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ST2 GROUP 20/7/11
Ethical Scenario: Cardiovascular System
GP COMMISSIONING SCENARIO
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You have decided to take the plunge and join a GP
commissioning consortium. Within a few weeks of starting the
job you are required to make a high profile budget decision.
The local hospital trust has increased it’s spending on 2
significant areas within cardiology – ICD implantation and
cardiac ablation.
ICD implantation has been proven to prolong life as well as
potentially improve quality of life. It is used mainly for older
adults who have a history of VT or severe left ventricular
dysfunction. The cost of the device is £20000, but the
treatment cost over 5 years (device changes, hospital
treatment and investigation, prolonged life ) amounts to
£70000. The life expectancy after implantation is around 5
years.
Cardiac ablation is generally used for patients with AF and a
reduced quality of life (normally younger/active patients) who
have not responded well to conservative treatment. The costs
of cardiac ablation are around £5000 per patient, but many
more would be eligible than for ICD devices. There is also
evidence that it improves survival compared to drug
treatment.
GP COMMISSIONING SCENARIO
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Unfortunately you have inherited a large amount of
debt from the PCT, and are being asked to reduce
costs through efficiency savings.
You think that you may be able to increase the
spending on one of the procedures, but only through
withdrawing funding for the other.
A local pressure group called ‘Heart to Heart’, tipped
off by a local Cardiologist, has brought this dilemma
to the attention of the media. A press conference has
been organised for you to announce your decision.
Your options seem to be to increase funding for one
procedure while stopping the other, not to increase
funding for either, or to try and fund an increase in
both by making cuts elsewhere.
GP COMMISSIONING SCENARIO
Divide into 2 groups – the consortium and the
press. The consortium group needs to prepare a
decision and their justification/reasoning, then
elect one or more spokesperson/s. The media
group should plan out their lines of questioning
for the different outcomes- remember you need
to get a sensational story!
 A third group could be activists from ‘Heart to
Heart’ who have been picketing outside the hall,
and have managed to sneak into the conference.
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NICE ICD IMPLANTATION GUIDANCE
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1.1. The use of implantable cardioverter defibrillators (ICDs)
should be routinely considered for patients in the following
categories:
1.1.1 ‘Secondary prevention’ i.e. for patients who present, in the
absence of a treatable cause, with:• Cardiac arrest due to either ventricular tachycardia (VT) or
ventricular fibrillation (VF)
• Spontaneous sustained VT causing syncope or significant
haemodynamic compromise
• Sustained VT without syncope/cardiac arrest, and who have an associated
reduction in ejection fraction (less than 35%) but are no worse than class 3 of
the New York Heart Association functional classification of heart failure.
1.1.2 ‘Primary prevention’ for patients (see paragraph 2.5 for
definition) with:
• a history of previous myocardial infarction (MI) and all of the following:
i) non sustained VT on Holter (24 hour ECG) monitoring;
ii) inducible VT on electrophysiological testing;
iii) left ventricular dysfunction with an ejection fraction (EF)
less than 35% and no worse than class III of the New York Heart Association
functional classification of heart failure.
• a familial cardiac condition with a high risk of sudden death, including long
QT syndrome, hypertrophic cardiomyopathy, Brugada syndrome,
arrhythmogenic right ventricular dysplasia (ARVD) and following repair of
NICE RADIOFREQUENCY ABLATION GUIDANCE:
EXTRACTS
2.1.4 Percutaneous radiofrequency ablation is a
treatment option for symptomatic patients with atrial
fibrillation refractory to anti-arrhythmic drug therapy
or where medical therapy is contraindicated because
of co-morbidity or intolerance.
2.3.2 In a non-randomised comparative study of 1171
patients, 78% of patients treated with radiofrequency
ablation were estimated to be free of atrial fibrillation
at 3 years, compared with 37% of patients treated
with medication (p < 0.001). Patients receiving
percutaneous radiofrequency ablation had a 54%
reduction in risk of death compared with those
receiving medication (p < 0.001).