HEART RHYTHM DISORDERS
The Relation Between Patients' Outcomes and the Volume of Cardioverter-Defibrillator Implantation Procedures Performed by Physicians Treating Medicare Beneficiaries
Sana M. Al-Khatib, MD, MHS, FACC*,*,
F. Lee Lucas, PhD ,
James G. Jollis, MD*,
David J. Malenka, MD and
David E. Wennberg, MD
* Duke Clinical Research Institute, Durham, North Carolina
Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine
Manuscript received December 28, 2004;
revised manuscript received April 11, 2005,
accepted May 11, 2005.
* Reprint requests and correspondence: Dr. Sana M. Al-Khatib, Duke Clinical Research Institute, P.O. Box 17969, Durham, North Carolina 22715
(Email: alkha001{at}mc.duke.edu).
OBJECTIVES: The purpose of this study is to determine if implantable cardioverter-defibrillator (ICD) implantation should be limited to physicians with high procedural volume.
BACKGROUND: Expanding indications for ICDs will result in an increasing number of physicians implanting these devices.
METHODS: Using the 20% Part B Medicare files for 1999 through 2001, we identified new ICD implantations and the corresponding denominator files. We used Medicare Provider Analysis and Review hospital records and the appropriate International Classification of Diseases-9 diagnosis and procedure codes to define complications within 90 days. We defined physician volume categories by assigning one-quarter of the patients to each quartile. A logistic regression model was used to adjust outcomes for potential confounders.
RESULTS: Ninety-day mortality did not differ between patients who had their ICD implanted by physicians with the highest volume of implants and those who had their ICD implanted by physicians with the lowest volume of implants (6.2% vs. 5.9%; odds ratio [OR] 0.99; 95% confidence interval [CI] 0.75 to 1.30). Within 90 days, mechanical complications were significantly higher in the lowest volume quartile (OR 1.47; 95% CI 1.09 to 1.99) but were comparable for physicians who implanted at least 11 ICDs per year. The risk of ICD infection was significantly higher in patients who had their ICD implanted by physicians with the lowest volume of implants (OR 2.47; 95% CI 1.18 to 5.17).
CONCLUSIONS: We observed an association between a higher volume of ICD implants and a lower rate of mechanical complications and infections. This association suggests that ICD implantation should not be performed by physicians without regard to their procedural volume.
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Abbreviations and Acronyms
| | CI = confidence interval | | ICD = implantable cardioverter-defibrillator | | LVEF = left ventricular ejection fraction | | MEDPAR = Medicare Provider Analysis and Review | | OR = odds ratio |
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