Institutional Variation in Quality of Cardiovascular Implantable Electronic Device Implantation: A Cohort Study.

BACKGROUND

Cardiovascular implantable electronic devices (CIEDs) are associated with procedure-related complications, yet little is known about variation in complication rates among institutions that may suggest disparities in care quality.

OBJECTIVE

To assess institutional variation in risk-standardized complication rates (RSCRs) for CIED.

DESIGN

Cohort study.

SETTING

174 hospitals in Australia and New Zealand, 98 of which implanted at least 25 CIEDs during the study period.

PARTICIPANTS

81 304 patients older than 18 years (mean, 74.7 years [SD, 12.4]; 37.9% female) who received a new CIED (65 711 permanent pacemakers [PPMs] and 15 593 implantable cardioverter-defibrillators [ICDs]) in 2010 to 2015.

MEASUREMENTS

RSCRs and frequencies of major device-related complications during hospitalization or within 90 days of discharge.

RESULTS

Of the cohort, 6664 patients (8.2%) had a major complication. Although complication rates were higher for ICDs than PPMs (10.04% vs. 7.76%), 76.5% of all complications were attributable to PPMs (5098 vs. 1566 for ICDs). Among hospitals that implanted at least 25 CIEDs, the median RSCR was 8.1%; however, rates varied from 5.3% to 14.3%, with 22 hospitals identified as having RSCRs that differed significantly from the national average. Similar variation was observed when RSCRs for PPM implantation (n = 96 hospitals) (median RSCR, 7.6% [range, 5.4% to 12.9%]) were considered separately from those for ICD placement (n = 68 hospitals) (median RSCR, 9.7% [range, 6.2% to 16.9%]) and persisted when only elective procedures were assessed (n = 88 hospitals) (median RSCR, 7.4% [range, 4.7% to 13.0%]).

LIMITATION

Possible unmeasured confounding from the use of administrative data.

CONCLUSION

CIED complications are common and vary among hospitals, suggesting institutional variation in CIED care quality. Concerted clinical and policy interventions are needed to address CIED-related complications. These efforts should preferentially target PPMs, because most CIED complications are attributable to these devices.

PRIMARY FUNDING SOURCE

The Hospitals Contribution Fund Research Foundation.