Dutch cardiologists too quick to implant internal defibrillators

Cardiologists in the Netherlands are too quick to implant internal defibrillators, according to an “improvement report” by the Zorginstituut. In one in five cases, the ICD does not contribute to a patient’s chance of survival, while there is a risk of complications, the Zorginstituut said, the Volkskrant reports.

The Zorginstituut is the government body that determines what is included in the basic health insurance package. About 6,000 patients in the Netherlands get an ICD per year. According to the Zorginstituut, 1,200 of those ICD surgeries are unnecessary. If cardiologists don’t implant them, healthcare costs would be 20 million euros lower per year.

The Zorginstituut is specifically concerned about ICD surgeries on patients with non-ischemic cardiomyopathy (NICM). That is an umbrella term for disorders of the heart muscle. According to the institute, literature research shows no indication that an ICD can help this group live longer. Particularly now that other treatment methods, like medication, have taken off in recent years, it makes no sense to subject these patients to surgery to place an ICD.

The institute also found that cardiologists are not honest enough about the risks involved in an ICD implant. If hospital websites mention the risks at all, they report too low complication figures of around 1 percent. In reality, over 8 percent of patients experience serious complications, and there have been cases of patients dying when an ICD is placed.

Cardiologists can improve their information provision about ICD complications, Cor Allaart, professor of cardiology at Amsterdam UMC and the co-author of many important cardiology guidelines, said to the Volkskrant. But “there is a difference of opinion between what the Zorginstituut considers good care and what cardiologists consider good care,” he said.

Allaart has difficulty with the image the Zorginstituut’s report creates “that we are implanting ICDs for the money. You are really selling cardiologists short with that.” According to him, the Zorginstituut now forces cardiologists “based on thin evidence” to stop implanting ICDs and start a new treatment method.

The NICM condition has many subgroups, and you have to look at each one of them before declaring that ICDs don’t work and ordering doctors to stop using them, Allaart said. “As long as you can’t say whether it works for a subgroup, it feels reckless to suddenly throw the ICD overboard. You deprive a patient of potentially life-saving treatment.”

Nevertheless, cardiologists will tighten their guidelines for using ICDs before March 1 this year, Allaart said.