An Increasing Burden of Disease: Emergency Department Visits Among Patients With Ventricular Assist Devices From 2010 to 2017

Abstract

Background With a growing population of patients supported by ventricular assist devices (VADs) and the improvement in survival of this patient population, understanding the healthcare system burden is critical to improving outcomes. Thus, we sought to examine national estimates of VAD-related emergency department (ED) visits and characterize their demographic, clinical, and outcomes profile. Additionally, we tested the hypotheses that resource use increased and mortality improved over time. Methods and Results This retrospective database analysis uses encounter-level data from the 2010 to 2017 Nationwide Emergency Department Sample. The primary outcome was mortality. From 2010 to 2017, >880 million ED visits were evaluated, with 44 042 VAD-related ED visits identified. The annual mean visits were 5505 (SD 4258), but increased 16-fold from 2010 to 2017 (824 versus 13 155). VAD-related ED visits frequently resulted in admission (72%) and/or death (3.0%). Median inflation-adjusted charges were $25 679 (interquartile range, $7450, $63 119) per encounter. The most common primary diagnoses were cardiac (22%), and almost 30% of encounters were because of bleeding, stroke, or device complications. From 2010 to 2017, admission and mortality decreased from 82% to 71% and 3.4% to 2.4%, respectively (P for trends <0.001, both). Conclusions We present the first study using national-level data to characterize the growing ED resource use and financial burden of patients supported by VAD. During the past decade, admission and mortality rates decreased but remain substantial; in 2017 ≈1 in every 40 VAD ED encounters resulted in death, making it critical that clinical decision-making be optimized for patients with VAD to maximize good outcomes.

Keywords: emergency; mortality; ventricular assist device.

Figure 1. Overall charges of emergency department and associated admissions by primary diagnosis.

Charges were higher in visits associated with VAD‐related complications, and highest in those with device complications. VAD indicates ventricular assist device.

Figure 2. Trends in VAD‐related emergency department encounters.

VAD‐related ED visits increased 16‐fold during the 8 years of the study. This trend mirrored the overall increase in VAD implants from 2010 to 2017, highlighting the growing resource burden of VAD‐supported patients. Of note, VAD implants per year are abstracted from the Society of Thoracic Surgeons Intermacs Database Annual Report 2019, which does not include VADs implanted as part of a clinical trial. Thus, this may underestimate the true annual VAD implantation rate. ED indicates emergency department; and VAD, ventricular assist device. Adapted from Kormos et al ¹⁹ with permission. Copyright © 2019, Elsevier.

Figure 3. Trends in charges per encounter.

Overall charges of VAD‐related encounters decreased, with annual fluctuations correlating with changes in admission/transfer rate. VAD indicates ventricular assist device.

Figure 4. Changes in mortality over time.

Among VAD‐supported patient encounters, mortality increased from 2010 to 2012 and then decreased during the past 3 years of the study. In contrast, overall mortality for emergency department encounters remained stable during the same time period. VAD indicates ventricular assist device.