Inequity of use of implantable cardioverter defibrillators in England:
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《英国医生杂志》
1 Health Care Research Unit, University of Southampton, Southampton SO16 6YD, 2 Papworth Hospital, Cambridge, 3 NHS Information Authority, Tavistock House, London
Correspondence to: J Parkes jules@soton.ac.uk
Introduction
Use of ICDs varies between English health regions, and use is not commensurate with need. Although incomplete data could be contributing, an inverse care law seems to be operating. This, along with the slow diffusion of the technology and setting of services predominantly in larger tertiary centres, is similar to the pattern previously seen for coronary revascularisation.3 4
Demand for ICDs will probably increase in the future, particularly in view of expanding indications with randomised evidence of the benefits of ICDs in post-myocardial infarction patients with a low left ventricular ejection fraction.5 Planned expansion of implanting centres and resources are needed to tackle low levels of referral, geographical and social inequity, and the expected increase in demand for ICDs. Strategies should include referral guidelines and targeted education to ensure appropriate identification and referral of eligible patients. These analyses highlight the value of robust national data to inform service development and the need for adequate resources to collect and analyse such information.
What is already known on this topic
Implantation of implantable cardioverter defibrillators in England lags behind most western European and North American countries
What this study adds
An inverse care law seems to be operating on implantation of new implantable cardioverter defibrillators in England
Demand for implantable cardioverter defibrillators is likely to increase in the near future, and a pressing need exists to tackle any inequity and perceived barriers to care
This article was posted on bmj.com on 4 February 2005: http://bmj.com/cgi/doi/10.1136/bmj.38337.635648.82
We thank Scot Harris for statistical support and Morag Cunningham, administrator of the national pacemaker and ICD database.
Contributors: JP led the project, cleaned the dataset, did the analyses, constructed the questionnaire and conducted the survey, wrote the first draft of the paper, and is the guarantor. DLC did the analyses, conducted the survey, and helped in writing the paper. AG helped with the survey, commented on drafts, and provided clinical perspective and support to the study. DC is project leader of the national pacemaker and ICD database,provided the 1998-2000 dataset in which data quality and completeness had been improved, and commented on drafts of the paper. PJR oversaw the project, supervised JP and DLC, supplied epidemiology expertise for analyses, and commented on drafts of the paper.
Funding: AG and JP are grant holders of HTA grant 93/23/04 (a review of the evidence on the effects and costs of implantable cardioverter defibrillator (ICD) therapy in different patient groups, and modelling of cost effectiveness and cost utility for these groups in a UK context). Professor Martin Buxton is the principal investigator of this study. DLC is funded by an NHS South East Research and Development Fellowship.
Competing interests: None declared.
Ethical approval: Not needed for this study, as it used aggregated anonymised data and no patient contact.
References
Ezekowitz JA, Armstrong PW, McALister FA. Implantable cardioverter defibrillators in primary and secondary prevention: a systematic review of randomised controlled trials. Ann Intern Med 2003;138: 445-52.
National Institute for Clinical Excellence. Guidance on the use of implantable cardioverter defibrillators for arrhythmias. London: NICE, 2000. (Technology Appraisal Guidance No 11.)
Payne N, Saul C. Variations in use of cardiology services in a health authority: comparison of coronary artery revascularisation rates with prevalence of angina and coronary mortality. BMJ 1997;314: 257-61.
Langham S, Basnett I, McCarthy P, Charles Normand C, Pickering J, Sheers D, et al. Addressing the inverse care law in cardiac services. J Public Health 2003;25: 202-7.
Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 2002;346: 877-83.(Julie Parkes, MRC clinical training fell)
Correspondence to: J Parkes jules@soton.ac.uk
Introduction
Use of ICDs varies between English health regions, and use is not commensurate with need. Although incomplete data could be contributing, an inverse care law seems to be operating. This, along with the slow diffusion of the technology and setting of services predominantly in larger tertiary centres, is similar to the pattern previously seen for coronary revascularisation.3 4
Demand for ICDs will probably increase in the future, particularly in view of expanding indications with randomised evidence of the benefits of ICDs in post-myocardial infarction patients with a low left ventricular ejection fraction.5 Planned expansion of implanting centres and resources are needed to tackle low levels of referral, geographical and social inequity, and the expected increase in demand for ICDs. Strategies should include referral guidelines and targeted education to ensure appropriate identification and referral of eligible patients. These analyses highlight the value of robust national data to inform service development and the need for adequate resources to collect and analyse such information.
What is already known on this topic
Implantation of implantable cardioverter defibrillators in England lags behind most western European and North American countries
What this study adds
An inverse care law seems to be operating on implantation of new implantable cardioverter defibrillators in England
Demand for implantable cardioverter defibrillators is likely to increase in the near future, and a pressing need exists to tackle any inequity and perceived barriers to care
This article was posted on bmj.com on 4 February 2005: http://bmj.com/cgi/doi/10.1136/bmj.38337.635648.82
We thank Scot Harris for statistical support and Morag Cunningham, administrator of the national pacemaker and ICD database.
Contributors: JP led the project, cleaned the dataset, did the analyses, constructed the questionnaire and conducted the survey, wrote the first draft of the paper, and is the guarantor. DLC did the analyses, conducted the survey, and helped in writing the paper. AG helped with the survey, commented on drafts, and provided clinical perspective and support to the study. DC is project leader of the national pacemaker and ICD database,provided the 1998-2000 dataset in which data quality and completeness had been improved, and commented on drafts of the paper. PJR oversaw the project, supervised JP and DLC, supplied epidemiology expertise for analyses, and commented on drafts of the paper.
Funding: AG and JP are grant holders of HTA grant 93/23/04 (a review of the evidence on the effects and costs of implantable cardioverter defibrillator (ICD) therapy in different patient groups, and modelling of cost effectiveness and cost utility for these groups in a UK context). Professor Martin Buxton is the principal investigator of this study. DLC is funded by an NHS South East Research and Development Fellowship.
Competing interests: None declared.
Ethical approval: Not needed for this study, as it used aggregated anonymised data and no patient contact.
References
Ezekowitz JA, Armstrong PW, McALister FA. Implantable cardioverter defibrillators in primary and secondary prevention: a systematic review of randomised controlled trials. Ann Intern Med 2003;138: 445-52.
National Institute for Clinical Excellence. Guidance on the use of implantable cardioverter defibrillators for arrhythmias. London: NICE, 2000. (Technology Appraisal Guidance No 11.)
Payne N, Saul C. Variations in use of cardiology services in a health authority: comparison of coronary artery revascularisation rates with prevalence of angina and coronary mortality. BMJ 1997;314: 257-61.
Langham S, Basnett I, McCarthy P, Charles Normand C, Pickering J, Sheers D, et al. Addressing the inverse care law in cardiac services. J Public Health 2003;25: 202-7.
Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 2002;346: 877-83.(Julie Parkes, MRC clinical training fell)