Variations in Implantable Cardioverter Defibrillator (ICD) Utilization in the Louisiana

Health System

Principal Investigator: Tekeda F. Ferguson, MPH, MSPH, PhDLSUHSC New Orleans

School of Public Health

No financial disclosures

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.

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• 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

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

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

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.

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 ICD ICD

N= 39,830 N= 6,346 N= 4,932 N= 1,431 Age, mean ± SD* 57.0 ± 13.2 54.1 ± 11.6 53.9 ± 11.7 54.6 ± 11.3BMI, kg/m2 33.3 ± 10.4 31.7 ± 8.9 31.7 ± 9.0 31.6 ± 8.2 % % % %Gender*

Male 48.7 64.2 37.1 68.9Female 51.3 35.8 62.9 31.1

Race* White 40.9 37.0 34.7 45.0Black 56.8 60.9 63.4 52.5Other 2.3 2.1 1.9 2.5

Insurance coverage

Commercial 6.7 4.7 4.1 6.7Medicaid 17.9 20.0 19.8 20.6Medicare 27.2 20.3 19.7 22.6

Free 30.7 37.8 39.4 32.4Self-Pay 14.0 16.3 16.4 15.6

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

% % % 0 13.2 13.5 12.01 26.4 27.8 21.72 22.7 22.7 22.53 15.9 15.2 18.44 11.8 11.2 14.05 or more 10.0 9.6 11.4

*The comorbidities included hypertension, diabetes, other CHD (Coronary Heart Disease), hypercholesterolemia, hyperglyceridemia, hyperlipidemia, COPD (Chronic Obstructive Pulmonary Disease), chronic liver disease, chronic kidney disease.

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 ICD ICD P-value

N= 39,830 N= 6,346 N= 4,932 N= 1,431 % % % %

Other CHD* 30.1 32.6 28.8 45.6 <.0001

Hypercholesterolemia 18.0 15.1 14.7 16.8 0.0417

COPD* 24.7 20.1 20.6 18.2 0.0408 Chronic liver disease 3.7 3.0 3.2 2.2 0.0606

Acute Myocardial

Infarction7.6 9.9 9.5 11.3 0.0479

Abbreviations: CHD (Coronary Heart Disease); COPD (Chronic Obstructive Pulmonary Disease)

Table 4. The prevalence of ICD implantation among heart failure patients diagnosed in LSU HCSD, by facility, 1998-2012

EKL - Earl K. Long Hospital CenterMCL - Interim LSU Public HospitalBMC - Bogalusa Medical CenterLAK - Lallie Kemp Regional Medical Center

W.O. - Regional Medical Center

UMC - University Medical CenterLJC - L. J. Chabert Medical Center

Facility No. of heart failure

No. Heart Failure EF

<40

No. of ICD implantatio

n

Prevalence of ICD (%)

EKLa 5,664 1,164 77 6.6MCLb 13,250 1,924 756 39.3BMCc 4,035 284 138 48.6LAKd 2,716 414 41 9.9WOMe 3,225 580 43 7.4UMCf 5,761 1,007 263 16.2LJCg 5,179 973 113 11.6

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

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.

Acknowledgements

• Lee Arcement, MD, MPH– L.J. Chabert Medical Center

• Ronald Horswell, PhD• Meghan Brashear, MPH• Lu Zhang, MPH

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