Principal Investigator: Tekeda F. Ferguson, MPH, MSPH, PhD LSUHSC New Orleans

1. Variations in Implantable Cardioverter Defibrillator (ICD) Utilization in the Louisiana Health System Principal Investigator: Tekeda F. Ferguson, MPH, MSPH, PhD LSUHSC New Orleans School of Public Health No financial disclosures

2. Project Summary • Purpose: to investigate the prevalence and variation in ICD utilization by hospital characteristics, income, or cardiovascular risk factor prevalence, as well as the related survival outcome among heart failure patients in the Louisiana State University Health Care Services Division (HCSD). • Data will allow the evaluation of cost-effective optimal treatments in the heart failure patient population.

3. Background • Implantable cardioverter defibrillators (ICDs) are an established therapy for the prevention of sudden cardiac death. • American College of Cardiology/American Heart Association Guidelines • New York Heart Association Functional Classification of Heart Failure • Physician judgment clearly plays a large role in implant decisions, determining optimal candidates • Underutilized has been observed when academic centers are uninvolved in the patient's care

4. Methods • Inclusion Criteria: All patients diagnosed with chronic heart failure between 1999 through June 30, 2012 • Heart Failure: (ICD-9 codes: 398.9, 411.89, 428, 402.01, 402.11, 402.91, 404.01, 404.11, 404.91, 404.03, 404.13, 404.93) with an ejection fraction <40 for 4 or more consecutive measurements as eligible for device • Validation Analysis • 150 patient records were reviewed from CLIQ • sample 1: 25 patients which our codes showed had an ICD (and also possibly a pacemaker) • sample 2: 25 patients which our codes showed had a pacemaker, but not an ICD • sample 3: 100 patients which our codes showed had no device • Analysis • Prevalence was calculated for heart failure disease and ICD utilization • chi square test were be used to explore the variation of ICD utilization by hospital characteristics and cardiovascular risk factors • survival analysis will be used to investigate the improved survival related with ICD utilization

5. LSU ICON Core Services • Medical Informatics Core • Design & Analysis Core • Network Evaluation Support Team (Nest) • Other Administrative Services

6. Preliminary Results • Approximately 39,830 patients diagnosed with heart failure in the LSU HCSD hospitals over the last 13 years. 3.6% have an Implantable Cardioverter Defibrillator (ICD). • Among viable candidates the rate of ICD has increased and approximately 22.5% have an ICD • Slightly higher proportion of more females than males with heart failure in the LSU HCSD population; however, ICDs are higher among men. • Blacks have a higher rate of heart failure in the HCSD population and receipt of ICD.

7. Table 1. Characteristics of heart failure patients diagnosed by Louisiana State University Health Care Services Division (LSU HCSD) hospitals in 1998-2012

8. Table 2.The number of comorbidities* among heart failure patients at Louisiana State University Health Care Services Division (LSU HCSD) hospitals *The comorbidities included hypertension, diabetes, other CHD (Coronary Heart Disease), hypercholesterolemia, hyperglyceridemia, hyperlipidemia, COPD (Chronic Obstructive Pulmonary Disease), chronic liver disease, chronic kidney disease.

9. Table 3. Comorbidities of heart failure patients within Louisiana State University Health Care Services Division (LSU HCSD) hospitals in 1998-2012 Abbreviations: CHD (Coronary Heart Disease); COPD (Chronic Obstructive Pulmonary Disease)

10. Table 4. The prevalence of ICD implantation among heart failure patients diagnosed in LSU HCSD, by facility, 1998-2012 EKL - Earl K. Long Hospital Center MCL - Interim LSU Public Hospital BMC - Bogalusa Medical Center LAK - LallieKemp Regional Medical Center W.O. - Regional Medical Center UMC - University Medical Center LJC - L. J. Chabert Medical Center

11. Next Steps & Timeline • Continue with the trend analysis evaluating differences in survival rates by comorbidities, demographics, treatments, and hospitals • April – May 2013 • Performing a subgroup analysis with additional chart abstraction to determine utilization of optimal drug regimens for systolic heart failure patients post diagnosis • May – August 2013

12. Potential Impact • This area holds much potential for gaining an understanding about allocation of resources in heart failure care and as a consequence to policy development for standardized patient treatment and care.

13. Acknowledgements • Lee Arcement, MD, MPH • L.J. Chabert Medical Center • Ronald Horswell, PhD • Meghan Brashear, MPH • Lu Zhang, MPH

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17. S-ICD