Abstract 15978: Variability of Practice Patterns in Device Closure of Atrial Septal Defects and Patent Ductus Arteriosus: An Analysis of Data From the Impact® Registry
Introduction: The IMPACT® registry provides the first opportunity to measure practice variation in trans-catheter interventions for congenital heart disease, specifically device closure of atrial septal defect (ASD) and patent ductus arteriosus (PDA).
Methods: ASD and PDA cases in IMPACT® from 1/2011 to 9/2015 were included. We used hierarchical multivariable models to adjust for patient characteristics and identify variability by center, assessing the distribution of indications for closure and, in cases whose indication was right (RVVO) or left ventricular volume overload (LVVO), the factors influencing probability of a ratio of pulmonary to systemic blood flow (Qp:Qs) >1.5:1 and of a small defect (ASD <5mm or PDA<2mm).
Results: 4459 ASD and 5233 PDA cases at 77 centers were included. The indications for ASD closure were RVVO (84%) and stroke prevention (13%), and varied by region (4% stroke prevention in the Northeast and 19% in the South, p<0.001). Indications for PDA closure were LVVO (57%), endocarditis prevention (36%), and pulmonary hypertension (7%). For both procedures: region, hospital setting, and hospital-type had significant influence on the distribution of indications for closure after adjusting for patient-level factors. There was also significant variability in indications between centers for ASD and PDA closure (p<0.001). Among LV/RVVO cases, the probability of a Qp:Qs>1.5:1 increased with increasing PDA/ASD volume (p=0.04, 0.05). For ASD, the probability of a Qp:Qs>1.5:1 decreased at centers with a larger proportion of adult cases (p=0.007). In multivariable models there was no inter-center variability in closing small ASD (p=0.17). In comparison, small PDA comprised >30% of cases at 30% of centers. After adjusting for patient characteristics, there was significant inter-center variability in closure of small PDA (median rate ratio: 1.4, p<0.001). Increasing annual catheterization volume was associated with a lower proportion of small PDA closures for LVVO (p=0.02).
Conclusion: There are center-level differences in the practice of ASD and PDA device closure even after adjustment for covariates, with greater variability in PDA closure. This suggests differences in the treatment of similar patients based on center factors.
Author Disclosures: M.L. O’Byrne: None. K.F. Kennedy: None. J.J. Rome: None. A.C. Glatz: None.
- © 2016 by American Heart Association, Inc.