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Adrian F. Hernandez, MD, MHS; Alisa M. Shea, MPH; Carmelo A. Milano, MD; Joseph G. Rogers, MD; Bradley G. Hammill, MS; Christopher M. O’Connor, MD; Kevin A. Schulman, MD; Eric D. Peterson, MD, MPH; Lesley H. Curtis, PhD

JAMA. 2008;300(20):2398-2406.

Context  In 2003, Medicare expanded coverage of ventricular assist devices as destination, or permanent, therapy for end-stage heart failure. Little is known about the long-term outcomes and costs associated with these devices.

Objective  To examine the acute and long-term outcomes of Medicare beneficiaries receiving ventricular assist devices alone or after open-heart surgery.

Design, Setting, and Patients  Analysis of inpatient claims from the Centers for Medicare & Medicaid Services for the period 2000 through 2006. Patients were Medicare fee-for-service beneficiaries who received a ventricular assist device between February 2000 and June 2006 alone as primary therapy (primary device group; n = 1476) or after cardiotomy in the previous 30 days (postcardiotomy group; n = 1467).

Main Outcome Measures  Cumulative incidence of device replacement, device removal, heart transplantation, readmission, and death, accounting for censoring and competing risks. Patients were followed up for at least 6 months and factors independently associated with long-term survival were identified. Medicare payments were used to calculate total inpatient costs and costs per day outside the hospital.

Results  Overall 1-year survival was 51.6% (n = 669) in the primary device group and 30.8% (n = 424) in the postcardiotomy group. Among primary device patients, 815 (55.2%) were discharged alive with a device. Of those, 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 readmitted within 6 months and 355 (76.6%) were 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 $111 769 (SD, $95 413) in the postcardiotomy group.

Conclusions  Among Medicare beneficiaries receiving a ventricular assist device, early mortality, morbidity, and costs remain high. Improving patient selection and reducing perioperative mortality are critical for improving overall outcomes.

Author Affiliations: Duke Clinical Research Institute (Drs Hernandez, Rogers, O’Connor, Schulman, Peterson, and Curtis, Ms Shea, and Mr Hammill) and Departments of Medicine (Drs Hernandez, Rogers, O’Connor, Schulman, Peterson, and Curtis) and Surgery (Dr Milano), Duke University School of Medicine, Durham, North Carolina.

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