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Clinical Effectiveness of Implantable Cardioverter- Defibrillators Among Medicare Beneficiaries With Heart Failure

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Clinical Effectiveness of Implantable Cardioverter-DefibrillatorsAmong Medicare Beneficiaries With Heart Failure

Adrian F. Hernandez, MD, MHS; Gregg C. Fonarow, MD; Bradley G. Hammill, MS; Sana M. Al-Khatib, MD, MHS; Clyde W. Yancy, MD; Christopher M. O’Connor, MD; Kevin A. Schulman, MD; Eric D. Peterson, MD, MPH; Lesley H. Curtis, PhD


Background

Previous reports have demonstrated that participation in Get With The Guidelines- Heart Failure (GWTG-HF), a national quality initiative of the American Heart Association, is associated with improved guideline adherence for patients hospitalized with HF. We sought to establish whether these benefits from participation in GWTG-HF were sustained over time.


  • Introduction

  • The American Heart Association (AHA) and the American College of Cardiology (ACC) have developed treatment guidelines for patients with heart failure (HF).

    • Despite widely available evidence-based therapies that have been shown to improve clinical outcomes for patients with heart failure (HF), a treatment gap exists between clinical practice and use of guideline recommended therapies.

  • GWTG-HF quality improvement program has shown significant improvements in guideline adherence for patients hospitalized with HF.


Objective
Objective

The clinical effectiveness of implantable cardioverter-defibrillators (ICDs) in older patients with HF has not been established, and older patients have been underrepresented in previous studies. The purpose of the paper was to evaluate the clinical effectiveness of ICD therapy in older patients and women to address the potential risks and benefits.


Methods
Methods

  • Patient population included 4685 patients with heart failure who

    -were aged 65 years or older and were eligible for an ICD,

    -had left ventricular ejection fraction of 35% or less, and -were discharged alive from hospitals participating in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure and the Get With the Guidelines–Heart Failure quality-improvement program

  • Study period of January 1, 2003, through December 31, 2006.

  • Patients matched to Medicare claims to examine long-term outcomes.

  • The main outcome measure was all-cause mortality over 3 years.


Results
Results

  • Mortality was significantly lower among patients who received an ICD compared with those who did not over the three year period (19.8% vs. 27.6% at one year, 30.9% vs. 41.9% at 2 years and 38.1% vs. 52.3% at 3 years; P> .001 for all comparisons).

  • No differences in were seen in the risk of mortality based on age, sex and etiology of HF.

  • A beneficial effect of ICD therapy on mortality was seen among patients who had a LVEF of 30% or less and among patients discharged with both ACE inhibitors/ARBs and Beta-blockers.

  • Medicare beneficiaries hospitalized with HF and LVEF of 35% or less who were selected for ICD therapy had a lower risk-adjusted long-term mortality as compared with those who did not receive an ICD.


Limitations
Limitations

  • The analysis included only fee-for-service Medicare beneficiaries who were included in the clinical registries. We also excluded patients aged 85 years or older, patients discharged to a skilled nursing facility, and elective admissions. Thus, our findings may not be generalizable to these populations.

  • The registries may disproportionately include hospitals that are more likely to follow evidence-based recommendations, which in turn may influence long-term outcomes.

  • Patients with prior ICD implantations were not included because implantation dates were not available long-term survival could not be estimated accurately.

  • The data on doses of medications such as ACE inhibitors, beta-blockers, and diuretics or follow-up data on changes in medications after discharge were not available.

  • Complications of device implantation, measures of appropriate and inappropriate device discharges, NYHA functional class, quality of life, socioeconomic factors, and post-discharge health status were not available, though all are important considerations in evaluating the use of ICD therapy.


Conclusion
Conclusion

Medicare beneficiaries hospitalized with heart failure and LVEF of 35% or less who were eligible for ICD therapy had significantly lower adjusted risk of death over 3 years compared with patients discharged without an ICD. These findings are consistent with the results of randomized clinical trials of ICD therapy.


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