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Variations in Implantable Cardioverter Defibrillator (ICD) Utilization in the Louisiana Health System Principal Investigator: Tekeda F. Ferguson, MPH,

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Presentation on theme: "Variations in Implantable Cardioverter Defibrillator (ICD) Utilization in the Louisiana Health System Principal Investigator: Tekeda F. Ferguson, MPH,"— Presentation transcript:

1 Variations in Implantable Cardioverter Defibrillator (ICD) Utilization in the Louisiana Health System Principal Investigator: Tekeda F. Ferguson, MPH, MSPH, PhD LSUHSC New Orleans School of Public Health No financial disclosures

2 Project Summary Purpose: to investigate the prevalence and variation in ICD utilization by hospital characteristics, income, or cardiovascular risk factor prevalence, as well as the related survival outcome among heart failure patients in the Louisiana State University Health Care Services Division (HCSD). Data will allow the evaluation of cost-effective optimal treatments in the heart failure patient population.

3 Background Implantable cardioverter defibrillators (ICDs) are an established therapy for the prevention of sudden cardiac death. American College of Cardiology/American Heart Association Guidelines – New York Heart Association Functional Classification of Heart Failure New York Heart Association Functional Classification of Heart Failure Physician judgment clearly plays a large role in implant decisions, determining optimal candidates Underutilized has been observed when academic centers are uninvolved in the patient's care

4 Methods Inclusion Criteria: All patients diagnosed with chronic heart failure between 1999 through June 30, 2012 – Heart Failure: (ICD-9 codes: 398.9, 411.89, 428, 402.01, 402.11, 402.91, 404.01, 404.11, 404.91, 404.03, 404.13, 404.93) with an ejection fraction <40 for 4 or more consecutive measurements as eligible for device Validation Analysis – 150 patient records were reviewed from CLIQ sample 1: 25 patients which our codes showed had an ICD (and also possibly a pacemaker) sample 2: 25 patients which our codes showed had a pacemaker, but not an ICD sample 3: 100 patients which our codes showed had no device Analysis – Prevalence was calculated for heart failure disease and ICD utilization – chi square test were be used to explore the variation of ICD utilization by hospital characteristics and cardiovascular risk factors – survival analysis will be used to investigate the improved survival related with ICD utilization

5 LSU ICON Core Services Medical Informatics Core Design & Analysis Core Network Evaluation Support Team (Nest) Other Administrative Services

6 Preliminary Results Approximately 39,830 patients diagnosed with heart failure in the LSU HCSD hospitals over the last 13 years. 3.6% have an Implantable Cardioverter Defibrillator (ICD). Among viable candidates the rate of ICD has increased and approximately 22.5% have an ICD Slightly higher proportion of more females than males with heart failure in the LSU HCSD population; however, ICDs are higher among men. Blacks have a higher rate of heart failure in the HCSD population and receipt of ICD.

7 Table 1. Characteristics of heart failure patients diagnosed by Louisiana State University Health Care Services Division (LSU HCSD) hospitals in 1998-2012 Heart Failure Heart Failure EF <40 Without ICDICD N= 39,830N= 6,346N= 4,932N= 1,431 Age, mean ± SD*57.0 ± 13.254.1 ± 11.653.9 ± 11.754.6 ± 11.3 BMI, kg/m 2 33.3 ± 10.431.7 ± 8.931.7 ± 9.031.6 ± 8.2 %% Gender* Male48.764.237.168.9 Female51.335.862.931.1 Race* White40.937.034.745.0 Black56.860.963.452.5 Other2.32.11.92.5 Insurance coverage Commercial6.74.74.16.7 Medicaid17.920.019.820.6 Medicare27.220.319.722.6 Free30.737.839.432.4 Self-Pay14.016.316.415.6

8 Table 2. The number of comorbidities* among heart failure patients at Louisiana State University Health Care Services Division (LSU HCSD) hospitals No. of Comorbidities* Heart Failure EF <40 Without ICD ICD %% 013.213.512.0 126.427.821.7 222.7 22.5 315.915.218.4 411.811.214.0 5 or more10.09.611.4 *The comorbidities included hypertension, diabetes, other CHD (Coronary Heart Disease), hypercholesterolemia, hyperglyceridemia, hyperlipidemia, COPD (Chronic Obstructive Pulmonary Disease), chronic liver disease, chronic kidney disease.

