Implantable Cardioverter

Defibrillators

in VHA and Healthcare Cost Gr

2001‐2010

Peter W. Groeneveld, M

Philadelphia VA

University University of Penns

Penns
Acknowledgements

• Diane Richardson, PhD

• Elina Medvedeva Medvedeva

, MS

• C. Brent Roberts, BS• QUERI RRP Award #09

‐117

• VA CHF QUERI
Conflicts Conflicts of Interest Interest

• No relationships to disclose
Background/1

• Implantable Implantable cardioverter cardioverter‐defibrillato

defibrillato

(ICDs):

– Class IA guideline‐recommended thera

2005 for patients with chronic heart fa

(CHF) and reduced reduced left ventricular ventricular ejec

ejec

fraction
Background/2

• Chronic Chronic heart failure failure (CHF) is commo

veterans over age 65

• Large numbers of veterans are likely ICD‐e• Unknown Unknown how many VHA‐enrolled enrolled v

v

with CHF have received ICDs during t

decade
Background/3

• ICDs are costly to implant implant (>$30,000 

cost alone) and to monitor

• Unclear how ICDs have impacted VA

care costs

• Likewise uncertain how ICDs implant

o tside outside VA among veterans eterans enrolled enrolled ultimately impacted VA’s costs of car
Study Objectives/1

• To identify identify the total number of dual‐en

en

(i.e., Medicare and VHA) veterans who

received ICDs during 2001‐2010

• To quantify the fraction of veterans wit

who received received devices devices at VA (vs. outside

outside

• To determine the number of veterans l

with an ICD who receive ongoing devic

at VA
Study Objectives/2

• To determine determine costs of VA health care

attributable to ICD implantation and

ongoing d i ev ce care

• To measure measure the rate of VA ICD impla

impla

among historically disadvantaged gro

veterans
Data

• VA national national administrative administrative data from 

2010 (Medical SAS datasets)

• VA Fee Basis data

• VIReC VA‐M di e care merged d t a a

(inpatient/outpatient facility claims aphysician claims)
Identifying implantation and con

care in VA data

• Implantation identified by relevant ICD

CPT codes in the VA’s hospitalization, s

procedure, or fee‐basis administrative 

• ICD continuity care identified by

– 1 relevant ICD‐9 or CPT code on an outpat

administrative record after a confirmed im

– 2 distinct outpatient entries with relevant 

for patients with no prior documented im
Identifying implantation and con

care in Medicare data

• ICD implantation identified by the relev

ICD‐9 or CPT codes in Medicare hospita

or outpatient facility claims

• ICD continuity care identified by:

– 1 relevant ICD‐9 or CPT code on an outpat

claim subsequent to a confirmed implanta

– 2 distinct outpatient claim with relevant c

patients with no prior documented implan
Cost attribution

• Costs of VA health care were estimated estimated 

HERC’s Average Cost Datasets using 1‐t

matches between Medical SAS and ACDrecords, added to Fee‐Basis paid costs

• ICD implantation implantation costs included included the ho

ho

costs of implant plus any other ICD‐rela

encounters within 30 days of implant

• ICD continuity costs included all ICD‐re

costs outside outside of the implant implant window
wei hted were identified as low SES

Identifying Identifying Race and SE

• Veterans Veterans’ race determined determined from Medic

Medic

enrollment data

• Veterans’ socioeconomic status (SES)

approximated by median income (2000 

Census) from veterans’ residential ZIP c

• Veterans Veterans living in ZIP codes from the lo

25th percentile median income (popula

weighted) were identified as low‐SES
1500

ICD Implants Implants in the VHA, 2001

Implants per 

2500 

year 

2000 1000 1500 

500 

0 

2001 2002 2003 2004 2005 2006 2007 2008 
Total Veterans Veterans Receiving ceiving ICD‐rela

rela

Healthcare, 2001‐2010

30,000 20,000 25,000 15,000 

5,000 

10,000 

0 

2001 2002 2003 2004 2005 2006 2007 2008 
% of ICD Implants Implants Among Du

Eligible Veterans Occurring in 

12 

% 

8 

10 

6 2 4 0 

2001 2002 2003 2004 2005 2006 20
Origin of Veterans Veterans’ ICDs

Among veterans receiving regular ICD

continuity care in VA from 2006‐2008:

• 26% originally received ICD in VA

• 34% received ICD outside VA covered b

Medicare

• 40% had no prior ICD implantation reco

either VA or M di e care d t a a
Per‐patient patient ICD Implantation Implantation 

