studied, the results must be interpreted with some caution. Is there incentive for the authors to underreport the usage of the product? Yes. Is it likely to convolute their science? That’s not clear.

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