Referring physicians' discordance with the primary prevention implantable cardioverter-defibrillator guidelines: a national survey.
BACKGROUND
The American College of Cardiology, the American Heart Association, and the Heart Rhythm Society guidelines provide patient selection criteria for primary prevention implantable cardioverter-defibrillators (ICDs). For unknown reasons, guideline-discordant practice is common.


OBJECTIVE
To determine referring physicians' concordance with the primary prevention ICD guidelines.


METHODS
We mailed a survey regarding ICD guidelines and individual practice characteristics to a random national sample of 3000 physicians selected from the American Medical Association Masterfile-one-third each specializing in family medicine, internal medicine, and general cardiology.


RESULTS
Sixty-four percent with correct contact information responded. Three hundred ninety-five (28%; 95% confidence interval [CI] 25%-30%) respondents never refer patients with the intent of consideration for a primary prevention ICD, including 7% (95% CI 5%-10%) of cardiologists. Two hundred twelve (15%; 95% CI 13%-17%) believe ventricular arrhythmias are required before a primary prevention ICD is indicated; 525 (36%; 95% CI 34%-39%) believe that an ejection fraction of >40% warrants a primary prevention ICD; and 361 (25%; 95% CI 23%-27%) would refer a patient for a primary prevention ICD within 40 days of a myocardial infarction. In multivariate analyses, family practice physicians and physicians residing in the western United States most often provided guideline-discordant answers, while cardiologists and those who refer to an electrophysiologist most often provided guideline-concordant answers. Primary care physicians who manage heart failure patients without referral to a subspecialist were not more likely to provide guideline-concordant answers.


CONCLUSIONS
Answers discordant with the primary prevention ICD guidelines were common, suggesting that referring physician beliefs are an important barrier to appropriate patient referrals for primary prevention ICD implantation.
Department of Medicine, University of California, San Francisco, CA 94143-1354, USA.
Jorge M
JM
Castellanos
Lisa M
LM
Smith
Paul D
PD
Varosy
Christine
C
Dehlendorf
Gregory M
GM
Marcus
D001145:Arrhythmias, Cardiac / Q000150:complications / Q000628:therapy; D016757:Death, Sudden, Cardiac / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D017147:Defibrillators, Implantable / Q000592:standards / Q000706:statistics & numerical data*; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D008875:Middle Aged; D018579:Patient Selection; D010820:Physicians / Q000706:statistics & numerical data*; D017410:Practice Guidelines as Topic; D011322:Primary Prevention / Q000379:methods*; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D015996:Survival Rate / Q000639:trends; D014481:United States / Q000453:epidemiology