January 1, 2011

Guidelines exist for a reason. In medicine, they represent evidence-based best practices, a standard of care. And the relationship between a surgeon and a patient — in Portland or in Timbuktu — is based on the patient’s trust in the surgeon to perform the appropriate procedure for the patient’s condition. A study reported last week in the Journal of the American Medical Association revealed that surgeons veered from one specific guideline in an alarming number of cases.

An implantable cardioverter-defibrillator (ICD) is used for patients at high risk of sudden cardiac death. The ICD detects and corrects fast and slow heart rhythms. The device then delivers a shock to the heart to restore a normal rhythm. The guidelines recommend an ICD in cases of advanced heart failure. ICDs are not recommended for patients with a recent diagnosis of heart failure, nor are they recommended for patients with a limited life expectancy. Also, the device is not recommended for patients who have recently undergone bypass surgery or who have recently suffered a heart attack.

The researchers in the JAMA study looked at the records of 112,000 implant patients, covering the years 2006 through 2009. They broke down the data into patients for whom ICDs were recommended under the guidelines and those for whom ICDs were not recommended. The data showed that 22 percent of the patients were not candidates for ICDs under the guidelines and that the outcomes for those patients were markedly worse than the other group.

The incidence of in-hospital death was greater for patients who fell outside the guidelines, as was the risk of post-surgery complications. This group also tended to log longer hospital stays. Both intermediate and long-term outcomes were worse for these patients.

The study concludes with two calls to action. The first is to conduct further research to clarify some of the findings. The second was reiterated by one of the study’s author in an interview. She said that she believes the unnecessary surgeries were the result of doctors not knowing or not agreeing with the guidelines. The study calls for more education/awareness training of these and other guidelines.

The medical guidelines were developed not only to help with the how-to’s, but also the when-to’s of the surgical procedure. The ICD study begs the question of how many other patients are harmed by surgeons who don’t follow the guidelines. How can the health care profession improve enforcement?

Source: “One in Five Defibrillator Implants (ICDs) May Be Outside the Guidelines” 01/04/11


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