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. 2023 Apr 1;158(4):e228127.
doi: 10.1001/jamasurg.2022.8127. Epub 2023 Apr 12.

Association of Days Alive and Out of the Hospital After Ventricular Assist Device Implantation With Adverse Events and Quality of Life

Pierre-Emmanuel Noly  1   2 , Xiaoting Wu  1 , Hechuan Hou  1 , Kathleen L Grady  3 , James W Stewart 2nd  4 , Robert B Hawkins  1 , Guangyu Yang  5 , K Dennie Kim  6 , Min Zhang  5 , Lourdes Cabrera  1 , Keith D Aaronson  7 , Francis D Pagani  1 , Donald S Likosky  1 ; Michigan Congestive Heart Failure Investigators
Collaborators, Affiliations

Association of Days Alive and Out of the Hospital After Ventricular Assist Device Implantation With Adverse Events and Quality of Life

Pierre-Emmanuel Noly et al. JAMA Surg. .

Abstract

Importance: There is a need to better assess the cumulative effect on morbidity and mortality in patients undergoing durable left ventricular assist device (LVAD) implantation. This study evaluates a patient-centered performance metric (days alive and out of hospital [DAOH]) for durable LVAD therapy.

Objective: To determine the incidence of percent of DAOH before and after LVAD implantation and (2) explore its association with established quality metrics (death, adverse events [AEs], quality of life).

Design, settings, and participants: This was a retrospective national cohort study of Medicare beneficiaries implanted with a durable continuous-flow LVAD between April 2012 and December 2016. The data were analyzed from December 2021 to May 2022. Follow-up was 100% complete at 1 year. Data from The Society of Thoracic Surgeons Intermacs registry were linked to Medicare claims.

Main outcomes and measures: The number of DAOH 180 days before and 365 days after LVAD implantation and daily patient location (home, index hospital, nonindex hospital, skilled nursing facility, rehabilitation center, hospice) were calculated. Percent of DAOH was indexed to each beneficiary's pre- (percent DAOH-BF) and postimplantation (percentage of DAOH-AF) follow-up time. The cohort was stratified by terciles of percentage of DAOH-AF.

Results: Among the 3387 patients included (median [IQR] age: 66.3 [57.9-70.9] years), 80.9% were male, 33.6% and 37.1% were Interfaces Patient Profile 2 and 3, respectively, and 61.1% received implants as destination therapy. Median (IQR) percent of DAOH-BF was 88.8% (82.7%-93.8%) and 84.6% (62.1-91.5%) for percent of DAOH-AF. While DAOH-BF was not associated with post-LVAD outcomes, patients in the low tercile of percentage of DAOH-AF had a longer index hospitalization stay (mean, 44 days; 95% CI, 16-77), were less likely to be discharged home (mean. -46.4 days; 95% CI, 44.2-49.1), and spent more time in a skilled nursing facility (mean, 27 days; 95% CI, 24-29), rehabilitation center (mean, 10 days; 95% CI, 8-12), or hospice (mean, 6 days; 95% CI, 4-8). Increasing percentage of DAOH-AF was associated with patient risk, AEs, and indices of HRQoL. Patients experiencing non-LVAD-related AEs had the lowest percentage of DAOH-AF.

Conclusions and relevance: Significant variability existed in the percentage of DAOH within a 1-year time horizon and was associated with the cumulative AEs burden. This patient-centered measure may assist clinicians in informing patients about expectations after durable LVAD implantation. Validation of percentage DAOH as a quality metric for LVAD therapy across centers should be explored.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Grady reported personal fees from Amgen and the American Heart Association, and registration and travel expense fees from the International Society for Heart and Lung Transplantation outside the submitted work. Dr Aaronson reported personal fees from Medtronic Independent Physician Quality Panel and research fees from Abbott to the University of Michigan outside the submitted work. Dr Pagani reported grants from the Agency for Healthcare Research & Quality during the conduct of the study. Dr Likosky reported grants from the Agency for Healthcare Research & Quality and the National Institutes of Health, partial salary support from Blue Cross Blue Shield Michigan to their institution, and personal fees from AmSECT outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Distribution of Percentage of Days Alive and Out of Hospital (DAOH) Following Left Ventricular Assist Device (LVAD) Implantation
Distribution of percent DAOH (Pareto diagram) following LVAD implantation (percentage of DAOH-AF) in the entire cohort (A), in patients who were alive at 1 year (B), in patients who died (C), and in patients who received a transplant within the year following LVAD implantation (D).
Figure 2.
Figure 2.. Association Between Percentage of Days Alive and Out of Hospital (DAOH-AF) and Adverse Events (AEs) Following Left Ventricular Assist Device (LVAD) Implantation
Percentage of DAOH following LVAD implantation according to the presence or absence of the specified event (AE) during follow-up. The bars represent the median and the boxes Q1 through Q3 for percentage of DAOH-AF. RVAD indicates right ventricular assist device; GI, gastrointestinal.
Figure 3.
Figure 3.. Patients’ Location Before and After Left Ventricular Assist Device (LVAD) Implantation
This figure represents the daily cross-sectional analysis of the distribution of patients before (180 days) and after (365 days) LVAD implantation. The colored area under each curve represents the proportion of patients in each setting. For each day, the sum of the proportion of patients is 100%. The proportion of patients in various locations (alive at home, dead, in hospital, in skilled nursing facility location, in rehabilitation center, or in hospice) is represented by each color. The graph represents 545 individual bar graphs showing the proportion of patients alive at home, hospitalized in the implanting hospital, hospitalized (preimplantation) or rehospitalized in the index hospital, hospitalized in another hospital, and those who died in a skilled nursing facility location, a rehabilitation center, or were in hospice on each day of follow-up in the entire cohort.
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References

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