One size fits all doesn't work

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Kaitlyn Dmyterko, staff writer

The forecast for medical specialties, such as cardiology, is questionable and the only way out is to focus more on aligning incentives, lowering costs and optimizing patient care. One way to get over this hump may be focusing on what therapies should not be used in patients as opposed to what exciting, costly therapies should be used.

A meta-analysis published this week in Archives of Internal Medicine showed surprising results: 40 percent of patients who receive cardiac resynchronization therapy (CRT) may not benefit. Sipahi et al found that CRT in patients with a moderate QRS duration (120-150 msec) may be unnecessary, and in fact, the only patients who saw benefit from the therapy were those with QRS durations above 150 msec. The authors called into question whether current CRT guidelines should be revised.

The current study coincides with Al-Khatib et al's research, which found that 22.5 percent of ICD implantations did not fall within evidence-based guidelines. The results of this study created a stir within the industry when many began to question whether these ICD implants that fell outside the guidelines were unnecessary.

"While a small risk of complications is acceptable when a procedure has been shown to improve outcomes, no risk is acceptable if a procedure has no demonstrated benefit," the researchers wrote.

However, Alan H. Kadish, MD, of the Northwestern University Feinberg School of Medicine in Chicago, told Cardiovascular Business that there are some gray areas pertaining to ICD implantations and in some cases a patient may benefit from these devices despite the fact that they may not fit into the guidelines.

He added that some physicians may be practicing defensive medicine, in desiring to treat very sick patients with these types of technologies.

Michael O. Sweeney, MD, of Brigham and Women's Hospital in Boston, told Cardiovascular Business during a previous interview that while many patients benefit from ICD therapy, providers should have a better understanding of those patients who do not benefit to ensure that ICD therapy is being used more appropriately without increasing mortality risk of arrhythmias.

What implications do these findings have on clinical practice? In an environment that is hunting for ways to cut costs while at the same time optimizes outcomes, how do these possibly “unnecessary” or at least treatments that aren't beneficial, affect practice? CRT is not easy nor is it inexpensive; however, it is being used in 40 percent of patients unnecessarily, according to Sipahi et al.

Lynn Warner Stevenson, MD, of Brigham and Women’s Hospital in Boston, told Cardiovascular Business that the industry may be too focused on what’s good for patients rather than what is bad.

N.A. Mark Estes at ACC this year relayed that CRT could reduce the relative risk of all-cause mortality by 22 percent and reduce overall heart failure hospitalizations by 37 percent. These results topped both medical and ICD therapy.

Stevenson said that the healthcare system faces a tough challenge, which is how to take results from clinical trials and make sure that they are applied correctly to patients. As more and more treatment options begin to surface, physicians will have to be careful not to take a one size fits all approach to care and instead should focus on an individualized approach to care.

Kaitlyn Dmyterko
Senior writer, Cardiovascular Business