Consideration of patient age and life expectancy in implantable cardioverter-defibrillator referral

Background Primary prevention implantable cardioverter-defibrillator (ICD) guidelines recommend device consideration for at-risk patients with a life expectancy of greater than 1 year regardless of age. We sought to assess the influence of patient age and prognosis on ICD referral. Methods A survey was mailed to a random, national sample of 3,000 physicians in the specialties of cardiology, family medicine, and internal medicine. Participants were asked focused questions regarding patient age, life expectancy, and ICD referral. Results The overall response rate was 64%. More than one quarter of physicians (n = 386 [27%], 95% CI 25%-30%) withhold primary prevention ICD referral solely because of patient age. Life expectancy is not considered by 23% (n = 324, 95% CI 20%-25%) of physicians before referral, whereas 13% (n = 144, 95% CI 11%-15%) refer patients with a prognosis of less than 1 year. Providers who refer patients for ICD implantation with a life expectancy of less than 1 year are less likely to be cardiologists (odds ratio [OR] 0.50, 95% CI 0.32-0.79, P =.003), are less often affiliated with a teaching hospital (OR 0.62, 95% CI 0.41-0.94, P =.025), and have a greater number of years in practice (OR 1.25 for each 10 years in practice, 95% CI 1.03-1.51, P =.026). Only a minority (n = 315 [22%], 95% CI 20%-24%) of physicians use a life expectancy threshold of 1 year to guide ICD referral. Conclusion Physicians frequently withhold ICD referral because of patient age. The referral of patients with a prognosis of less than 1 year or without consideration of life expectancy is common.