Hospital Variation in the Utilization of Short-Term Nondurable Mechanical Circulatory Support in Myocardial Infarction Complicated by Cardiogenic Shock

Abstract

Background: Limited knowledge exists on inter-hospital variation in the utilization of short-term, non-durable mechanical circulatory support (MCS) for myocardial infarction (MI) complicated by cardiogenic shock (CS). Methods and Results: Hospitalizations for MI with CS in 2014 in a nationally representative all-payer database were included. The proportion of hospitalizations for MI with CS using MCS (MCS ratio) and in-hospital mortality were evaluated. Hospital characteristics and outcomes were compared across quartiles of MCS usage. Of 1,813 hospitals evaluated, 1,440 (79.4%) performed ≥10 PCIs annually. Of these, 1,064 [73.9%] had at least one code for MCS. Forty-one percent of hospitals did not use MCS. The median (interquartile range [IQR]) proportion of MCS use among admissions for MI with CS was 33.3% (0.0–50.0%). High MCS utilizing hospitals were larger (p <0.001). Eighty-five percent (2808/3301) of MCS use was intra-aortic balloon pump (IABP). There was significant variation in receipt of MCS at different hospitals (median OR of receiving MCS at two random hospitals: 1.58; 95% CI 1.45–1.70). Adjusted in-hospital mortality was not different across quartiles of MCS use (Q4 vs Q1; OR 0.95; 95% CI 0.77–1.16, p = 0.58). Conclusions: Wide variation exists in hospital use of MCS for MI with CS, unexplained by patient characteristics. The predominant form of MCS use is IABP. Risk-adjusted mortality rates were not different between higher and lower MCS-utilizing hospitals.

Cardiogenic shock teams and centres: a contemporary review of multidisciplinary care for cardiogenic shock

“…Patient selection for MCS also differs in hospitals with different rates of MCS utilization, which could affect variation in clinical outcomes across hospitals. 33 Overall, given the complexity of CS, dedicated training and experience is needed to maintain competency in delivering safe and effective non-invasive and invasive interventions. It is possible to build upon the volume-outcome relationship by establishing multidisciplinary CS teams within specialized referral centres adept at providing comprehensive care for CS patients.…”

“…Furthermore, appropriate patient selection for advanced therapies may be a determinant of outcomes. Patient selection for MCS also differs in hospitals with different rates of MCS utilization, which could affect variation in clinical outcomes across hospitals 33 …”

Limited duration of antiarrhythmic drug use for newly diagnosed atrial fibrillation in a nationwide population under age 65

“…This mirrors the geographic variation seen with cardiac devices more generally. [27][28][29] Further investigation is required to understand the drivers of these differences, which may include physician training networks, patient preferences, and access to CA.…”

Prognostic Impact of Active Mechanical Circulatory Support in Cardiogenic Shock Complicating Acute Myocardial Infarction, Results from the Culprit-Shock Trial

“…These devices, among others, include the microaxial flow pumps from the Impella ® family, the TandemHeart ® and ECMO [6]. Although frequently used in clinical routine, data supporting a prognostic benefit with active MCS devices in infarct-related CS are limited [14][15][16][22][23][24][25][26][27][28][29][30]. The aim of the present analysis was to investigate the prognostic role of active MCS devices rather than an outcome analysis of patients treated with IABP.…”