Trends in the Use and Outcomes of Ventricular Assist Devices Among Medicare Beneficiaries, 2006 Through 2011

Abstract

Objectives This study sought to examine trends in mortality, readmission, and costs among Medicare beneficiaries receiving ventricular assist devices (VADs) and associations between hospital-level procedure volume and outcomes. Background VADs are an option for patients with advanced heart failure, but temporal changes in outcomes and associations between facility-level volume and outcomes are poorly understood. Methods This is a population-based, retrospective cohort study of all fee-for-service Medicare beneficiaries with heart failure who received an implantable VAD between 2006 and 2011. We used Cox proportional hazards models to examine temporal changes in mortality, readmission, and hospital-level procedure volume. Results Among 2,507 patients who received a VAD at 103 centers during the study period, the in-hospital mortality decreased from 30% to 10% (p < 0.001), the 1-year mortality decreased from 42% to 26% (p < 0.001), and the all-cause readmission was frequent (82% and 81%; p = 0.70). After covariate adjustment, in-hospital and 1-year mortality decreased (p < 0.001 for both), but the all-cause readmission did not change (p = 0.82). Hospitals with a low procedure volume had higher risks of in-hospital mortality (risk ratio: 1.72; 95% confidence interval [CI]: 1.28 to 2.33) and 1-year mortality (risk ratio: 1.55; 95% CI: 1.24 to 1.93) than high-volume hospitals. Procedure volume was not associated with risk of readmission. The greatest cost was from the index hospitalization and remained unchanged ($204,020 in 2006 and $201,026 in 2011; p = 0.21). Conclusions Short- and long-term mortality after VAD implantation among Medicare beneficiaries improved, but readmission remained similar over time. A higher volume of VAD implants was associated with lower risk of mortality but not readmission. Costs to Medicare have not changed in recent years.

Present-Day Hospital Readmissions after Left Ventricular Assist Device Implantation: A Large Single-Center Study

“…[25][26][27] The centers vary in regard to the time frames studied and the proportion of BTT patients in the study populations, but the relatively high rates of hospitalization after LVAD implantation and the primary causes for readmission are remarkably homogeneous. In providing details on readmission trends that involved 2,507 LVAD implantations from 2006 through 2011, a Medicare database report 37 showed that the mean number of hospitalizations after LVAD implantation was stable at 1.8 ± 2.1 and that readmission rates were not affected by center volume.…”

Delirium in the Cardiac Intensive Care Unit

“…For example, advanced heart failure patients are now commonplace in the CICU, as are temporary13 and permanent14 mechanical ventricular support devices. These devices may contribute to delirium given prolonged immobility and increased need for sedative medications.…”

Implantable Ventricular Assist Device Use and Outcomes in People With End‐Stage Renal Disease

“…Diabetes mellitus is the most common cause of ESRD, and was the most common cause of ESRD among our cohort. Diabetes mellitus itself is associated with higher mortality and other adverse outcomes with VADs (including stroke, pump thrombosis, and device infection) 21, 40. As VADs are more commonly used, they are being implanted in people with higher comorbidity burden.…”

“…The claims also had to include diagnoses for HF or cardiogenic shock, in which case it was classified as primary therapy, or there had to be a claim within 30 days prior for a separate major cardiac surgery, in which case it was classified as post‐cardiotomy (Table S1). 20, 21 In 2005, before our study period, ICD‐9‐CM procedure codes were refined to distinguish implantable (37.66) and non‐implantable (37.62 and 37.65) ventricular assist devices 20. We required the VAD index date to be >30 days after the ESRD index date, which was obtained from the ESRD Medicare Evidence Report (Centers for Medicare & Medicaid Services Form 2728).…”