Variations in Practice Patterns and Consistency With Published Guidelines for Balloon Aortic and Pulmonary Valvuloplasty: An Analysis of Data From the IMPACT Registry

Abstract

Objectives: The authors sought to study variation in the practice of balloon aortic (BAV) and pulmonary valvuloplasty (BPV).

Background: The IMPACT (IMProving Adult and Congenital Treatment) registry provides an opportunity to study practice variation in transcatheter interventions for congenital heart disease.

Methods: The authors studied BAV and BPV in the IMPACT registry from January 1, 2011, to September 30, 2015, using hierarchical multivariable models to measure hospital-level variation in: 1) the distribution of indications for intervention; and 2) in cases with "high resting gradient" as the indication, consistency with published guidelines.

Results: A total of 1,071 BAV cases at 60 hospitals and 2,207 BPV cases at 75 hospitals were included. The indication for BAV was high resting gradient in 82%, abnormal stress test or electrocardiogram (2%), left ventricular dysfunction (11%), and symptoms (5%). Indications for BPV were high resting gradient in 82%, right-left shunt (6%), right ventricular dysfunction (7%), and symptoms (5%). No association between hospital characteristics and distribution of indications was demonstrated. Among interventions performed for "high resting gradient," there was significant adjusted hospital-level variation in the rates of cases performed consistently with guidelines. For BAV, significant differences were seen across census regions, with hospitals in the East and South more likely to practice consistently than those in the Midwest and West (p = 0.005). For BPV, no association was found between hospital factors and rates of consistent practice, but there was significant interhospital variation (median rate ratio: 1.4; 95% confidence interval: 1.2 to 1.6; p < 0.001).

Conclusions: There is measurable hospital-level variation in the practice of BAV and BPV. Further research is necessary to determine whether this affects outcomes or resource use.

Keywords: cardiac catheterization; congenital heart disease; health services research; outcomes research.

Figure 1:. The IMProving Adult and Congenital Treatment (IMPACT®) Registry

The map demonstrates the location of 87 centers submitting data to the IMPACT® registry at the time of the study. Also shown are the divisions of the United States into four census regions (Northeast, South, Midwest, and West).

Figure 2:. Study cohort

Figure 3:. Percentage of cases performed consistent with published guidelines

This bar graph depicts the percentage of balloon aortic valvuloplasty (A) and balloon pulmonary valvuloplasty (B) cases performed consistently with published guidelines at each hospital in the study population in order of decreasing consistency. Overall, 86% of all aortic valvuloplasty cases were performed consistently with published guidelines, vs. 66% of pulmonary valvuloplasty cases. The red line marks the 80% threshold for individual hospitals. For aortic valvuloplasty, 27% of hospitals were below this threshold, while for pulmonary valvuloplasty 70% were.