What are the national trends in overall use of pulmonary artery catheters (PACs) and in previously common indications for PAC placement?
In this cohort study of Medicare beneficiaries, rates of PAC use decreased 67.8% from 1999 to 2013, while the rate of PAC use in heart failure admissions decreased from 1999 to 2009, followed by a subsequent increase. Use of PACs in admissions for myocardial infarction and respiratory failure decreased during the study period.
Overall use of PACs has decreased, and disparate trends have emerged in admissions for heart failure, respiratory failure, and myocardial infarction, raising questions about the drivers of these trends.
Recent studies have observed an increase in the rate of pulmonary artery catheter (PAC) use in heart failure admissions. Little is known about the national trends in other previously common indications for PAC placement, PAC use overall, or outcomes associated with PAC placement.
To determine national trends in PAC use overall as well as across sociodemographic groups and key clinical conditions, including acute myocardial infarction, heart failure, and respiratory failure.
Design, Setting, and Participants
Centers for Medicare and Medicaid Services inpatient claims data and International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to conduct a serial cross-sectional cohort study between January 1, 1999, and December 31, 2013, identifying hospitalizations during which a PAC was placed. Data analysis was conducted from September 25, 2015, to April 10, 2017.
Main Outcomes and Measures
Rate of use of a PAC per 1000 admissions, 30-day mortality, and length of stay.
Among the 68 374 904 unique Medicare beneficiaries in the study, there were 469 582 hospitalizations among 457 193 patients (204 232 women and 252 961 men; mean [SD] age, 76.3 [6.9] years) during which a PAC was placed. There was a 67.8% relative decrease in PAC use (6.28 per 1000 admissions in 1999 to 2.02 per 1000 admissions in 2013; P < .001), with 2 distinct trends: significant year-on-year decreases from 1999 to 2011, followed by stable use through 2013. There was variation in rates of PAC use across race/ethnicity, age, and sex, but use decreased across all subgroups. Although there were sustained decreases in PAC use for acute myocardial infarction (20.0 PACs placed per 1000 admissions in 1999 to 5.2 in 2013 [74.0% reduction]; P < .001 for trend) and respiratory failure (29.9 PACs placed per 1000 admission in 1999 to 2.3 in 2013 [92.3% reduction]; P < .001 for trend) during the study period, there was an initial decrease in PAC use in heart failure, with a nadir in 2009 followed by a subsequent increase (9.1 PACs placed per 1000 admissions in 1999 to 4.0 in 2009 to 5.8 in 2013). In-hospital mortality, 30-day mortality, and length of stay decreased during the study period.
Conclusions and Relevance
In the wake of mounting evidence suggesting a lack of benefit to the routine use of PACs, there has been a de-adoption of PAC use overall and across sociodemographic groups but heterogeneity in patterns of use across clinical conditions. The clinical outcomes of patients with PACs have significantly improved. These findings raise important questions about the optimal use of PACs and the drivers of the observed trends.
Ikuta K, Wang Y, Robinson A, Ahmad T, Krumholz HM, Desai NR. National Trends in Use and Outcomes of Pulmonary Artery Catheters Among Medicare Beneficiaries, 1999-2013. JAMA Cardiol. Published online June 07, 2017. doi:10.1001/jamacardio.2017.1670