Dataset Information

Impact of Center Left Ventricular Assist Device Volume on Outcomes After Implantation: An INTERMACS Analysis.

ABSTRACT:

Objectives

This study examined patient outcomes after left ventricular assist device (LVAD) implantation across a range of center surgical volumes.

Background

In order for a center to qualify for reimbursement, Centers for Medicare and Medicaid Services (CMS) requires it to implant ≥10 LVADs or total artificial hearts over a 3-year period. The impact of center LVAD surgical volumes on patient outcomes has not been thoroughly scrutinized.

Methods

Center volumes were provided for 7,416 patients undergoing LVAD implantation who were enrolled in INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support). Center LVAD volume was categorized as either very low (≤10 implants/year, n = 617), low (11 to 30 implants/year, n = 2,561), medium (31 to 50 implants/year, n = 2,458), or high (>50 implants/year, n = 1,750). The main outcome of interest was patient survival based on center volume derived from Kaplan-Meier and multivariate Cox regression.

Results

Overall survival was associated with center volume (p = 0.003), as follows: 71 ± 1.8% (very low volume), 81 ± 0.8% (low volume), 83 ± 0.8% (medium volume), and 79 ± 1.0% (high volume) at 1 year. Compared with medium volume centers, the 90-day mortality was higher in very low volume (odds ratio [OR]: 1.35; p = 0.04) and high volume (OR: 1.28; p = 0.018) VAD centers. The adjusted hazard ratios (HRs) for mortality were 1.32 (95% confidence interval [CI]: 1.11 to 1.56), 1.07 (95% CI: 0.95 to 1.21), and 1.17 (95% CI: 1.03 to 1.30) for very low, low, and high volume centers, respectively. Center volume did not predict mortality (p = 0.25; n = 3,688) in INTERMACS profile 1 patients (patients who had sustained cardiogenic shock) and profile 2 patients (patients with progressive hemodynamic decline despite inotropes).

Conclusions

Center volume correlates with post-VAD survival, with worse survival noted at very-low volume centers. These findings suggest that current U.S. VAD center standards warrant reconsideration.

SUBMITTER: Cowger JA

PROVIDER: S-EPMC8453659 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundLeft ventricular assist device (LVAD) therapy is an increasingly viable alternative for patients who are not candidates for heart transplantation or who are waiting for a suitable donor. We aimed to determine whether there is an association between sex, race/ethnicity, insurance coverage, and neighborhood income and access to/outcomes of LVAD implantation. We further analyzed whether access to LVAD improved in states that did versus did not expand Medicaid.Methods and resultsRetrospective cohort study using State Inpatient Databases to identify patients 18 to 85 years of age admitted for heart failure, cardiogenic shock, or LVAD implantation from 2012 to 2015. Logistic regression analyses adjusting for age, all the sociodemographic factors above, medical comorbidities, and a hospital random effect were used to quantify odds of receipt of LVADs, as well as outcomes conditional on receiving an LVAD, for the sociodemographic groups of interest. A total of 925 770 patients were included; 3972 (0.43%) received LVADs. After adjusting for age, comorbidities, and hospital effects, women (adjusted odds ratio [aOR], 0.45 [0.41-0.49]), black patients (aOR, 0.83 [0.74-0.92]), and Hispanic patients (aOR, 0.74 [0.64-0.87]) were less likely to receive LVADs than whites. Medicare (aOR, 0.79 [0.72-0.86]), Medicaid (aOR, 0.52 [0.46-0.58]), and uninsured patients (aOR, 0.17 [0.11-0.25]) were less likely to receive LVADs than the privately insured, and patients in low-income ZIP codes were less likely than those in higher income areas (aOR, 0.71 [0.65-0.77]). Among those who received LVADs, women (aOR, 1.78 [1.38-2.30]), patients of unknown race or race other than white, black, or Hispanic (aOR, 1.97 [1.42-2.74]), and uninsured patients (aOR, 4.86 [1.92-12.28]) had higher rates of in-hospital mortality. Medicaid expansion was not associated with an increase in LVAD implantation.ConclusionsThere are meaningful sociodemographic disparities in access and outcomes for LVAD implantation. Medicaid expansion was not associated with an increase in LVAD rates.

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