different countries appear to differ significantly with respect to rates of permanent pacemaker ( ppm ) implantations . for example , the number of ppm implantations per capita is much lower in the populations of asian countries than in western populations . according to the 2009 11th world survey of arrhythmias project,1 ) the number of new ppm implantations in 2009 was 927 per million in germany and 767 per million in the united states . in contrast , in japan , ppms were implanted in 272 patients per million as opposed to only 35 per million in korea  an eight - fold difference in the rates of per capita ppm implantations . possible explanations for the differences between two countries may include ( 1 ) differences in reimbursement policies , ( 2 ) differences in the incidence of sinus node or conduction disorders , and ( 3 ) cultural differences regarding the acceptance of device implantation among physicians and patients that may serve as barriers to ppm implantation . we conducted a survey among physicians in japan and korea to determine what factors may be influencing their decision to implant ppms . a survey was created that included 15 different clinical case scenarios representative of the class i , iia , iib , and iii indications for ppm implantation stated in the 2008 aha / acc / hrs guidelines.2 ) members of the korean and japanese societies of cardiology ( including electrophysiologists , non - electrophysiologists , and cardiac surgeons ) were asked to respond to a questionnaire to determine whether or not they would implant a ppm in each of the clinical scenarios presented to them . although the classes were not indicated in the questionnaire , they could be broken down as follows : five in class i ( group 1 ) , 6 in class iia ( group 2 ) , 2 in class iib ( group 3 ) , and 2 in class iii ( group 4 ) . respondents , who remained anonymous , were asked to rate each scenario according to a 5-point scale ; a score of 5 signified that the respondent was confident that a ppm should be implanted and a score of 1 signified that the physician was confident that it should not be implanted . for the purpose of our analysis , scores of 4 and 5 were considered to be positive for the decision to implant a ppm . survey results were compiled and analyzed using spss software version 15.0 ( spss inc . , chicago , il , usa ) . the surveys were sent to 330 korean physicians and 390 japanese physicians , of whom 89 ( 27% ) and 192 ( 49% ) returned the completed questionnaires . table 1 lists the characteristics of the respondents , and the responses to each questionnaire from the two physician groups are presented in supplemental table 2 . results were analyzed according to either class indications or disease entities ( table 2 and fig . , there was no significant difference in the decision to implant a ppm between korean and japanese physicians . however , for the group 2 , the japanese physicians were significantly more likely than the korean physicians to implant a ppm ( 48% vs. 37% , p<0.001 ) ; corresponding rates were 40% vs. 19% ( p<0.001 ) for group 3 and 36% vs. 18% ( p<0.001 ) for the group 4 scenarios . these results did not change when the cases were categorized based on disease entity , such as sinus node dysfunction and conduction abnormality . this study demonstrates significant differences in the clinical decisions made by korean and japanese physicians based on various indications for ppm implantation . most likely , these differences are not simply due to relative conservatism among korean electrophysiologists compared with their japanese counterparts . other factors such as national reimbursement policies and cultural differences with respect to patient acceptance of ppm implantation may also influence their decisions . the korean government is in charge of the single health insurance organization in the country , and all medical practices are monitored by the health insurance review and assessment ( hira ) service . the japanese government runs two health insurance organizations but does not impose the additional level of regulation found in korea ( korean hira ) . in general , the reimbursement environment is more strict in korea than in japan . in japan , all the procedures and treatments are reimbursed by the insurance system regardless of the class indications stated in the aha / acc / hrs guidelines . in contrast , physicians in korea can be reimbursed only for class i and selective class iia indications in implanting a ppm . this difference in reimbursement systems between the two countries is likely to play a major role in physician decisions about whether or not to implant a ppm . according to our survey analysis , korean and japanese physicians differed mainly in their decisions regarding class ii ppm indication scenarios ( groups 2 and 3 ) . in both countries , the majority of respondents did not favor implantation of ppms for class iii indication scenarios ( group 4 ) , although japanese physicians responded more positively to these scenarios . japanese physicians have their own guidelines for pacemaker implantation3 ) that do not include class iii indications in patients with sinus node dysfunction or atrioventricular block , and this could explain the difference in their decisions regarding the group 4 scenarios . it is well known that racial differences can affect decisions about the utilization of certain medical procedures.4)5)6 ) this discrepancy may be due in part to cultural factors regarding the acceptance of innovative medical technologies.7 ) differences in the relative acceptance of pacemaker implantation by patients in korea and japan may also influence physician decision making processes . the response rate was lower in korea ( 27% ) than in japan ( 49% ) . in studies with this type of methodological design in addition , in order to increase participation in this survey , we limited the number of questions and made each question as simple as possible . our case scenarios were carefully designed to represent scenarios for which a divergence of opinion was likely , thus disclosing subtle differences in physician decision making . furthermore , during the design of the questionnaire , each case scenario required consensus among three electrophysiologists in the assignment of appropriate class indications . korean physicians are generally less likely to favor implantation of a ppm than are japanese physicians for class iia and iib ppm indications . these differences in physician decision making probably contribute to the small number of ppms implanted in korea , as compared with japan . insurance reimbursement systems as well as cultural differences might influence physicians ' decision in implanting a ppm . the present study has several limitations . the response rate was lower in korea ( 27% ) than in japan ( 49% ) . in studies with this type of methodological design in addition , in order to increase participation in this survey , we limited the number of questions and made each question as simple as possible . our case scenarios were carefully designed to represent scenarios for which a divergence of opinion was likely , thus disclosing subtle differences in physician decision making . furthermore , during the design of the questionnaire , each case scenario required consensus among three electrophysiologists in the assignment of appropriate class indications . korean physicians are generally less likely to favor implantation of a ppm than are japanese physicians for class iia and iib ppm indications . these differences in physician decision making probably contribute to the small number of ppms implanted in korea , as compared with japan . insurance reimbursement systems as well as cultural differences might influence physicians ' decision in implanting a ppm .
background and objectivesthe number of permanent pacemakers ( ppms ) implanted in patients in japan and korea differs significantly . 
 we aimed to investigate the differences in decision making processes of implanting a ppm.materials and methodsour survey included 15 clinical case scenarios based on the 2008 aha / acc / hrs guidelines for device - based therapy of cardiac rhythm abnormalities ( class unspecified ) . 
 members of the korean and japanese societies of cardiology were asked to rate each scenario according to a 5-point scale and to indicate their decisions for or against implantation.resultseighty-nine korean physicians and 192 japanese physicians replied to the questionnaire . for the case scenarios 
 in which there was a class i indication for ppm implantation , the decision to implant a ppm did not differ significantly between the two physician groups . 
 however , the japanese physicians were significantly more likely than the korean physicians to choose implantation in class iia scenarios ( 48% vs. 37% , p<0.001 ) , class iib scenarios ( 40% vs. 19% , p<0.001 ) , and class iii scenarios ( 36% vs. 18% , p<0.001 ) 
 . these results did not change when the cases were categorized based on disease entity , such as sinus node dysfunction and conduction abnormality.conclusionkorean physicians are less likely than japanese physicians to favor a ppm implantation when considering a variety of clinical case scenarios , which probably contributes to the relatively small number of ppms implanted in patients in korea as compared with those in japan .