Abstract P108: Extent of and Reasons for Under-Utilization of Implantable Cardioverter Defibrillator Devices Among Eligible Patients With Left Ventricular Systolic Dysfunction in Clinical Practice
Authors: Allen Lapointe Nancy M , Al-Khatib Sana M , Piccini Jonathan P , Atwater Brett D , Honeycutt Emily , Thomas Kevin , Shah Bimal R , Zimmer Louise O , Sanders Gillian , Peterson Eric D 
Published: July 2021

Objective:
Several studies using claims or registry data have reported high rates of under-utilization of ICDs in clinical practice. Women and elderly were reported to be particular subgroups at risk for non-use. We used detailed chart review to determine the true extent of ICD non-use in patients with left ventricular systolic dysfunction.

Methods:
Using hospital claims and clinical data, we identified patients hospitalized between 1/07 through 8/07 at a tertiary care center with a heart failure (HF) diagnosis and LVEF ≤ 30% who also had follow-up at the same institution. Placement of an ICD or CRT-D up to 1 year after hospitalization was determined. Medical records for patients without an ICD were abstracted to determine reasons for non-use.

Results:
Of the 542 patients identified as potentially eligible for an ICD, 224 (41%) did not have an ICD up to 1 year after hospitalization. Among these, women (adjusted OR 1.93; 95% CI 1.28-2.93) and those with advanced age (adjusted OR 1.08; 95%CI 1.04-1.12) were more likely to not have an ICD (

Table

). Detailed chart review found that 38 (7%) patients refused an ICD and 117 (22%) were ineligible for an ICD (53 had improvement in EF after index hospitalization, 54 had limited life expectancy, 1 had complicated anatomy precluding ICD implant, and 9 had Class IV HF). Therefore, with only 69 patients found to be eligible for an ICD after chart review, the true rate of ICD non-use was 13%. In this population, factors significantly associated with non-use of an ICD are shown in the

Table.

Of note, women and those of advanced age were not significantly more likely to be non-recipients of an ICD.

Conclusion:
Previously reported rates of ICD under-utilization using claims or registry data may be an overestimate. After detailed record review, only 13% of truly eligible hospitalized HF patients failed to receive an ICD. Gender and age differences in ICD use may also be accounted for by ICD eligibility differences.

Adjusted Odds Ratios and 95% Confidence Intervals for Characteristics Associated with No ICD

Characteristics
All ICD Recipients versus All Non-Recipients
All ICD Recipients versus Non-Recipients Without Refusal/Contraindication

No Ventricular Arrhythmia
3.32 (2.21, 5.00)
5.62 (2.82, 11.11)

Index Hospitalization on Non-Cardiology Service
3.36 (2.03, 5.56)
4.59 (2.33, 9.09)

Age (per 1 year)
1.08 (1.04, 1.12)
1.02 (1.00, 1.04)

Female
1.93 (1.28, 2.93)
1.00 (0.52, 1.92)

Qualifying EF (per 1% increase)
1.03 (1.00, 1.07)
1.05 (1.00, 1.10)

Days from Qualifying EF to Index Hospital discharge (per 10 days) 0-200 days 200+ days
- - 0.92 (0.89, 0.95) 1.01 (1.00, 1.03)
- - 0.91 (0.87, 0.97) 1.01 (0.99, 1.03)

No Health Insurance
1.58 (0.89, 2.80)
2.96 (1.39, 6.29)

African American race
1.38 (0.90, 2.11)
1.27 (0.66, 2.45)

Ischemic Heart Disease
1.15 (0.75, 1.75)
1.03 (0.54, 1.94)

Diabetes
0.87 (0.65, 1.44)
0.58 (0.32, 1.07)