Are Patients in Rural Areas Being Deprived of Potentially Lifesaving Therapy?

New report in the Canadian Journal of Cardiology shows that rural patients have lower referral rates and higher refusal rates for implantable cardioverter defibrillators, a standard device therapy for prevention of sudden death in heart failure patients

Philadelphia, PA, January 25, 2017

The implantable cardioverter defibrillator (ICD), a primary prevention device therapy, can help save the lives of patients suffering from heart failure or following a heart attack. Specialized heart function clinics often refer patients for implantation of this device, but a new report in the Canadian Journal of Cardiology indicates that a significant proportion of patients at clinics in both rural and urban geographic locations were not referred and that this disparity was greater among patients in rural locations. Furthermore, the patient referral refusal and death rates were higher in rural areas.

“In our study of specialized heart function clinics, mortality rates were compared between patients who refused referral or refused an ICD to those patients who were found to be eligible and received an ICD. Patients who underwent ICD implantation were found to have a significant reduction in mortality when an ICD was implanted, compared to patients who were documented to have refused an ICD,” explained lead investigator Ratika Parkash, MD, MS, QE II Health Sciences Centre, Halifax, NS, Canada.

Data were drawn from three heart function clinics in Nova Scotia, Canada, one urban tertiary care center with onsite cardiac electrophysiology specialists, and two rural secondary care centers without onsite cardiac electrophysiologists but with cardiac care services. Patients admitted to the heart function clinics from January 1, 2006 until December 31, 2011 with an initial left ventricular ejection fraction of </=35% were included, while patients with known terminal illness, metastatic cancer, or dementia were excluded. ICD implantation and mortality data were tracked using various provincial registries.

This study, covering 335 eligible patients (240 urban and 95 rural), demonstrated there are important differences in referral patterns among heart function clinics with and without onsite cardiac electrophysiology services, with referral rates being lower and patient refusal rates higher, in sites where these services do not exist. “Our study demonstrated a lower referral rate from rural centers, predominantly due to an increased rate of patient refusal to be referred to a cardiac electrophysiologist, when located in a rural center. There may be several factors that influence this, including patient preferences, socioeconomic factors, and physician practice patterns,” noted Dr. Parkash.

While more than 73% of all patients were referred for ICD implantation, investigators found that the referral rate from the urban center was 80.4%, while from the rural centers it was only 68.3%. Of those, 18 patients refused a referral (5 urban and 13 rural). Once patients were referred, there was no difference in rates of ICD implantation or patient refusal among urban or rural groups.

Despite well-established guidelines for the use of ICD therapy, the investigators suggest that application of these guidelines remains an issue. “The use of primary prevention ICDs has become a mainstay in therapy for the heart failure population, including cardiac resynchronization therapy, which has been found to impact heart failure hospitalization and mortality. Improving access to care for patients who are eligible for this therapy could improve mortality through prevention of sudden cardiac death. Ensuring appropriate use of ICDs in this population should have an immediate impact on reduction of sudden cardiac death. Efforts to provide better, more timely access to care should be pursued by physicians to ensure that eligible patients receive this benefit, as well as ensuring that patients are engaged in the shared decision-making process. Improvements in telemedicine, device technology, as well as improvements in remote follow-up may lessen the gap in access to care apparent between rural and urban populations in application of this therapy,” commented Dr. Parkash.

In Canada, heart failure causes about 4000 deaths annually and is the fourth most common reason for hospitalization. Caring for the 600,000 Canadians with heart failure entails direct costs totaling $2.8 billion annually.

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Notes for editors
The article is "Primary Prevention of Sudden Cardiac Death with Device Therapy in Urban and Rural Populations," by Ratika Parkash, Howard Wightman, Graham Miles, John Sapp, Martin Gardner, Chris Gray, Brenda Brownell, Karen Giddens, and Miroslaw Rajda (doi: 10.1016/j.cjca.2016.10.020.). It is published online in advance of its issue of the Canadian Journal of Cardiology by Elsevier.

Full text of this article and editorial is available to credentialed journalists upon request. Contact Eileen Leahy at +1 732-238-3628or cjcmedia@elsevier.com to obtain copies. Journalists wishing to reach the authors for comment should contact Ratika Parkash at +1 902-473-4474 or Ratika.Parkash@nshealth.ca

About the Canadian Journal of Cardiology
The Canadian Journal of Cardiology is the official journal of the Canadian Cardiovascular Society. It is a vehicle for the international dissemination of new knowledge in cardiology and cardiovascular science, particularly serving as a major venue for the results of Canadian cardiovascular research and Society guidelines. The journal publishes original reports of clinical and basic research relevant to cardiovascular medicine as well as editorials, review articles, case reports, and papers on health outcomes, policy research, ethics, medical history, and political issues affecting practice.

About the Editor-in-Chief
Editor-in-Chief Stanley Nattel, MD, is Paul-David Chair in Cardiovascular Electrophysiology and Professor of Medicine at the University of Montreal and Director of the Electrophysiology Research Program at the Montreal Heart Institute Research Center.

About the Canadian Cardiovascular Society
The Canadian Cardiovascular Society is the professional association for Canadian cardiovascular physicians and scientists working to promote cardiovascular health and care through knowledge translation, professional development, and leadership in health policy. The CCS provides programs and services to its 1900+ members and others in the cardiovascular community, including guidelines for cardiovascular care, the annual Canadian Cardiovascular Congress, and, with the Canadian Cardiovascular Academy, programs for trainees. More information about the CCS and its activities can be found at www.ccs.ca.

About Elsevier
Elsevier is a global information analytics business that helps institutions and professionals progress science, advance healthcare and improve performance for the benefit of humanity. Elsevier provides digital solutions and tools in the areas of strategic research management, R&D performance, clinical decision support, and professional education; including ScienceDirect, Scopus, ClinicalKey and Sherpath. Elsevier publishes over 2,500 digitized journals, including The Lancet and Cell, more than 35,000 e-book titles and many iconic reference works, including Gray's Anatomy. Elsevier is part of RELX Group, a global provider of information and analytics for professionals and business customers across industries. www.elsevier.com

Media contact
Eileen Leahy
Elsevier
+1 732-238-3628
cjcmedia@elsevier.com