Referring Physicians’ Discordance with the Primary ...



|West: CA, AZ, AK, CO, HI, ID, MT, NM, NV, OR, UT, WA, WY |

|South: AR, AL, FL, GA, KY, LA, MS, NC, SC, TN, TX, VA, WV |

|Midwest: IA, IL, IN, KS, MI, MN, MO, ND, NW, OH, OK, SD, WI |

|Northeast: CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT |

ONLINE Appendix

Appendix Table 1. Regions of the United States used for the analyses.

ONLINE Appendix: Survey

INSTRUCTION: For the following questions, please EXCLUDE patients with an inherited disease that is known to be associated with ventricular arrhythmias and sudden death (e.g. hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia, or catecholaminergic polymorphic ventricular tachycardia).

WE DO NOT EXPECT PARTIPANTS TO BE EXPERTS IN THIS AREA AND WOULD APPRECIATE YOUR “BEST GUESS” RATHER THAN NO ANSWER FOR AS MANY QUESTIONS AS POSSIBLE- THANK YOU

1. Case scenario: Imagine you are seeing a 50 year old patient who has New York Heart Association Class III heart failure symptoms (i.e., marked limitation in daily activities due to shortness of breath), a normal resting electrocardiogram and no other medical problems.

Would the left ventricular ejection fraction (measured by your preferred method) provide sufficient information to determine that an implantable cardioverter-defibrillator (ICD) is indicated for the primary prevention of sudden death?

No [Skip to question 2]

Yes

a. What left ventricular ejection fraction cut-off do you believe warrants consideration of an ICD?

__ __ __% (Please write your response in whole integers: five percent =5%, not 0.05)

2. In your opinion, is an ICD ever indicated in patients without any ventricular arrhythmias?

No

Yes

3. Among your patients, how necessary are the following in evaluating a patient for consideration of ICD placement for the primary prevention of sudden death?

| |1 |2 |3 |4 |5 |Don’t |

| |Never |Rarely |Sometimes |Usually |Always |Know |

|History of ischemic heart disease | | | | | | |

|An inducible, sustained or hemodynamically unstable | | | | | | |

|ventricular arrhythmia during an invasive | | | | | | |

|electrophysiology (EP) study | | | | | | |

|A particular New York Heart Association Class | | | | | |

|Concern regarding the possibility of device infection | | | | | |

|Concern regarding the possibility of device recall | | | | | |

|Patient preference | | | | | |

|Patient substance abuse issues | | | | | |

|Concern regarding the frequency of inappropriate shocks | | | | | |

13. Does a patient’s life expectancy influence your decision to refer a patient for consideration of ICD implantation for the primary prevention of sudden death?

No [Skip to question 14]

Yes

a. What life expectancy do you think is appropriate before referring a patient for an ICD implantation for the primary prevention of sudden death? (Please only choose one time scale: weeks, months, or years)

__ __ __ weeks or __ __ __ months or __ __ __ years

The following last few questions have to do with you and your medical practice

14. What specialty or sub-specialty of medicine are you primarily practicing? (Choose only one option)

Family medicine

Internal medicine

Cardiology

Other

15. Please select the specialty (or specialties) in which you are board certified (Choose all that apply)

Family medicine

Internal medicine

Cardiology

Other

16. Are you a member of any of the following? ( Choose all that apply)

American Academy of Family Physicians

American College of Physicians

Society of Hospital Medicine

American College of Cardiology

American Heart Association

Heart Rhythm Society

17. Do you implant ICDs?

No [Skip to question 18]

Yes

a. On average, how many ICDs do you implant for the primary prevention of sudden cardiac death per year?

__ __ __ (please write in a number)

18. Do you implant pacemakers?

No

Yes

19. Do you have formal training in cardiac electrophysiology?

No

Yes

20. What is your current age?

__ __ __ years

21. Approximately how many years have you been in practice since completing your medical training?

__ __ __ years

22. Approximately how many miles is your practice from a major medical center (meaning a tertiary care or referral center)? Please write “0” if your practice is located in such a center.

__ __ __miles

23. In what state is your practice?

__ __

23. Do you practice in a teaching hospital or clinic (ie, with medical students or residents)?

No

Yes

24. Which best describes your practice? (Choose only one option)

Private Practice

HMO

University Hospital

Group Practice

Veterans Affairs System

County Hospital

Other Government Setting

Other

25. Approximatelywhat percent of your patients are over 60?

__ __ __% (Please write your response in whole integers: five percent =5%, not 0.05)

26. Do you accept patients who have Medicaid?

No

Yes

27. Approximately what percent of your clinical practice is outpatient (as opposed to inpatient)?

__ __ __ %(Please write your response in whole integers: five percent =5%, not 0.05)

28. Within the past year, on average, approximately how many patients do you see per week?

__ __ __ patients

29. Do you refer patients to a sub-specialist with the specific intent of having the patient considered for a primary prevention ICD?

No [Skip to question 30]

Yes

a. Approximately how many patients do you refer for primary prevention ICD implantation per year?

__ __ __patients (please write in a number)

30. What percent of your patients with a reduced ejection fraction do you manage without referral to a sub-specialist (cardiologist or cardiac electrophysiologist)? PLEASE LEAVE THIS QUESTION BLANK IF YOU ARE A CARDIOLOGIST

__ __ __%(Please write your response in whole integers: five percent =5%, not 0.05)

31. What is the lowest ejection fraction that you manage without assistance from a sub-specialist (cardiologist or cardiac electrophysiologist)? PLEASE LEAVE THIS QUESTION BLANK IF YOU ARE A CARDIOLOGIST

Less than 65%

Less than 60%

Less than 55%

Less than 50%

Less than 45%

Less than 40%

Less than 35%

Less than 30%

Less than 25%

Less than 20%

Less than 15%

Less than 10%

Less than 5%

I do not manage patients with a low ejection fraction independently

32. What type of physician implants ICDs in your patients? (Choose all that apply)

Cardiac Electrophysiologist

Cardiologist other than an electrophysiologist

Cardiac Surgeon

I am not sure

Other

33. Do you have someone that implants ICDs…?

In your group

At your institution, hospital, or practice

I refer outside my local institution or hospital for ICD implantation

I am not sure

Other

34. Is there anything else about ICDs that is important and that we failed to ask?

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REGARDING YOUR CLINICAL PRACTICE

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