National Trends in Pulmonary Artery Catheter Use

Study Questions:

What are national trends in pulmonary artery catheter (PAC) use overall, and among sociodemographic groups and patients with acute myocardial infarction (AMI), heart failure (HF), and respiratory failure (RF)?

Methods:

The authors used Medicare inpatient claims data to identify hospital stays in which PACs were used. For each year between 1999 and 2013, the rate of PAC placement per 1,000 admissions was calculated. Among patients with PAC placement, the annual rates of in-hospital, 30-day, 6-month, and 1-year all-cause mortality were determined. The use of PACs was also examined among patients with AMI, HF, and RF.

Results:

The authors analyzed 68,374,904 unique Medicare beneficiaries between January 1, 1999 and December 31, 2013. There were 469,582 hospitalizations in which PACs were used, representing 457,193 patients. Over the study period, there was a 67.8% relative decrease in the rate of PAC use from 1999 to 2013, from 6.28 per 1,000 all-cause admissions in 1999 to 2.02 per 1,000 all-cause admissions in 2013 (p < 0.001). Significant reduction in PAC use occurred among demographic subgroups including sex, race/ethnicity, and age. There were significant reductions in PAC use in patients admitted with AMI (20.0 per 1,000 admissions in 1999 to 5.2 per 1,000 in 2013, 74.0% relative reduction, p < 0.01) and RF (29.9 per 1,000 admissions in 1999 to 2.3 per 1,000 in 2013, 92.3% relative reduction). Patients admitted with HF showed a different PAC trend, with an initial reduction from 1999 to 2009 followed by an increase in PAC placement (9.1 PAC per 1,000 admissions in 1999 to 4.0 per 1,000 in 2009, and 5.8 per 1,000 in 2013). In-hospital mortality among patients with PAC decreased significantly during the study period, from 30.1% in 1999 to 8.6% in 2013 (p < 0.001). Similarly, 30-day mortality decreased from 33.8% to 13.4% during the study period (p < 0.001).

Conclusions:

The use of PACs has decreased from 1999 to 2013, and clinical outcomes for these patients have significantly improved. There is heterogeneity in PAC use across clinical indications, with substantial and sustained decreases in patients with AMI and RF. For patients with HF, PAC initially decreased, with an increase in PAC use more recently.

Perspective:

In line with guidelines recommending against the routine use of PACs for management of HF or acute respiratory distress syndrome, this study demonstrates a national trend of decreased PAC use, which extends across age, sex, and race/ethnicity. Of interest is the heterogeneity in PAC usage among clinical indications, with HF showing a more modest initial decrease compared with AMI and RF, and rates of PAC use in HF patients increasing in the last 4 years of the study. These data raise important questions as to the drivers of the observed decreased PAC usage. Importantly, given the improvement in mortality despite increased comorbidities in patients who received PACs, questions remain as to the optimal use and patient selection for PACs.

Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure

Keywords: Acute Coronary Syndrome, Cardiac Catheterization, Comorbidity, Heart Failure, Hospital Mortality, Inpatients, Length of Stay, Medicare, Myocardial Infarction, Primary Prevention, Pulmonary Artery, Respiratory Distress Syndrome, Adult, Respiratory Insufficiency


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