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Institutional Variation in Quality of Cardiovascular Implantable Electronic Device Implantation: A Cohort Study
Isuru Ranasinghe1, Clementine Labrosciano2, Dennis Horton3
1Basil Hetzel Institute for Translational Research, University of Adelaide, and Central Adelaide Local Health Network, Adelaide, South Australia, Australia (I.R.).
Insights
Complications from cardiovascular implantable electronic devices (CIEDs) are common and vary significantly between hospitals, indicating disparities in care quality. Interventions are needed to address these issues, particularly for permanent pacemakers (PPMs).
Area of Science:
- Cardiology
- Health Services Research
- Medical Device Technology
Background:
- Cardiovascular implantable electronic devices (CIEDs) are crucial for managing cardiac conditions but are associated with procedure-related complications.
- Little is known about variations in complication rates across different healthcare institutions, raising concerns about potential disparities in care quality.
Purpose of the Study:
- To assess institutional variation in risk-standardized complication rates (RSCRs) for CIED procedures.
- To identify hospitals with significantly different complication rates compared to the national average.
Main Methods:
- A cohort study was conducted involving 81,304 patients who received a new CIED (pacemakers or implantable cardioverter-defibrillators) between 2010 and 2015 across 174 hospitals in Australia and New Zealand.
- Risk-standardized complication rates (RSCRs) were calculated for major device-related complications occurring during hospitalization or within 90 days of discharge.
- Analysis included 98 hospitals that implanted at least 25 CIEDs, with separate assessments for permanent pacemakers (PPMs) and implantable cardioverter-defibrillators (ICDs).
Main Results:
- Overall, 8.2% of patients experienced a major complication.
- While implantable cardioverter-defibrillators (ICDs) had a higher complication rate (10.04%) than permanent pacemakers (PPMs) (7.76%), PPMs accounted for 76.5% of all complications.
- A significant variation in median RSCRs was observed among hospitals (8.1%), ranging from 5.3% to 14.3%, with 22 hospitals showing rates significantly different from the national average.
Conclusions:
- Complications associated with CIEDs are prevalent and exhibit considerable variation among hospitals, suggesting differences in the quality of CIED care.
- Targeted clinical and policy interventions are necessary to mitigate CIED-related complications, with a focus on permanent pacemakers due to their higher contribution to overall complications.
- Addressing these variations is crucial for improving patient outcomes and ensuring equitable care quality in CIED procedures.
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.
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