Ethical Scenario: Cardiovascular System ST2 Group 20/7/11 Ethical Scenario: Cardiovascular System

GP Commissioning Scenario 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 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.

NICE ICD implantation guidance 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 Tetralogy of Fallot.

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).