Receipt of ventricular assist devices associated with poor outcomes, high costs

Medicare patients who receive ventricular assist devices (a type of heart pump) have high rates of death, illness, prolonged hospital stays, with resulting high costs of care, according to a study in the November 26 issue of JAMA, the Journal of the American Medical Association.

A ventricular assist device consists of a mechanical pump that takes over the function of a damaged ventricle of the heart and helps restore normal blood flow. These devices are used primarily in patients with end-stage heart failure who are awaiting heart transplantation, as "destination," or permanent therapy for patients who are not candidates for transplantation, or as a rescue procedure for patients with shock after open-heart surgery that is not responding to treatment, according to background information in the article. In 2003, Medicare expanded coverage of ventricular assist devices as permanent therapy for end-stage heart failure. Little is known about the long-term outcomes and costs associated with these devices.

Adrian F. Hernandez, M.D., M.H.S., of Duke University School of Medicine, Durham, N.C., and colleagues analyzed trends in use, outcomes and costs of ventricular assist devices for all Medicare fee-for-service beneficiaries from February 2000 through June 2006 by examining inpatient claims from the Centers for Medicare & Medicaid Services for this period. This study included beneficiaries who received a ventricular assist device as primary therapy (primary device group; n = 1,476) or after cardiotomy (heart surgery, such as coronary bypass surgery or valve replacement surgery) in the previous 30 days (postcardiotomy group; n = 1,467).

The researchers found that overall 1-year survival, regardless of subsequent heart transplantation or device removal, was 51.6 percent (n = 669) in the primary device group and 30.8 percent (n = 424) in the postcardiotomy group. Of the 815 patients in the primary device group who were discharged alive with a device, 55.6 percent were readmitted within 6 months. On average, these patients spent 29.8 days in the hospital during the subsequent 2 years; survival was 64.7 percent at 2 years. Among patients in the postcardiotomy group who were discharged alive with a device (n = 493), 48.3 percent were readmitted within 6 months. These patients spent an average of 16.7 days in the hospital during the subsequent 2 years; survival was 69.4 percent at 2 years.

For patients in the 2000 through 2005 groups, the average Medicare payment to hospitals for inpatient care in the first year after implantation of a ventricular assist device was $144,298 per patient. One-year Medicare payments for inpatient care of primary device patients totaled approximately $228 million, and was about $151 million for inpatient care of postcardiotomy patients.

"Ventricular assist devices are an evolving technology with modest adoption in the Medicare population. Mortality, morbidity, and costs remain high, so periodic surveillance using Medicare claims may complement other postmarketing surveillance efforts," they write. "Improving outcomes will require a focus on the high perioperative [around the time of surgery] mortality found in this and other studies. Identifying patients who are likely to benefit from ventricular assist devices and excluding those whose likelihood of survival is low is warranted."


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