State-Level Variation in Inferior Vena Cava Filter Utilization Across Medicare and Commercially Insured Populations

Epidemiology of the use of inferior vena cava filters in Brazil between 2008 and 2019

OBJECTIVES

The primary objective was to study the totality of inferior vena cava filter placements and their temporal and geographic distribution in the Brazilian Public Health System, which insures more than 160 million Brazilians. The secondary objective was to analyze in-hospital mortality after filter placement and deaths due to pulmonary embolism.

METHODS

Public and open data on in-hospital mortality due to pulmonary embolism and on rates of inferior vena cava filters placement, its associated diagnosis, and in-hospital mortality in Brazilian public hospitals between January 2008 and December 2019 were extracted from Ministry of Health databases.

RESULTS

A total of 9108 inferior vena cava filters were placed, 98.18% of which was therapeutic. We observed a significant increase in the use of these devices over the years, from 508 inferior vena cava filters placed in 2008 to 965 in 2019. In-hospital mortality rate in patients who received inferior vena cava filters was 6.21%, stable over time, and 96.64% of causes of these causes were attributed to venous thromboembolism. The in-hospital mortality rate due to pulmonary embolism, regardless of the placement of vena cava filters, has increased significantly.

CONCLUSION

We observed a low but increasing rate of inferior vena cava filter placements in Brazil between 2008 and 2019, most indications were therapeutic. Our findings were heterogeneous across Brazilian regions and contrasted to those observed in the USA, which is likely due to cultural and socioeconomic factors.

Population-Based Disparities in Inferior Vena Cava Filter Procedures Among Medicare Enrollees With Acute Venous Thromboembolism

PURPOSE

Venous thromboembolism (VTE) imposes a significant clinical and financial burden on patients and society. Inferior vena cava filters (IVCFs) are considered for patients with absolute contraindications or failures of anticoagulation. However, studies examining the population-based disparities of IVCF placement and retrieval are limited. The association between patient and clinical characteristics in the likelihood of and time to IVCF placement and retrievals in a nationally representative cohort was examined.

METHODS

Medicare patients aged ≥65 years with index VTE claims between 2015 and 2018 were followed through 2019 to identify IVCF placements and retrievals. Rates were compared using survival analysis methods.

RESULTS

Of the 516,978 patients with VTE diagnoses, 5,864 (1.1%) had IVCFs placed, and 1,884 (32.1%) of those underwent retrieval procedures. Placement and retrieval rates varied significantly by demographics, comorbidity burden, and geographic region. From Cox regression, older age (hazard ratio [HR], 1.26; P < .0001), higher baseline comorbidity (Elixhauser) score (HR, 1.07; P < .0001), and outpatient (vs inpatient) site of VTE service (HR, 2.11; P < .0001) were associated with increased frequency of IVCF placement. The rate of retrieval was significantly lower for men (HR, 0.83; P = .0393), patients with higher comorbidity scores (HR, 0.95; P = .0037), and those with outpatient (vs inpatient) VTE sites of service (HR, 0.77; P = .0173). Neither facility- nor county-level characteristics were significantly associated with placements or retrievals.

CONCLUSIONS

This large cohort of Medicare beneficiaries with newly diagnosed VTE demonstrated inequities in IVCF placement and retrieval.

Evaluation of Changing Vena Cava Filter Use and Inpatient Hospital Mortality from 2016-2019: A Single-Institution Quality Improvement Project

Objective

To evaluate the changing trends of vena cava filter (VCF) insertion and determine whether changes in VCF use affected inpatient mortality.

Patients and Methods

A quality improvement project at Mayo Clinic, Rochester, Minnesota, tracks the type and reason for VCF insertions from January 1, 2016, through December 31, 2019, to facilitate appropriate retrieval. The rate of VCF insertions was compared with inpatient mortality rates, normalized for patient volumes using the number of hospital inpatient discharges.

Results

A total of 698 VCFs were placed in 695 patients: 2016 (n=243), 2017 (n=156), 2018 (n=156), and 2019 (n=120). The rate of VCF insertions (per 1000 inpatient discharges) was 4.02 in 2016, 2.91 in 2017, 2.54 in 2018, and 1.93 in 2019. Mean ± SD age at placement was 62±16.4 years and 59.2% (413/698) were men. Most VCFs were retrievable (85.1%; 594/698) and were placed for treatment (78.4%; 547/698) indications (acute venous thromboembolism within 3 months). The rate of VCF insertions was compared with the inpatient mortality rate (per 100 inpatient discharges) and remained stable (1.83 in 2016, 1.79 in 2017, 1.83 in 2018, and 1.76 in 2019) despite the significant decline in VCF use.

Conclusion

Data from this quality improvement study demonstrate a reduction of more than 50% in the use of VCFs from 2016 through 2019 at a large academic hospital. These changes are difficult to attribute to any single change in clinical use and there was no appreciable increase in the inpatient hospital mortality rate associated with this decrease in VCF filter use.

Changes in Care for Acute Pulmonary Embolism Through A Multidisciplinary Pulmonary Embolism Response Team

BACKGROUND

Optimal management of acute pulmonary embolism requires expertise offered by multiple subspecialties. As such, pulmonary embolism response teams (PERTs) have increased in prevalence, but the institutional consequences of a PERT are unclear.

METHODS

We compared all patients that presented to our institution with an acute pulmonary embolism in the 3 years prior to and 3 years after the formation of our PERT. The primary outcome was in-hospital pulmonary embolism-related mortality before and after the formation of the PERT. Sub-analyses were performed among patients with elevated-risk pulmonary embolism.

RESULTS

Between August 2012 and August 2018, 2042 patients were hospitalized at our institution with acute pulmonary embolism, 884 (41.3%) pre-PERT implementation and 1158 (56.7%) post-PERT implementation, of which 165 (14.2%) were evaluated by the PERT. There was no difference in pulmonary embolism-related mortality between the two time periods (2.6% pre-PERT implementation vs 2.9% post-PERT implementation, P = .89). There was increased risk stratification assessment by measurement of cardiac biomarkers and echocardiograms post-PERT implementation. Overall utilization of advanced therapy was similar between groups (5.4% pre-PERT implementation vs 5.4% post-PERT implementation, P = 1.0), with decreased use of systemic thrombolysis (3.8% pre-PERT implementation vs 2.1% post-PERT implementation, P = 0.02) and increased catheter-directed therapy (1.3% pre-PERT implementation vs 3.3% post-PERT implementation, P = 0.05) post-PERT implementation. Inferior vena cava filter use decreased after PERT implementation (10.7% pre-PERT implementation vs 6.9% post-PERT implementation, P = 0.002). Findings were similar when analyzing elevated-risk patients.

CONCLUSION

Pulmonary embolism response teams may increase risk stratification assessment and alter application of advanced therapies, but a mortality benefit was not identified.