9 Table 3. Comorbidities of heart failure patients within Louisiana State University Health Care Services Division (LSU HCSD) hospitals in 1998-2012 Comorbidity Heart Failure Heart Failure EF <40 Without ICDICDP-value N= 39,830N= 6,346N= 4,932N= 1,431 %% Other CHD*30.132.628.845.6<.0001 Hypercholesterolemia18.015.114.716.80.0417 COPD*24.720.120.618.20.0408 Chronic liver disease3.73.03.22.20.0606 Acute Myocardial Infarction 7.69.99.511.30.0479 Abbreviations: CHD (Coronary Heart Disease); COPD (Chronic Obstructive Pulmonary Disease)

10 Table 4. The prevalence of ICD implantation among heart failure patients diagnosed in LSU HCSD, by facility, 1998-2012 EKL - Earl K. Long Hospital Center MCL - Interim LSU Public Hospital BMC - Bogalusa Medical Center LAK - Lallie Kemp Regional Medical Center W.O. - Regional Medical Center UMC - University Medical Center LJC - L. J. Chabert Medical Center Facility No. of heart failure No. Heart Failure EF <40 No. of ICD implantatio n Prevalence of ICD (%) EKL a 5,6641,164 77 6.6 MCL b 13,2501,92475639.3 BMC c 4,035 284 13848.6 LAK d 2,716 414 41 9.9 WOM e 3,225 580 43 7.4 UMC f 5,761 1,00726316.2 LJC g 5,179 973 113 11.6

11 Next Steps & Timeline Continue with the trend analysis evaluating differences in survival rates by comorbidities, demographics, treatments, and hospitals – April – May 2013 Performing a subgroup analysis with additional chart abstraction to determine utilization of optimal drug regimens for systolic heart failure patients post diagnosis – May – August 2013

12 Potential Impact This area holds much potential for gaining an understanding about allocation of resources in heart failure care and as a consequence to policy development for standardized patient treatment and care.

13 Acknowledgements Lee Arcement, MD, MPH – L.J. Chabert Medical Center Ronald Horswell, PhD Meghan Brashear, MPH Lu Zhang, MPH

14 References Allen LA, Stevenson LW, Grady K, Goldstein NE, Matlock DD, Around RM, Cook NR, Felker GM, Francis GS, Hauptman PJ, Havranek EP, Krumholz HM, Mancini D, Riegel Barbara, Spertus JA. Decision Making in Advanced Heart Failure: A Scientific Statement from the American Heart Association. Circulation 201; 152: 1928-1952. Hauptman P, Swindle JP, Masoudi, FA and Burroughs, TE. Cardioverter-Defibrillator and Cardiac Resynchronization Procedures. Circ Cardiovasc Qual Outcomes 2010;3;204-211. Hebert K, McKinnie J, Horswell R, Arcement L, Stevenson L. Expansion of Heart Failure Device Therapy Into a Rural Indigent Population in Louisiana: Potential Economic and Health Policy Implications. Journal of Cardiac Failure Vol. 12 No. 9 2006. Hjalmarson A, Goldstein S, Fagerberg B, Wedel H, Waagstein F, Kjekshus J, Wikstrand J, El Allaf D, Vítovec J, Aldershvile J, Halinen M, Dietz R, Neuhaus KL, Ja´nosi A, Thorgeirsson G, Dunselman PH, Gullestad L, Kuch J, Herlitz J, Rickenbacher P, Ball S, Gottlieb S, Deedwania P. Effects of controlled-release metoprolol on total mortality, hospitalizations, and well- being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF): MERIT-HF Study Group. JAMA. 2000;283:1295–1302. Hunt et al. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2001;104:2996-3007. Noyes K, Corona E, Zwanziger J, Hall WJ, Zhao H, Wang H, Moss AJ, Dick AW,. Health-related quality of life consequences of implantable cardioverter defibrillators: results from MADIT II. Med Care 2007;45:377-85. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomized trial. Lancet. 1999;353:9 –13.

15 References (2) Packer M, Bristow MR, Cohn JN, Colucci WS, Fowler MB, Gilbert EM, Shusterman NH. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure: US Carvedilol Heart Failure Study Group. N Engl J Med. 1996;334:1349 –1355. Packer M, Coats AJ, Fowler MB, Katus HA, Krum H, Mohacsi P, Rouleau JL, Tendera M, Castaigne A, Roecker EB, Schultz MK, DeMets DL. Effect of carvedilol on survival in severe chronic heart failure. N Engl J Med. 2001;344:1651–1658. Tung R, Swerdlow C. Refining Patient Selection for Primary Prevention Implantable Cardioverter- Defibrillator Therapy. Circ. 2009; 120:825-827. Smith T, Jordaens L, Theuns DA, et al. The cost-effectiveness of primary prophylactic implantable defibrillator therapy in patients with ischaemic or non-ischaemic heart disease: a European analysis. Eur Heart J. 2013;34:211–9. SC Wijers, BM van der Kolk, AE Tuinenburg, PAF Doevendans, MA Vos, M Meine. Implementation of guidelines for implantable cardioverter-defibrillator therapy in clinical practice: Which patients do benefit? Neth Heart J. 2013 Apr 10.

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