Division of Cardiovascular Medicine (T.A.B, S.P.), Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City.
Department of Cardiovascular Medicine, Heart, Thoracic and Vascular Institute, Cleveland Clinic, OH (A.M., M.D.).
Circ Cardiovasc Interv. 2022 Aug;15(8):e011778. doi: 10.1161/CIRCINTERVENTIONS.121.011778. Epub 2022 Jul 29.
Percutaneous ventricular assist devices (PVADs) have been replacing intra-aortic balloon pumps for hemodynamic support during percutaneous coronary intervention (PCI), even though data supporting a benefit for hard clinical end points remain limited. We evaluated diffusion of PVADs across US markets and examined the association of market utilization of PVAD with mortality and cost.
Using the 2013 to 2019 Medicare data, we identified all patients aged ≥65 years who underwent PCI with either a PVAD or intra-aortic balloon pump. We used hospital referral region to define regional health care markets and categorized them in quartiles based on the proportional use of PVADs during PCI. Multilevel models were constructed to determine the association of patient, hospital, and market factors with utilization of PVADs and the association of PVAD utilization with 30-day mortality and cost.
A total of 79 176 patients underwent PCI with either intra-aortic balloon pump (47 514 [60.0%]) or PVAD (31 662 [40.0%]). The proportion of PCI procedures with PVAD increased over time (17% in 2013 to 57% in 2019; for trend, <0.001), such that PVADs overtook intra-aortic balloon pump for hemodynamic support during PCI in 2018. There was a large variation in PVAD utilization across markets (range, 0%-85%), which remained unchanged after adjustment of patient characteristics (median odds ratio, 2.05 [95% CI, 1.91-2.17]). The presence of acute myocardial infarction, cardiogenic shock, and emergent status was associated with a 45% to 50% lower odds of PVAD use suggesting that PVADs were less likely to be used in the sickest patients. Greater utilization of PVAD at the market level was not associated with lower risk mortality but was associated with higher cost.
Although utilization of PVADs for PCI continues to increase, there is large variation in PVAD utilization across markets. Greater market utilization of PVADs was not associated with lower mortality but was associated with higher cost.
在经皮冠状动脉介入治疗（PCI）期间，经皮心室辅助装置（PVAD）已取代主动脉内球囊泵用于血液动力学支持，尽管支持硬临床终点获益的数据仍然有限。我们评估了 PVAD 在全美市场的普及情况，并研究了 PVAD 的市场使用与死亡率和成本的关系。
使用 2013 年至 2019 年的 Medicare 数据，我们确定了所有年龄≥65 岁且接受过 PVAD 或主动脉内球囊泵治疗的 PCI 患者。我们使用医院转诊区定义区域医疗保健市场，并根据 PCI 期间 PVAD 的使用比例将其分为四等份。构建多水平模型以确定患者、医院和市场因素与 PVAD 使用的关系，以及 PVAD 使用与 30 天死亡率和成本的关系。
共有 79176 例患者接受了主动脉内球囊泵（47514[60.0%]）或 PVAD（31662[40.0%]）的 PCI 治疗。随着时间的推移，接受 PVAD 的 PCI 手术比例逐渐增加（2013 年为 17%，2019 年为 57%；趋势检验，<0.001），以至于 2018 年 PVAD 在 PCI 期间超越主动脉内球囊泵成为首选血液动力学支持装置。各市场之间的 PVAD 使用情况存在较大差异（范围，0%-85%），但在调整患者特征后保持不变（中位数优势比，2.05[95%置信区间，1.91-2.17]）。存在急性心肌梗死、心源性休克和紧急状态与 PVAD 使用的可能性降低 45%至 50%相关，这表明在病情最严重的患者中，PVAD 不太可能被使用。在市场层面上，PVAD 的使用量增加与较低的风险死亡率无关，但与更高的成本相关。
尽管用于 PCI 的 PVAD 的使用不断增加，但各市场之间的 PVAD 使用情况存在较大差异。更大的 PVAD 市场使用率与死亡率降低无关，但与成本增加有关。
