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

ONLINEAppendix

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

ONLINEAppendix: 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

  1. 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
Never / 2
Rarely / 3
Sometimes / 4
Usually / 5
Always / Don’t
Know
History of ventricular arrhythmias
History of ischemic heart disease
A wide QRS
An inducible, sustained or hemodynamically unstable ventricular arrhythmia during an invasive electrophysiology (EP) study
A depressed ejection fraction
A particular New York Heart Association Class
  1. Would you ever refer a patient for consideration of placement of an ICD for the primary prevention of sudden death in a patient who recently suffered a myocardial infarction?

No [Skip to question 5]

Yes

  1. How long after the myocardial infarction would you wait? (Please only choose one time scale: days, weeks, months, or years)

______days or______weeks or______months or ______years

  1. Independent of co-morbidities, do you have an age limit after which you would NOT refer a patient for consideration of ICD placement for the primary prevention of sudden death?

No [Skip to question 6]

Yes

  1. What is your age limit?

______years

FOR QUESTIONS 6 THROUGH 11, PLEASE PROVIDE YOUR “BEST GUESS” IF YOU ARE UNCERTAIN OF THE ANSWER

6. On average, over a 1 year period, what do you believe is the chance that a patient with an ICD placed for primary prevention of sudden death will receive an appropriate shock (i.e. a shock that was appropriately delivered in response to a potentially lethal ventricular arrhythmia)?

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

7. On average, over a 1 year period, what do you believe is the chance that a patient with an ICD placed for primary prevention of sudden death will receive an inappropriate shock (i.e. a shock that was delivered for any reason other than a potentially lethal ventricular arrhythmia)?

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

8.On a scale from 0 to 10 how painful would you rate the pain a patient feels with a typical ICD shock?

__ __ (0 = no pain, 10 = worst possible pain)

9. For a new ICD implant:

  1. What percent do you believe will become infected?

______%

  1. What percent do you believe will be recalled by the manufacturer?

______%

  1. What percent do you believe have peri-procedure complications?

______%

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

10. How long would you estimate most ICD batteries last before they need to be changed?

______years (Please write in a number)

11. Approximately what percent of your patients in whom you believe an ICD is indicated for primary prevention of sudden death do you actually refer for consideration of an ICD?

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

12. When you decide againstreferring a patient for consideration of ICD implantation, how often do the following factors determine that decision?

1
Never / 2
Rarely / 3
Sometimes / 4
Usually / 5
Always
1)It is not a sufficiently high priority to consider routinely
2)Concern regarding nation-wide health care costs
3)Concern regarding the possibility of device infection
4)Concern regarding poor patient-compliance or follow-up
5)Concern regarding the possibility of device recall
6)Patient cost or problems with insurance
7)Patient preference
8)Patient psychiatric issues
9)Patient substance abuse issues
10)Concern you would lose your patient to another physician
11)Concern regarding the frequency of inappropriate shocks
12)
13)Concern regarding the pain associated with an ICD shock
  1. 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

  1. 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)

______weeksor______monthsor______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

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

Family medicine

Internal medicine

Cardiology

Other

  1. 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

  1. 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)

  1. Do you implant pacemakers?

No

Yes

  1. Do you have formal training in cardiac electrophysiology?

No

Yes

  1. What is your current age?

______years

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

______years

  1. 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

  1. 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)

1

Private Practice

HMO

University Hospital

Group Practice

Veterans Affairs System

County Hospital

Other Government Setting

Other

1

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

  1. 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)

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

______patients

  1. 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)

  1. 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)

  1. 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

1

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

1

1

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

1

1

Cardiac Electrophysiologist

Cardiologist other than an electrophysiologist

Cardiac Surgeon

I am not sure

Other

  1. 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

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

______

1

1