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Renda Soylemez Wiener, MD; H. Gilbert Welch, MD, MPH

JAMA. 2007;298:423-429.

Context  Although there is now substantial evidence that pulmonary artery (PA) catheterization does not reduce mortality in critically ill patients, it is unknown whether national utilization has decreased in response.

Objective  To determine trends in PA catheterization use in the United States.

Design, Setting, and Participants  A time trend analysis on national estimates of PA catheterization utilization from 1993-2004 using data from all US states contributing to the Nationwide Inpatient Sample. Hospital admissions for those participants aged 18 years or older were assessed, with primary analysis focused on admissions with a medical diagnosis related group and a secondary analysis focused on surgical admissions. PA catheterization was identified by 5 International Classification of Diseases, Ninth Revision procedure codes describing PA or wedge-pressure monitoring, measurement of mixed venous blood gases, or monitoring of cardiac output by oxygen consumption or other technique.

Main Outcome Measure  Annual PA catheterization use per 1000 medical admissions.

Results  Between 1993 and 2004, PA catheterization use decreased by 65% from 5.66 to 1.99 per 1000 medical admissions (risk ratio [RR], 0.35; 95% confidence interval [CI], 0.29-0.42). Among patients who died during hospitalization, a group whose disease severity may be consistent across time, the relative decline was similar, decreasing from 54.7 to 18.1 per 1000 deaths (RR, 0.33; 95% CI, 0.28-0.38). A significant change in trend occurred following a 1996 study that suggested increased mortality with PA catheterization. The decline in utilization was similar in surgical patients (RR, 0.37; 95% CI, 0.25-0.49). Among common diagnoses associated with PA catheterization, the decline was most prominent for myocardial infarction, which decreased by 81% (RR, 0.19; 95% CI, 0.15-0.23), and least prominent for septicemia, which decreased by 54% (RR, 0.46; 95% CI, 0.38-0.54). Sensitivity analyses suggested findings were not due to artifact of changing procedure coding practice.

Conclusion  Use of the PA catheter, previously a hallmark of critical care practice, has decreased in the United States during the last decade, possibly due to growing evidence that this invasive procedure does not reduce mortality.

Author Affiliations: Veterans Affairs Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vermont (Drs Wiener and Welch); Departments of Medicine (Dr Wiener) and Family and Community Medicine (Drs Wiener and Welch), Dartmouth Medical School, Hanover, New Hampshire.

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