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J Am Geriatr Soc. 2019 Jul;67(7):1370-1378. doi: 10.1111/jgs.15839. Epub 2019 Mar 20.

Influence of Multimorbidity on Burden and Appropriateness of Implantable Cardioverter-Defibrillator Therapies.

Author information

1
Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
2
Meyers Primary Care Institute, a Joint Endeavor of University of Massachusetts Medical School, Fallon Health, and Reliant Medical Group, Worcester, Massachusetts.
3
Division of Research, Kaiser Permanente Northern California, Oakland, California.
4
Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
5
Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
6
Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado.
7
Center for Clinical Epidemiology & Population Health, Marshfield Clinic Research Foundation, Marshfield, Wisconsin.
8
Department of Public Health Sciences, Henry Ford Hospital, Detroit, Michigan.
9
Department of Cardiac Electrophysiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California.
10
Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
11
Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon.
12
National Cardiovascular Data Registry, American College of Cardiology Foundation, Washington, DC.
13
Department of Cardiac Electrophysiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California.
14
Heart and Vascular Institute, Henry Ford Health System, Detroit, Michigan.
15
Marshfield Clinical Research Foundation, Marshfield Clinic, Marshfield, Wisconsin.
16
Department of Medicine, Mayo Clinic, Rochester, Minnesota.
17
Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, California.
18
Departments of Medicine, Health Research and Policy, Stanford University School of Medicine, Palo Alto, California.

Abstract

OBJECTIVE:

To determine whether burden of multiple chronic conditions (MCCs) influences the risk of receiving inappropriate vs appropriate device therapies.

DESIGN:

Retrospective cohort study.

SETTING:

Seven US healthcare delivery systems.

PARTICIPANTS:

Adults with left ventricular systolic dysfunction receiving an implantable cardioverter-defibrillator (ICD) for primary prevention.

MEASUREMENTS:

Data on 24 comorbid conditions were captured from electronic health records and categorized into quartiles of comorbidity burden (0-3, 4-5, 6-7 and 8-16). Incidence of ICD therapies (shock and antitachycardia pacing [ATP] therapies), including appropriateness, was collected for 3 years after implantation. Outcomes included time to first ICD therapy, total ICD therapy burden, and risk of inappropriate vs appropriate ICD therapy.

RESULTS:

Among 2235 patients (mean age = 69 ± 11 years, 75% men), the median number of comorbidities was 6 (interquartile range = 4-8), with 98% having at least two comorbidities. During a mean 2.2 years of follow-up, 18.3% of patients experienced at least one appropriate therapy and 9.9% experienced at least one inappropriate therapy. Higher comorbidity burden was associated with an increased risk of first inappropriate therapy (adjusted hazard ratio [HR] = 1.94 [95% confidence interval {CI} = 1.14-3.31] for 4-5 comorbidities; HR = 2.25 [95% CI = 1.25-4.05] for 6-7 comorbidities; and HR = 2.91 [95% CI = 1.54-5.50] for 8-16 comorbidities). Participants with 8-16 comorbidities had a higher total burden of ICD therapy (adjusted relative risk [RR] = 2.12 [95% CI = 1.43-3.16]), a higher burden of inappropriate therapy (RR = 3.39 [95% CI = 1.67-6.86]), and a higher risk of receiving inappropriate vs appropriate therapy (RR = 1.74 [95% CI = 1.07-2.82]). Comorbidity burden was not significantly associated with receipt of appropriate ICD therapies. Patterns were similar when separately examining shock or ATP therapies.

CONCLUSIONS:

In primary prevention ICD recipients, MCC burden was independently associated with an increased risk of inappropriate but not appropriate device therapies. Comorbidity burden should be considered when engaging patients in shared decision making about ICD implantation.

KEYWORDS:

chronic disease; comorbidity; implantable cardioverter-defibrillator; multimorbidity; patient-centered outcomes

PMID:
30892695
DOI:
10.1111/jgs.15839

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