Background: Primary prevention implantable cardioverter defibrillators (ICD) are under-utilized despite multiple clinical trials that demonstrated reduced mortality and cost-effectiveness in patients at risk for sudden cardiac death. Our objectives were to determine physician knowledge about primary prevention ICD guidelines and to identify potential barriers impacting referral rates.
Methods: The Cardiovascular Arrhythmia and Stroke Working Group from Alberta, Canada developed a web- based survey as part of a quality assurance initiative to aid in the design of a complex device care pathway. The survey consisted of five case scenarios regarding primary prevention ICD guidelines and a list of potential barriers for ICD referral. Through expert consensus, case scenarios were developed based on current device guidelines. The survey was administered to physicians encountering patients eligible for ICD therapy, including General Internists and Cardiologists with Alberta Medical Association membership and Cardiology residents.
Results: The survey was completed by 109 of 799 (response rate =14%). Of those, 55% were General Internists, 32% were Cardiologists and 13% were Cardiology residents. The majority of physicians were male (62%) and practicing at a University Hospital (66%). Overall, 34% of participants answered all case scenarios correctly. A correct answer on all five case scenarios was demonstrated by 62.5% of Cardiologists, 61.5% of Cardiology residents and 16% of General Internists (p<0.0001). Figure 1 demonstrates significant differences regarding perceived barriers for ICD referral among physician groups (p<0.0001). There were also significant differences among physician age groups (p<0.0001), with younger physicians reporting more barriers. The most common barriers among all physician groups were cost- effectiveness (55%), concerns regarding knowledge of ICD guidelines (47%) and the risk of inappropriate shocks (41%).
Conclusion: Knowledge of indications for a primary prevention ICD is poor and a recognized barrier among physicians who may refer patients for device therapy. Adequate knowledge translation of ICD guidelines is crucial in order to improve ICD utilization.