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CLINICAL RESEARCH: HEART FAILURE

Hospital Variation and Characteristics of Implantable Cardioverter-Defibrillator Use in Patients With Heart Failure

Data From the GWTG-HF (Get With The Guidelines–Heart Failure) Registry

Bimal Shah, MD, MBA^_*, Adrian F. Hernandez, MD, MHS^_*,_*, Li Liang, PhD^_*, Sana M. Al-Khatib, MD, MHS^_*, Clyde W. Yancy, MD, FACC, Gregg C. Fonarow, MD, FACC, Eric D. Peterson, MD, MPH, FACC^_* on behalf of the Get With The Guidelines Steering Committee

^_* Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
Baylor Heart and Vascular Institute, Dallas, Texas
University of California–Los Angeles Medical Center, Los Angeles, California

Manuscript received July 8, 2008; revised manuscript received September 4, 2008, accepted September 29, 2008.

^_* Reprint requests and correspondence: Dr. Adrian F. Hernandez, Duke Clinical Research Institute, 2400 Pratt Street, Durham, North Carolina 27710 (Email: adrian.hernandez{at}duke.edu).

Objectives: The aim of this study was to describe hospital variation and factors associated with adherence to guidelines for implantable cardioverter-defibrillator (ICD) therapy.

Background: Studies have shown incomplete application of ICD therapy in eligible heart failure (HF) patients.

Methods: New or discharge prescription rates for ICD therapy (ejection fraction 30% without documented ICD contraindications) for hospitals were calculated from participants in the GWTG-HF (Get With The Guidelines–Heart Failure) registry during January 2005 to June 2007. With hierarchical modeling, hospitals' patient case-mix adjusted ICD rate and hospital factors associated with ICD use were determined. The association of ICD rate and other quality of care indicators and procedure use was determined.

Results: Overall use of ICD in-hospital or planned implantation rate was 20%. This rate ranged widely among hospitals, from 1% among the lowest tertile to 35% among the top tertile (p < 0.01). After adjusting for patient case mix, independent hospital characteristics associated with higher ICD use were percutaneous coronary intervention, coronary artery bypass grafting, and heart transplant capability as well as larger hospital bed size (p < 0.01). Hospital Centers for Medicare and Medicaid Services/Joint Commission on the Accreditation of Healthcare Organizations performance measures (discharge instructions, angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use, smoking cessation; p 0.05) were similar across ICD, whereas higher ICD-rate hospitals had higher adherence to GWTG-HF performance measures (beta-blocker use, evidence-based beta-blocker use, aldosterone-antagonist, hydralazine/nitrate; p < 0.05) except warfarin in patients with atrial fibrillation (p = 0.18).

Conclusions: There is significant unexplained hospital variation in the use of ICD therapy among potentially eligible HF patients. However, hospitals that use ICD therapy more often also have more rapidly adopted other newer evidence-based HF therapies.

Key Words: heart failure • hospital • ICD • registry

Abbreviations and Acronyms   ACC = American College of Cardiology   AHA = American Heart Association   CABG = coronary artery bypass grafting   CMS = Centers for Medicare and Medicaid Services   GWTG-HF = Get With The Guidelines–Heart Failure   HF = heart failure   ICD = implantable cardioverter-defibrillator   JCAHO = Joint Commission on the Accreditation of Healthcare Organizations   LV = left ventricular   LVEF = left ventricular ejection fraction   PCI = percutaneous coronary intervention

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