In 2003 Medicare extended coverage of ventricular assist devices (VAD) as destination (permanent) therapy for end-stage heart failure in the USA. Hernandez et al. performed an analysis to determine the short- and long-term clinical outcomes of patients receiving VAD therapy, as well as the costs involved, since this change.
The authors analysed Medicare claims made for VADs between 2000 and 2006; during this period 1476 patients received devices as primary therapy, while 1467 received them within 30 days of cardiotomy. The main outcome measure was the cumulative incidence of device replacement or removal, heart transplantation, readmission and death. Medicare payments were used to calculate total inpatient costs and costs per day outside the hospital.
The overall 1-year survival rate was 51.6% (n=669) in the primary device group and 30.8% (n=424) in the postcardiotomy group. 815 (55.2%) primary device patients were discharged alive with a device, however 450 (55.6%) were readmitted within 6 months and 504 (73.2%) were alive at 1 year. Of the 493 (33.6%) postcardiotomy patients discharged alive with a device, 237 (48.3%) were subsequently readmitted within 6 months and 355 (76.6%) alive at 1 year. Mean 1-year Medicare payments for inpatient care for patients in the 2000-2005 cohorts were $178,714 (SD $142,549) in the primary device group and $111,760 (SD $95,413) in the postcardiotomy group.
This analysis provides a blunt insight into the current limitations of VAD use. For example, fewer than half of the patients receiving VAD treatment were alive at one year – the National Heart, Lung and Blood Institute (NHLBI) in the US has set a goal of 50% survival at two years. Several clincal factors (age, renal failure, peripheral vascular disease) were associated with higher mortality in the primary group and exercising more caution in patients with these conditions could be one way to improve survival rates. Further clinical trials will be needed to define the role for VAD therapy aside from as a bridge to transplant.
- Hernandez AF, Shea AM, Carmelo A, et al. Long-term outcomes and costs of ventricular assist devices among Medicare beneficiaries. JAMA 2008; 300:2398-2406.