A disturbing and incorrect supposition has developed that doctors are not choosing the appropriate device for their patients and that patients outcomes are affected because of this.
Some important points need to be clarified:
1. Private patients in a Private hospital in Australia have world’s best procedural outcomes. Recent data from the GenesisCare network (Australia’s largest private cardiology group) has shown 30 day device complication rates that are up to 7 times lower than in the US or Europe and significantly better than the published complication rates in Australian public hospitals;
2. Private patients in a Private hospital in Australia have access to the best possible cardiac devices. The prosthesis list contains all of the currently available cardiac devices and the implanting cardiologist is free to choose any of these devices;
3. The implanting cardiologist in a Private hospital is responsible for the choice of device. I have not had any discussion with management about which device I implant and certainly no pressure by management to implant a specific device. This is not the case in many public hospitals where a tender process is typically conducted and a limited choice of devices is available;
4. The choice of cardiac device for a particular patient is complex and the implanting cardiologist considers many factors. The basic function of the device as a pacemaker, a defibrillator or a Cardiac resynchronization device is the fundamental decision. Beyond this, the extra features of the device are important – MRI conditional, Wireless, Remote Monitoring capable, multipolar leads, published reliability of the device and leads. Implantation and follow up of cardiac devices can be technically demanding and familiarity with implant tools and availability of technical support are important factors. Patient preference may also contribute to the decision;
5. It is not only ethically wrong but also against the recognized codes of conduct for an implanting cardiologist to choose a device based on pressure by hospital management or financial incentives. Each year as part of our registration, all doctors sign the Medical Board Code of Conduct, which states that good medical practice involves:
“Not asking for or accepting any inducement, gift or hospitality of more than trivial value, from companies that sell or market drugs or appliances or provide services that may affect, or be seen to affect, the way you prescribe for, treat or refer patients.”
A similar code of conduct from the MTAA prohibits device companies from offering incentives to implanting cardiologists.
6. It is my understanding that the price paid by a Health Fund for a cardiac device is set from Canberra via the prosthesis list. In this case, the commercial relationships between device companies and private hospitals would have no direct impact on device costs.
7. There is an underlying suggestion that doctors are upselling or inappropriately implanting cardiac devices. This is factually incorrect and distorts the most pressing issue related to cardiac devices. Most patients in Australia who are eligible for life saving cardiac devices do not receive these devices. Our implant rate is 40% of the US implant rate per million population and below many European countries. Whilst our overall implant rate is remarkably low, the situation is even worse for women, migrants, indigenous patients and patients of lower socioeconomic status who are consistently under implanted. From a medical viewpoint, the discussion on implantation of cardiac devices should focus on ensuring education and referral so that appropriate patients can access cardiac devices that have definitively been shown to prolong life.
A private patient in a private hospital in Australia receives the best possible cardiac device and has world best outcomes. The implanting cardiologist chooses the specific cardiac device and ethically and legally, this decision must be made in the best interests of our patient. Currently, the most pressing issue in Australia is the inappropriate lack of referral for implantation of life saving devices in eligible patients.
ABOUT THE AUTHOR
Dr David O’Donnell is a founding partner and the Chairman of Heart Care Victoria. David graduated from the University of Melbourne in 1993 and trained as a Cardiologist in Melbourne before undertaking a fellowship at Freeman Hospital, Newcastle Upon Tyne, England. He returned to Melbourne in 2002 working at Austin Health as an Interventional Electrophysiologist, becoming Director of Electrophysiology in 2012.
David’s hospital career has focused on the newer techniques for ablation of atrial fibrillation and ventricular tachycardia. In recent years his clinical and research emphasis has been in the device management of heart failure, pioneering a number of novel techniques for cardiac resynchronization. As a previous high performance athlete he has maintained a close involvement with elite athletes with heart conditions and has affiliations with a number of sporting clubs and organizations.
David has a passion for education and frequently lectures, educates and performs surgery around the world.