(2010 $thousands), 2001‐20

$70 $50 $60 

$50.5K

$30 $40 $10 $20 

$0 

2001 2002 2003 2004 2005 2006 2007 2008 
$

Per‐patient patient ICD Continuity Continuity Care 

(2010 $), 2001‐2010

$1,000 

$800 $400 

$600 

$200 

$0 

2001 2002 2003 2004 2005 2006 2007 2008 
Total VA Health Expenditures Expenditures o

Related Care (2010 $millions), 20

$180 $120 $140 $160 

$80 

$100 

$43

$20 $40 $60 million

$0 

$20 

2001 2002 2003 2004 2005 2006 2007 2008 
2001 2002 2003 2004 2005 2006 20

ets (% of Total V

Implants in Black Dual-Eligible Vets (% of Total Impla

2001 2002 2003 2004 2005 2006 20

ICD Implant Rates in

Black Veterans: VA and Medi

16 12 14 

10 6%

8 

10 

12 10.6%

4 6 0 2 VA Implants in Black Dual-Eligible V 

Medicare Implants 

% Hosp CHF 

veterans--black 

2001 

15 

2002 

14 

2003 

13 

2004 

14 

2005 

14 

2006 

14 

20

1
ets (% of To

Implants)

Implants in Low-SES Dual-Eligible Vets (% of Total 

ICD Implant Rates in SES Vete

VA and Medicare

35 31%25 30 20 25 10 15 

VA Implants in Low-SES Dual-Eligible V I l t i L M di I l t SES D l Eli ibl V t (% f T t l 

0 5 Medicare Implants 

% Hosp CHF 

2001 

33 

2002 

32 

2003 

32 

2004 

31 

2005 

31 

2006 

31 

200

30 

% Hosp CHF 

Veterans Low-SES 
• 

Conclusions – Volume of C

• VA ICD implant implant rates increased increased substan

substan

from 2001‐2005, but plateaued from 2

2010 at approximately 2,250 implants/The number of unique veterans veterans with IC

receive care in VA annually has increas

steadily steadily throughout throughout the last decade; decade; th

veterans now number ~30,000

• Sizeable numbers of veterans with ICDs 

their devices implanted outside VA
‐

Conclusions ‐ Costs

• Average Average VA inflation inflation‐adjusted adjusted cost o

implantation increased significantly f

$50,500 in 2001 to $64,600 in 2010

• Total VA expenditures on ICD care in

markedly, from $43 million to $166 m

from 2001‐2010

• At least $14 million in annual VA hea

costs result from ICD care for veteran

did not receive their devices in VA
Conclusions – defibrillators 

minority veterans

• The % of VA ICD recipients who were 

increased increased significantly significantly from 2001 to 

• VA implanted ICDs in a higher % of b

veterans than in the Medicare progr

• VA’s black ICD‐implant % in 2008

approximates the % of VA’s hospitaliCHF patients who are black
Conclusions – Defibrillators for l

veterans

• The % of VA ICD recipients who were 

low‐SES ZIP codes decreased slig y htl 

2001 to 2008

• VA implanted ICDs in a higher % of lo

veterans than in the Medicare progr

• Low‐SES ICD implant rates in VA wer

comparable to the % of low‐SES vete

hospitalized with CHF
Limitations

• VA records records may not accurately accurately capture capture 

implantations (e.g., contracted care)

• Cost attribution to ICDs was inexact—t

patients patients often have multiple multiple chronic chronic co

co

and thus it is possible costs were meas

with error

• There are no indicators of appropriate 

ICDs in either VA or Medicare data, thu

uncertain if ICDs were underused or ov
Impact of these findings indings on 

• ICDs were a source of significant significant cost grow

was unlikely to have been anticipated in 2

• Despite growing volume of ICD care and h

costs, there are no widely available source

data about clinical appropriateness/ outcoVA’s ICD implants

• VA often inherits the care (and costs) of

implantable implantable technology technology from other health

systems
VA’s Technology Technology Imperati

Imperati

• Costly implantable implantable devices devices are likely to

continue to be introduced as routine

components components of high‐quality quality care

• VA must balance the need to practice s

the‐art medi i c ne with the imperative to 

healthcare spending on technology

• VA must l ki ewise ensure that dd 

isa vant

veterans continue to receive high‐tech

care equal in quality to other veterans
Summary

• ICD implantation rates and the # of vet

who receive routine defibrillator care h

risen dramatically in VA during past dec

• VA’s ICD‐related healthcare costs have 

risen sharply over time

• VA appears appears to be delivering delivering equitable equitable h

technology care to disadvantaged popu