Go to content

Ontarians with heart failure do not have equal access to life-saving technology


Ontario’s Institute for Clinical Evaluative Sciences (ICES) has found that the use of implantable cardioverter defibrillators (ICDs) – an expensive cardiac technology – in patients with heart failure is characterized by major age, gender, geographic and income inequities, despite a 30-fold increase in the use of ICDs in this patient group over the last decade.

“Patients with heart failure are at increased risk of having a heart attack and dying. Studies have shown that those who survive a heart attack are at high risk of a subsequent life-threatening heart rhythm disturbance, and implanting an ICD (a device similar in size and surgical placement to a pacemaker) allows for heart monitoring and immediate shocking, if necessary, which improves survival. ICDs have also been shown to effectively serve as a means of primary prevention of sudden cardiac death in heart failure patients with no history of heart attacks,” said Dr. Douglas Lee, ICES scientist and study co-author.

“Recommendations for ICD use in heart failure patients have broadened in the last decade. However, there is still uncertainty about the optimal use of this costly technology and concern regarding the equity of its use in patients with heart failure.”

To further explore these issues, investigators tracked Ontarians who had survived following hospitalization for heart failure between January 1, 1993 and March 31, 2004. Among this group, they examined the influence of age, gender, place of residence, and socioeconomic status on rates of ICD implantation to prevent death.

Of the more than 48,000 patients hospitalized for heart failure who survived to hospital discharge, 440 received an ICD, with a gradual 30-fold increase in implantation rates over the study period (0.12% to 3.9%). The findings showed that, of these patients:

  • Men were more than four times more likely to receive an ICD than women.
  • Patients younger than 75 years of age were three times more likely to receive an ICD than older patients, while patients younger than 65 years of age were two times more likely than patients over 65 years of age to receive an ICD.
  • Urban-dwelling patients were significantly more likely to receive an ICD than those who lived in a rural area.
  • Higher income patients were more likely than lower income patients to receive an ICD.

“Whether these sociodemographic differences in access to ICD implantation influence mortality and morbidity is unknown, but it certainly warrants further investigation,” said Dr. Jacob Udell, study lead author and an ICES research fellow. “Nevertheless, in light of the current information on the survival benefits of ICDs, we need to take a closer look at how ICDs are distributed among heart failure patients. “As these devices are very expensive, governments will have to find methods to screen patients in a manner that will control the explosive potential costs of widespread ICD use, while still getting these devices to those in greatest need, regardless of gender, age, income, and geography.”

The study, “Inequitable distribution of implantable cardioverter defibrillators in Ontario”, is in the June 2007 issue of the International Journal of Technology Assessment in Healthcare.

Author affiliations: ICES (Drs. Udell, Juurlink, Lee, Tu, Mamdani, and Mr. Kopp); Department of Medicine (Drs. Juurlink, Tu and Udell) Sunnybrook Health Sciences Centre; Department of Medicine, University of Toronto (Dr. Udell); Department of Medicine, University Health Network (Dr. Lee).

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.


  • Julie Dowdie
  • Media Relations Officer, ICES
  • (416) 480-4780 or cell (416) 432-8143


Contributing ICES Scientists

Research Programs

Associated Sites

Read the Journal Article