Inpatient Complexity in Radiology-a Practical Application of the Case Mix Index Metric

With ongoing healthcare payment reforms in the USA, radiology is moving from its current state of a revenue generating department to a new reality of a cost-center. Under bundled payment methods, radiology does not get reimbursed for each and every inpatient procedure, but rather, the hospital gets reimbursed for the entire hospital stay under an applicable diagnosis-related group code. The hospital case mix index (CMI) metric, as defined by the Centers for Medicare and Medicaid Services, has a significant impact on how much hospitals get reimbursed for an inpatient stay. Oftentimes, patients with the highest disease acuity are treated in tertiary care radiology departments. Therefore, the average hospital CMI based on the entire inpatient population may not be adequate to determine department-level resource utilization, such as the number of technologists and nurses, as case length and staffing intensity gets quite high for sicker patients. In this study, we determine CMI for the overall radiology department in a tertiary care setting based on inpatients undergoing radiology procedures. Between April and September 2015, CMI for radiology was 1.93. With an average of 2.81, interventional neuroradiology had the highest CMI out of the ten radiology sections. CMI was consistently higher across seven of the radiology sections than the average hospital CMI of 1.81. Our results suggest that inpatients undergoing radiology procedures were on average more complex in this hospital setting during the time period considered. This finding is relevant for accurate calculation of labor analytics and other predictive resource utilization tools.

National Trends in the Use of Cardiac Resynchronization Therapy With or Without Implantable Cardioverter-Defibrillator

BACKGROUND

Candidates for cardiac resynchronization therapy (CRT) receive either a biventricular pacemaker or a biventricular pacemaker with an implantable cardioverter-defibrillator (CRT-D). Optimal device selection remains challenging because the benefit of implantable cardioverter-defibrillator therapy may not be uniform, particularly in patients at competing risk of nonsudden death.

METHODS AND RESULTS

In this serial cross-sectional study using the National Inpatient Sample database, we identified 311,086 admissions associated with CRT implant between 2006 to 2012. CRT-D was the most common device type (86.1%), including in patients ≥ 75 years of age with ≥ 5 Elixhauser comorbidities (75.5%). Multivariate predictors of CRT-D implant included demographic, clinical, and geographic factors: prior ventricular arrhythmia (rate ratio [RR], 1.14; 95% CI, 1.13-1.14), ischemic heart disease (RR, 1.11; 95% CI, 1.10-1.11), male sex (RR, 1.10; 95% CI, 1.09-1.10), black race (RR, 1.06; 95% CI: 1.04-1.07), and Northeast geographic region (RR, 1.06; 95% CI, 1.04-1.09). There was significant interhospital variation in the use of CRT-D (10-90 percentile range, 72.9%-98.0% CRT-D).

CONCLUSIONS

The majority of patients in this contemporary US cohort underwent implantation of CRT-D. Predictors of CRT-D implant included demographic, clinical, and geographic factors. In patient subgroups predicted to have an attenuated benefit from implantable cardioverter-defibrillator therapy (older adults with multiple comorbidities), CRT-D remained the dominant device type. An improved understanding of the determinants of device selection may aid in decision making and ultimately better align patient risk with device benefit at the time of CRT implantation.

Mortality in patients on renal replacement therapy and permanent cardiac pacemakers

End stage renal disease is a relatively frequent disease with high mortality due to cardiac causes. Permanent pacemaker (PM) implantation rates are also very common; thus combination of both conditions is not unusual. We hypothesized that patients with chronic kidney disease with a PM would have significantly higher mortality rates compared with end stage renal disease patients without PM. Our objectives were to analyze mortality of patients on renal replacement therapy with PM. 2778 patients were on renal replacement therapy (RRT) and 110 had a PM implanted during the study period. To reduce the confounding effects of covariates, a propensity-matched score was performed. 52 PM patients and 208 non-PM matched patients were compared. 41% of the PM were implanted before entering the RRT program and 59% while on RRT. Mortality was higher in the PM group. Cardiovascular disease and infections were the most frequent causes of death. Propensity analysis showed no differences in long-term mortality between groups. We concluded that in patients on RRT and PM mortality rates are higher. Survival curves did not differ from a RRT propensity-matched group. We concluded that the presence of a PM is not an independent mortality risk factor in RRT patients.

Optimal utilization and management of implanted cardiac rhythm devices in patients hospitalized for heart failure

Improved utilization and optimization of device therapy in the management of patients with decompensated heart failure (HF) is an important clinical priority. Diagnostic cardiac rhythm device data have been shown to predict hospitalization for HF. Cardiac resynchronization therapy is a highly effective therapy for the prevention of HF hospitalization. Evaluation and optimization of cardiac resynchronization therapy should be considered in all patients admitted with HF despite cardiac resynchronization therapy.

The potential role of nonpharmacologic electrophysiology-based interventions in improving outcomes in patients hospitalized for heart failure

Hospitalization for heart failure (HHF) is commonly associated with symptomatic improvement in response to standard medical therapy, yet there remains a substantial risk of rehospitalization and death. Clinically stable outpatients and decompensated inpatients represent two types of patients with chronic heart failure. In the former, treatment of common heart rhythm disorders with nonpharmacologic electrophysiology-based interventions is of substantial benefit in select patients. The potential benefits of these interventions in the hospitalized setting are not well studied. In this review, current knowledge is discussed and future research directions are suggested with nonpharmacologic electrophysiology-based interventions to reduce the morbidity and mortality associated with patients with HHF.

Cardiac resynchronization therapy for critically ill patients with left ventricular systolic dysfunction

BACKGROUND

The experience of cardiac resynchronization therapy (CRT) in critically ill patients with cardiogenic shock or advanced heart failure is limited and inadequately described in literature.

METHODS

CRT implants performed in patients on the cardiothoracic intensive care unit (ICU) at a tertiary cardiac centre during 2007-2010 were retrospectively studied.

RESULTS

We identified 24 patients, 17 male, of median age 76 years (IQR 11) treated with a CRT pacemaker (n=10) or CRT defibrillator (n=14). Prior to implantation median left ventricular ejection fraction (LVEF) was 26% (IQR 13) and median QRS duration 146 ms (IQR 29). Eleven (46%) patients were post elective cardiac surgery and 8 (33%) post emergency cardiac surgery or intervention with high prevalence of co-morbidities. Nineteen patients required inotropic support pre-implantation, 8 patients were on mechanical circulatory support and 18 were on mechanical ventilation. Post CRT LVEF improved from 26% to 39% (p=0.027) and the estimated glomerular filtration rate increased from 42 ml/min/1.73 m(2) (IQR 26) to 63 ml/min/1.73 m(2) (IQR 48, p=0.001). All but one patient were successfully weaned from inotropic support within a median of 4 days (IQR 5) post CRT and 22/24 (92%) survived to hospital discharge. After a median follow up of 392 days (IQR 538), 7 (33%) patients died. In-hospital and one year mortality rates were 8.3% and 29.4% respectively. Ten out of 12 patients (83%) were alive at long-term (22 ± 9 months) follow up.

CONCLUSIONS

CRT may assist weaning from circulatory and respiratory support in critically ill patients with left ventricular systolic dysfunction.