CRT Utilization for Heart Failure
Background Cardiac resynchronization therapy (CRT) has established efficacy for patients with systolic heart failure (HF). Treatment rates and factors associated with CRT utilization among eligible patients in outpatient cardiology practices have not been well studied.
Methods IMPROVE HF is a prospective cohort study designed to characterize current management of patients with chronic HF and left ventricular ejection fraction ≤35% in a registry of outpatient cardiology practices located throughout the United States. Baseline data were abstracted by trained chart review specialists from May 31, 2005, through June 22, 2007, for 15,381 patients attending 167 outpatient cardiology practices. Multivariable analyses of patient and practice characteristics identified predictors of CRT for eligible patients.
Results A total of 1,373 patients were eligible for CRT based on current guideline criteria, and 533 (38.8%) received a CRT device, with 84.1% of these treated with a CRT-defibrillator. Cardiac resynchronization therapy use varied widely among practices, with 11.1% at the 25th percentile and 53.4% at the 75th percentile. Patient age, insurance, longer QRS duration, and practice location were independently associated with higher CRT utilization rates among eligible patients, whereas sex, HF etiology, and other clinical and laboratory parameters were not.
Conclusions Despite being evidence based and guideline recommended, CRT is underutilized in eligible patients with significant variations associated with age, insurance, QRS duration, and geographic location of practices. Practice-specific performance improvement initiatives may be needed to reduce variations in use of CRT for eligible patients.
Heart failure (HF) is a chronic progressive disease associated with substantial morbidity and mortality. Evidence from randomized controlled trials demonstrates that cardiac resynchronization therapy (CRT) combined with medical therapies significantly reduces morbidity and mortality in patients with HF, reduced left ventricular ejection fraction (LVEF), and prolonged QRS duration. A recent meta-analysis of 6 randomized controlled trials of CRT for treatment of chronic, symptomatic left ventricular systolic dysfunction indicated that CRT was associated with a 28% reduction in all-cause mortality and a 37% reduction in new hospitalizations for exacerbation of HF. These results supported development of national guidelines for patients with chronic HF including CRT for those with LVEF ≤35%, QRS duration ≥120 milliseconds, and New York Heart Association (NYHA) functional class III or ambulatory class IV. Currently, few data are available that characterize CRT utilization in clinical practice other than estimates from randomized clinical trials. The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) is a prospective cohort study of patients with HF who are managed in outpatient cardiology practices. The baseline data collected for IMPROVE HF provide an opportunity to assess rates and predictors for use of CRT in a contemporary patient cohort.
Abstract and Introduction
Abstract
Background Cardiac resynchronization therapy (CRT) has established efficacy for patients with systolic heart failure (HF). Treatment rates and factors associated with CRT utilization among eligible patients in outpatient cardiology practices have not been well studied.
Methods IMPROVE HF is a prospective cohort study designed to characterize current management of patients with chronic HF and left ventricular ejection fraction ≤35% in a registry of outpatient cardiology practices located throughout the United States. Baseline data were abstracted by trained chart review specialists from May 31, 2005, through June 22, 2007, for 15,381 patients attending 167 outpatient cardiology practices. Multivariable analyses of patient and practice characteristics identified predictors of CRT for eligible patients.
Results A total of 1,373 patients were eligible for CRT based on current guideline criteria, and 533 (38.8%) received a CRT device, with 84.1% of these treated with a CRT-defibrillator. Cardiac resynchronization therapy use varied widely among practices, with 11.1% at the 25th percentile and 53.4% at the 75th percentile. Patient age, insurance, longer QRS duration, and practice location were independently associated with higher CRT utilization rates among eligible patients, whereas sex, HF etiology, and other clinical and laboratory parameters were not.
Conclusions Despite being evidence based and guideline recommended, CRT is underutilized in eligible patients with significant variations associated with age, insurance, QRS duration, and geographic location of practices. Practice-specific performance improvement initiatives may be needed to reduce variations in use of CRT for eligible patients.
Introduction
Heart failure (HF) is a chronic progressive disease associated with substantial morbidity and mortality. Evidence from randomized controlled trials demonstrates that cardiac resynchronization therapy (CRT) combined with medical therapies significantly reduces morbidity and mortality in patients with HF, reduced left ventricular ejection fraction (LVEF), and prolonged QRS duration. A recent meta-analysis of 6 randomized controlled trials of CRT for treatment of chronic, symptomatic left ventricular systolic dysfunction indicated that CRT was associated with a 28% reduction in all-cause mortality and a 37% reduction in new hospitalizations for exacerbation of HF. These results supported development of national guidelines for patients with chronic HF including CRT for those with LVEF ≤35%, QRS duration ≥120 milliseconds, and New York Heart Association (NYHA) functional class III or ambulatory class IV. Currently, few data are available that characterize CRT utilization in clinical practice other than estimates from randomized clinical trials. The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) is a prospective cohort study of patients with HF who are managed in outpatient cardiology practices. The baseline data collected for IMPROVE HF provide an opportunity to assess rates and predictors for use of CRT in a contemporary patient cohort.
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