Vena Caval Filter Utilization and Outcomes in Pulmonary Embolism: Medicare Hospitalizations From 1999 to 2010

Abstract

Background: Inferior vena caval filters (IVCFs) may prevent recurrent pulmonary embolism (PE). Despite uncertainty about their net benefit, patterns of use and outcomes of these devices in contemporary practice are unknown.

Objectives: The authors determined the trends in utilization rates and outcomes of IVCF placement in patients with PE and explored regional variations in use in the United States.

Methods: In a national cohort study of all Medicare fee-for-service beneficiaries ≥65 years of age with principal discharge diagnoses of PE between 1999 and 2010, rates of IVCF placement per 100,000 beneficiary-years and per 1,000 patients with PE were determined. The 30-day and 1-year mortality rates after IVCF placement were also investigated.

Results: Among 556,658 patients hospitalized with PE, 94,427 underwent IVCF placement. Between 1999 and 2010, the number of PE hospitalizations with IVCF placement increased from 5,003 to 8,928, representing an increase in the rate per 100,000 beneficiary-years from 19.0 to 32.5 (p < 0.001 for both). As the total number of PE hospitalizations increased (from 31,746 in 1999 to 54,392 in 2010), the rate of IVCF placement per 1,000 PE hospitalizations did not change significantly (from 157.6 to 164.1, p = 0.11). Results were consistent across demographic subgroups, although IVCF use was higher in blacks and patients ≥85 years of age. IVCF utilization varied widely across regions, with the highest rate in the South Atlantic region and the lowest rate in the Mountain region.

Conclusions: In a period of increasing PE hospitalizations among Medicare fee-for-service beneficiaries, IVCF placement increased as utilization rates in patients with PE remained greater than 15%. Mortality associated with PE hospitalizations is declining, regardless of IVCF use.

Keywords: deep vein thrombosis; mortality; trends.

Figure 1. Proportion of Medicare FFS Patients with PE with and without IVCF Placement in 1999 and 2010

Shown are the number of patients with PE, those that received IVCFs, and the fatalities in those who did and did not receive IVCFs. The size of each rectangle is proportionate to the number of patients in each subgroup. Note that the number of deaths in the entire cohort, as well as among those with and without IVCFs increased from 1999 to 2010. However, in the context of increasing PE hospitalizations (denominator), the mortality rates declined in all cohorts, with most notable decline in the subgroup that did not receive an IVCF. The fatalities in the figure represent 30-day unadjusted deaths. Adjusted 30-day and 1-year fatalities follow a similar pattern. FFS: Fee-For-Service, IVCF: inferior vena caval filter PE: pulmonary embolism.

Figure 2. Rates of Inferior Vena Caval Filter Placement Across 9 U.S. Regions in 1999 and 2010

Note the changes in 2010 compared with 1999, including the decline in the New England and the increase in most other regions. Rates are reported per 1,000 patients with PE. South Atlantic: Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington D.C., and West Virginia. New England: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. Mid Atlantic: New Jersey, New York, and Pennsylvania. East North Center: Illinois, Indiana, Michigan, Ohio, and Wisconsin. East South Center: Alabama, Kentucky, Mississippi, and Tennessee. West South Center: Arkansas, Louisiana, Oklahoma, and Texas. Pacific: Alaska, California, Hawaii, Oregon, and Washington. West North Center: Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota and South Dakota. Mountains: Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming

Central Illustration

IVC Filters in Older Adults with Pulmonary Embolism: Mortality and Hospitalization Rates from 1999 to 2010.