July 05, 2015

Shocking News

Much has been written lately about over-treatment of older patients. Only rarely does anyone suggest that older patients are getting too little treatment, but a new study in JAMA does just that. The reality isn't quite so clear.

The treatment is the implantable cardioverter defibrillator (ICD) and the patients are people over the age of 65 who have had a heart attack and are found afterwards to have a weak heart (defined as an ejection fraction less or equal to 35%). These patients are at risk of sudden death, of an irregular heart rhythm such as ventricular tachycardia, and the ICD is designed to deliver an electric shock if that happens, effectively bringing the patients back from death. By looking at the National Cardiovascular Data Registry, which keeps track of heart attack patients, the authors of the article found that only 8.1% of “eligible” patients actually received an ICD. As a result, they claim, the 92% of patients who didn’t get an ICD were more likely to die than their counterparts who did.

This is a surprising finding in light of the persuasive and cogent argument made by Sharon Kaufman in her recent book, Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where To Draw The Line. Kaufman makes the case that many high tech treatments come to be seen by physicians and patients as normal and necessary once Medicare agrees to pay for them. The end result for many marginally beneficial, burdensome, and expensive treatments, including the ICD, is that patients just can’t say no. If that's true, why are so few older people getting an ICD? 

Now it wouldn't be the first time that ageism or misinformation prevented older people from getting beneficial treatment. Many years ago, patients who were over a certain age were precluded from receiving clot-busting drugs (thrombolytic therapy) because it was widely assumed that in older age groups, the risks outweighed the benefits. It turned out that clot-busting drugs were actually more beneficial in older patients, basically because their heart disease tended to be severe which meant they stood to gain a great deal from treatment. Elevated systolic blood pressure was likewise once assumed to be normal in the geriatric population, or even desirable in order to improve blood flow to the brain. Studies eventually showed that elevated systolic blood pressure, even in older patients, predisposed to stroke and other unfortunate outcomes, and warranted treatment—though the recommendations about just how much blood pressure should be lowered have evolved over time. Is the ICD implantation rate just another case of bias or ignorance at work?

Dr. Robert Hauser of the Minnesota Heart Institute, writing an editorial published alongside this article, blames our fragmented health care system. He speculates that primary care physicians may not realize that their patients were supposed to get an ICD. The fact that there's supposed to be a 40-day waiting period between the onset of the heart attack and implantation of the ICD contributes to the problem. Hauser suggests that the primary care physician is so frazzled and overburdened that he is apt to neglect to send his patient to a cardiologist. Is this the explanation?

It can’t be the whole story. While patients who saw a cardiologist after hospital discharge were more likely to wind up with an ICD than patients who didn’t, only 30% of the patients who saw a cardiologist had an ICD implanted. Recall that 100% of them were, technically speaking, “candidates” for an ICD. So what else is going on?

Hauser hints at another explanation: “It is possible that some older patients may refuse ICD treatment for personal reasons or because comorbidities such as endstage kidney disease or advanced frailty were considered in the decision regarding ICD implantation.” He doesn't accept this explanation as sufficient, rightly recognizing that patients are very likely to accept whatever technological intervention their physician recommends and that shared decision-making, if it takes place at all, is apt to reflect the physician’s preferences as well as the patient’s. So the problem, if it is a problem, must lie with doctors, too. Physicians are not systematically and emphatically recommending ICD implantation to their older patients. Even the most technologically sophisticated academic medical centers only implanted ICDs in 16% of their eligible older patients. But is this a problem that needs fixing, like under-treatment of heart attacks with clot busters and inadequate treatment of high blood pressure in the past?

Dr.  Hauser believes it is, saying “even though the use of ICD for primary prevention may not seem to make as much sense for an 80 year old patient as it does for a patient in his 50s or 60s, an older patient at risk for sudden cardiac death should have the same opportunity to choose potentially lifesaving therapy.” But the benefits of ICD in those over 80 are far from clear. The studies include very few people in this age group. What data there is indicates that there is little if any survival benefit. Moreover, ICDs implanted in older people fire erroneously half the time. That means they deliver a very unpleasant electric shock to the hapless patient. In addition, if the ICD does work as intended, what that means is the abolition of sudden death. 

Maybe, just maybe, the low rate of ICD implantation in older people is a refreshing instance of massive civil disobedience—of both patients and doctors refusing to abide by prevailing clinical guidelines. We all have to die of something. An ICD virtually guarantees that the something will involve a protracted period of decline and suffering. If you had to choose between cancer, Alzheimer’s disease, and sudden death, which would you pick?

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