Assessing Variation in Implantable Cardioverter Defibrillator Therapy Guideline Adherence With Physician and Hospital Patient-sharing Networks

Med Care. 2018 Apr;56(4):350-357. doi: 10.1097/MLR.0000000000000883.


Background: Implantable cardioverter defibrillator (ICD) therapy is used for primary prevention of death among people with heart failure, and new evidence in 2005 on its effectiveness changed practice guidelines in the United States.

Objectives: The objective of this study is to examine how the connectedness of physicians and hospitals, measured using network analysis, relates to guideline-consistent ICD implantation.

Research design: We constructed physician and hospital networks for cardiovascular disease. Physicians were linked if they shared cardiovascular disease patients; these links were aggregated by hospital affiliation to construct a hospital network.

Subjects: Medicare beneficiaries who underwent ICD therapy for primary prevention from 2007 to 2011.

Measures: The clinical outcome of interest was guideline-consistent ICD implantation, calculated using the National Cardiovascular Data Registry. The exposure variables of interest were the network measures of the ICD surgeon, the referring hospital, and the hospital where the ICD surgery occurred.

Results: We focused on patients who were referred between hospitals for ICD implantation because they were more likely influenced by the hospital network (n=28,179). Patients were less likely to meet guidelines if their referring hospital had more connections to other hospitals (OR, 0.49; 95% confidence interval, 0.25-0.96) and more likely to meet guidelines if their ICD surgery hospital had more connections (OR, 1.61; 95% confidence interval, 0.98-2.64). The ICD surgeon's network measures were not associated with guideline-consistent implantation.

Conclusions: Associations between the hospital network measures and guideline adherence suggests new approaches to better disseminate clinical guidelines across health systems.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Aged, 80 and over
  • Defibrillators, Implantable*
  • Female
  • Guideline Adherence / statistics & numerical data*
  • Heart Failure / surgery*
  • Hospitals / statistics & numerical data*
  • Humans
  • Male
  • Medicare / statistics & numerical data
  • Middle Aged
  • Physicians / statistics & numerical data*
  • Practice Guidelines as Topic
  • Practice Patterns, Physicians'
  • Referral and Consultation / statistics & numerical data*
  • United States