Utilization of Palliative Care for Cardiogenic Shock Complicating Acute Myocardial Infarction: A 15-Year National Perspective on Trends, Disparities, Predictors, and Outcomes

Abstract

Background This study sought to evaluate the 15-year national utilization, trends, predictors, disparities, and outcomes of palliative care services (PCS) use in cardiogenic shock complicating acute myocardial infarction. Methods and Results A retrospective cohort from January 1, 2000 through December 31, 2014 was analyzed using the National Inpatient Sample database. Administrative codes for acute myocardial infarction-cardiogenic shock and PCS were used to identify eligible admissions. The primary outcomes were the frequency, utilization trends, and predictors of PCS. Secondary outcomes included in-hospital mortality and resources utilization. Multivariable regression and propensity-matching analyses were used to control for confounding. In this 15-year period, there were 444 253 acute myocardial infarction-cardiogenic shock admissions, of which 4.5% received PCS. The cohort receiving PCS was older, of white race, female sex, and with higher comorbidity and acute organ failure. The PCS cohort received fewer cardiac procedures, but more noncardiac organ support therapies. Older age, female sex, white race, higher comorbidity, higher socioeconomic status, admission to a larger hospital, and admission after 2008 were independent predictors of PCS use. Use of PCS was independently associated with higher in-hospital mortality (odds ratio 6.59 [95% CI 6.37-6.83]; P<0.001). The cohort with PCS use had >2-fold higher in-hospital mortality, 12-fold higher use of do-not-resuscitate status, lesser in-hospital resource utilization, and fewer discharges to home. Similar findings were observed in the propensity-matched cohort. Conclusions PCS use in patients with acute myocardial infarction-cardiogenic shock is low, though there is a trend towards increased adoption. There are significant patient and hospital-specific disparities in the utilization of PCS.

Keywords: acute myocardial infarction; cardiogenic shock; critical care; end‐of‐life care; outcomes research.

Figure 1

Temporal trends in the utilization of palliative care services in AMI‐CS classified by patient characteristics. Fifteen‐year trends in the use of palliative care services classified by sex (A), age groups (in years) (B), race (C), and median income quartile for zip code (D); all P<0.001 for trend. AMI‐CS indicates acute myocardial infarction complicated by cardiogenic shock.

Figure 2

Temporal trends in the utilization of palliative care services in AMI‐CS classified by hospital characteristics. Fifteen‐year trends in the use of palliative care services classified by hospital location and teaching status (A), bed size (B), and region (C); all P<0.001 for trend. AMI‐CS indicates acute myocardial infarction complicated by cardiogenic shock.