Background: Permanent pacemakers provide effective relief of symptoms and are life-saving in patients with symptomatic heart block. Since pacemakers are only implanted by cardiologists or cardiothoracic surgeons in tertiary hospitals, the rates of pacemaker implantation provide a readily auditable measure of tertiary health care.
Methods: A survey was conducted of pacemaker implantation in South Africa in 1998, using questionnaires completed by implanters and information on the total number of pacemakers sold during the period, supplied by pacemaker distributors.
Results: A total of 1,643 new pacemakers were implanted in 1998 by 112 doctors working in 31 institutions (9 public and 22 private). The annual implant rate per million population was 39, compared with 31/million in 1995, an increase of 25.8%. Public hospitals accounted for 31.7% of primary pacemaker implants in 1998 as opposed to 37% in 1995. Practice in the public sector differed from that in the private sector in that atrioventricular (AV) block was the major indication for pacing in 75.3% versus 45.3%, whereas sinus node dysfunction accounted for 34.9% of private patients, as opposed to 16.2% of public hospital patients. Simple VVI single-chamber pacemakers accounted for 49.5% of public hospital implants versus only 9.6% in private patients. The reverse was true for dual-chamber implants (12.1% v. 42.3%). Severe cost constraints in the public sector have resulted in increasing use of cheaper single-chamber pacemakers for more stringent indications (predominantly AV block). The overall implant rate remains low compared with a median of 283/million in Europe. Large discrepancies persist between race groups (232/million whites, as opposed to 8.8/million blacks) and regions (89.3/million in the Western Cape versus 10.8/million in the four provinces without pacemaker implanters).
Conclusion: It is likely that socio-economic factors play a major role in the unequal distribution of this highly effective treatment for potentially lethal bradyarrhythmias. The changing trends in pacemaker implantations indicate a shift of tertiary health care resources from the public to the private sectors.