Trends in the Use and Outcomes of Ventricular Assist Devices Among Medicare Beneficiaries, 2006-2011
What are the health care trends among Medicare beneficiaries receiving ventricular assist devices (VADs) and their impact on hospital-level procedure volume and outcomes?
This was a population-based, retrospective cohort study of all fee-for-service Medicare beneficiaries with heart failure who received an implantable VAD from 2006-2011. Changes in mortality (in-hospital and within 1 year after VAD implant), readmission, and hospital-level procedure volume (low volume [1-3 implants], medium volume [4-8 implants], or high volume [9 or more implants]) were studied using a Cox proportional hazards model.
A total of 2,507 patients received an implantable VAD at 103 centers during the study. Procedure volume increased from 192 in 2006 to 622 in 2011, with an increase in shock diagnosis (27%-44%; p < 0.001) and elective admissions for VAD placement (25%-41%; p < 0.001). In-hospital mortality declined from 30% to 10% (p < 0.001), 1-year mortality declined from 42% to 26% (p < 0.001), and all-cause readmission was frequent (82% and 81%; p = 0.70). After multivariable adjustment, in-hospital and 1-year mortality declined (p < 0.001 for both), but all-cause readmission did not change (p = 0.82). Hospitals with low procedure volume had higher risks of in-hospital (risk ratio, 1.72; 95% confidence interval, 1.28-2.33) and 1-year mortality (1.55; 1.24-1.93) than high-volume hospitals. However, there were no significant differences in all-cause and cardiovascular readmissions within each volume group.
The authors concluded that in-hospital and 1-year mortality have improved for patients receiving implantable VADs, whereas hospital length of stay and readmission have remained unchanged. Center volume does suggest a mortality benefit.
As in-hospital and 1-year mortality after VAD implantation have improved over time, low VAD volume remains associated with higher in-hospital and 1-year mortality. Readmissions continue to be a concern at all volume centers, with the greatest cost associated with index hospitalization.
Keywords: Hospital Mortality, Proportional Hazards Models, Fee-for-Service Plans, Heart-Assist Devices, Heart Failure, Medicare, Hospitalization, United States, Length of Stay
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