Over 150 potentially low-value health care practices: an Australian study

To the Editor: The article by Elshaug and colleagues on potentially low-value health care services1 raises an important issue, given spiralling health care costs and limited resources. However, we are concerned by the authors’ claim that use of prophylactic implantable cardioverter defibrillators (ICDs) “did not reduce the risk of death, was more expensive and less effective than control therapy”. Elshaug and colleagues did not consider six large randomised trials showing survival benefit from prophylactic ICD implantation compared with medical therapy in patients with severe left ventricular dysfunction,2 and instead presented two trials associated with neutral outcomes.3,4 The authors failed to appreciate that these two trials assessed prophylactic ICD implantation (i) early (ie, 6–40 days) after myocardial infarction and (ii) at the time of elective coronary artery bypass graft (CABG) surgery, respectively.4 ICDs are not approved for use in these situations in Australia (see Medicare Benefit Schedule criteria for prophylactic ICD implantation; http://www9.health.gov.au/mbs/search.cfm?q=38387&sopt=S). In addition, the CABG trial used a superseded epicardial defibrillator system.4 Moreover, studies have shown that prophylactic ICD implantation is cost-effective and is comparable to other “cost-effective” medical interventions, including antihypertensive therapy and hospital haemodialysis.4,5 This cost-effectiveness is acknowledged by both Australian and international guidelines. Given the widespread implications of the study by Elshaug and colleagues on health care provision by Medicare, the authors must take care to present a balanced and objective analysis to ensure that health professionals are not misled and that appropriate health care is delivered in Australia.