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Randomized Controlled Trial
. 2014 Mar 1;7(2):251-60.
doi: 10.1161/CIRCHEARTFAILURE.113.000761. Epub 2014 Jan 31.

Hospital variation in intravenous inotrope use for patients hospitalized with heart failure: insights from Get With The Guidelines

Larry A Allen  1 , Gregg C Fonarow, Maria V Grau-Sepulveda, Adrian F Hernandez, Pamela N Peterson, Chohreh Partovian, Shu-Xia Li, Paul A Heidenreich, Deepak L Bhatt, Eric D Peterson, Harlan M Krumholz; American Heart Association’s Get With The Guidelines Heart Failure Investigators
Affiliations
Randomized Controlled Trial

Hospital variation in intravenous inotrope use for patients hospitalized with heart failure: insights from Get With The Guidelines

Larry A Allen et al. Circ Heart Fail. .

Erratum in

  • Circ Heart Fail. 2014 May;7(3):547. Heidenrich, Paul A [corrected to Heidenreich, Paul A]

Abstract

Background: Prior claims analyses suggest that the use of intravenous inotropic therapy for patients hospitalized with heart failure varies substantially by hospital. Whether differences in the clinical characteristics of the patients explain observed differences in the use of inotropic therapy is not known.

Methods and results: We sought to characterize institutional variation in inotrope use among patients hospitalized with heart failure before and after accounting for clinical factors of patients. Hierarchical generalized linear regression models estimated risk-standardized hospital-level rates of inotrope use within 209 hospitals participating in Get With The Guidelines-Heart Failure (GWTG-HF) registry between 2005 and 2011. The association between risk-standardized rates of inotrope use and clinical outcomes was determined. Overall, an inotropic agent was administered in 7691 of 126 564 (6.1%) heart failure hospitalizations: dobutamine 43%, dopamine 24%, milrinone 17%, or a combination 16%. Patterns of inotrope use were stable during the 7-year study period. Use of inotropes varied significantly between hospitals even after accounting for patient and hospital characteristics (median risk-standardized hospital rate, 5.9%; interquartile range, 3.7%-8.6%; range, 1.3%-32.9%). After adjusting for case-mix and hospital structural differences, model intraclass correlation indicated that 21% of the observed variation in inotrope use was potentially attributable to random hospital effects (ie, institutional preferences). Hospitals with higher risk-standardized inotrope use had modestly longer risk-standardized length of stay (P=0.005) but had no difference in risk-standardized inpatient mortality (P=0.12).

Conclusions: Use of intravenous inotropic agents during hospitalization for heart failure varies significantly among US hospitals even after accounting for patient and hospital factors.

Keywords: cardiotonic agents; heart failure; outcome and process assessment (health care); physician’s practice patterns.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr. Allen reports receiving research grants from the National Institutes of Health and the American Heart Association; and serving as a consultant for Amgen, Inc, Johnson & Johnson, and Novartis. Dr. Fonarow reports receiving research grants or other research support from National Institutes of Health, and the Agency for Healthcare Research and Quality; consulting for Bayer, Gambro, Novartis, Medtronic, and Johnson & Johnson; Dr. Fonarow holds the Eliot Corday Chair of Cardiovascular Medicine at UCLA and is also supported by the Ahmanson Foundation (Los Angeles, California). Dr. Hernandez reported receiving research support from Johnson and Johnson, Medtronic, and Merck and Co.; serving on the speakers’ bureau for Novartis; and receiving honoraria from AstraZeneca and Medtronic. Dr. Heidenreich reported no conflicts. Dr. Bhatt reports the following relationships - Advisory Board: Elsevier Practice Update Cardiology, Medscape Cardiology, Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of Cardiovascular Patient Care; Chair: American Heart Association Get With The Guidelines Steering Committee; Honoraria: American College of Cardiology (Editor, Clinical Trials, Cardiosource), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor in Chief, Journal of Invasive Cardiology); Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), WebMD (CME steering committees); Data Monitoring Committees: Duke Clinical Research Institute; Harvard Clinical Research Institute; Mayo Clinic; Population Health Research Institute; Research Grants: Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, Roche, Sanofi Aventis, The Medicines Company; Unfunded Research: FlowCo, PLx Pharma, Takeda. Dr. Eric Peterson reported receiving research support from Bristol-Myers Squibb, Sanofi-Aventis, Merck and Co., and Eli Lilly; and serving as the principal investigator of the analytic center for the American Heart Association Get With the Guidelines Program. Dr. Krumholz reports that he is the recipient of a research grant from Medtronic, through Yale University, to develop methods of clinical trial data sharing and is chair of a cardiac scientific advisory board for UnitedHealth.. Drs. Hernandez and E. Peterson have made available online detailed listings of financial disclosures (http://www.dcri.duke.edu/research/coi.jsp).

Figures

Figure 1
Figure 1
Hospital rates of inotrope use among patients hospitalized with heart failure, with observed (blue) and risk-standardized (red) rates paired for each hospital site. Sites ordered from highest (left) to lowest (right) by hospital risk-standardized rates.
Figure 2
Figure 2
Temporal trends in use of intravenous inotropes. Panel A shows the hospital-level mean percent of patients hospitalized with heart failure treated with any inotrope (solid blue line), and treated with individual agents (dashed lines), in each of the years studied. Panel B shows a detailed breakdown of the agent(s) used among patients treated with an inotrope.
Figure 2
Figure 2
Temporal trends in use of intravenous inotropes. Panel A shows the hospital-level mean percent of patients hospitalized with heart failure treated with any inotrope (solid blue line), and treated with individual agents (dashed lines), in each of the years studied. Panel B shows a detailed breakdown of the agent(s) used among patients treated with an inotrope.
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