Hospital Variation in Intravenous Inotrope Use for Patients Hospitalized with Heart Failure: Insights from Get With The Guidelines
Background—Prior claims analyses suggest that the use of intravenous inotropic therapy for patients hospitalized with heart failure varies substantially by hospital. Whether differences in the clinical characteristics of the patients explain observed differences in the use of inotropic therapy is not known.
Methods and Results—We sought to characterize institutional variation in inotrope use among patients hospitalized with heart failure before and after accounting for patients' clinical factors. Hierarchical generalized linear regression models estimated risk-standardized hospital-level rates of inotrope use within 209 hospitals participating in Get With The Guidelines-Heart Failure (GWTG-HF) registry between 2005-2011. The association between risk-standardized rates of inotrope use and clinical outcomes were determined. Overall, an inotropic agent was administered in 7,691 of 126,564 (6.1%) HF hospitalizations: dobutamine 43%, dopamine 24%, milrinone 17%, or a combination 16%. Patterns of inotrope use were stable over the 7-year study period. Use of inotropes varied significantly between hospitals even after accounting for patient and hospital characteristics (median risk-standardized hospital rate 5.9%, IQR 3.7-8.6%, range 1.3-32.9%). After adjusting for case mix and hospital structural differences, model intra-class correlation indicated that 21% of the observed variation in inotrope use was potentially attributable to random hospital effects (i.e. institutional preferences). Hospitals with higher risk-standardized inotrope use had modestly longer risk-standardized length of stay (p=0.005) but had no difference in risk-standardized inpatient mortality (p=0.12)
Conclusions—Use of intravenous inotropic agents during hospitalization for heart failure varies significantly among U.S. hospitals, even after accounting for patient and hospital factors.
- Received June 20, 2013.
- Accepted January 23, 2014.