title: Hospital patterns of use of positive inotropic agents in patients with heart failure.
abstract: OBJECTIVE
  This study sought to determine hospital variation in the use of positive inotropic agents in patients with heart failure.
  
  
  BACKGROUND
  Clinical guidelines recommend targeted use of positive inotropic agents in highly selected patients, but data are limited and the recommendations are not specific.
  
  
  METHODS
  We analyzed data from 376 hospitals including 189,948 hospitalizations for heart failure from 2009 through 2010. We used hierarchical logistic regression models to estimate hospital-level risk-standardized rates of inotrope use and risk-standardized in-hospital mortality rates.
  
  
  RESULTS
  The risk-standardized rates of inotrope use ranged across hospitals from 0.9% to 44.6% (median: 6.3%, interquartile range: 4.3% to 9.2%). We identified various hospital patterns based on the type of agents: dobutamine-predominant (29% of hospitals), dopamine-predominant (25%), milrinone-predominant (1%), mixed dobutamine and dopamine pattern (32%), and mixed pattern including all 3 agents (13%). When studying the factors associated with interhospital variation, the best model performance was with the hierarchical generalized linear models that adjusted for patient case mix and an individual hospital effect (receiver operating characteristic curves from 0.77 to 0.88). The intraclass correlation coefficients of the hierarchical generalized linear models (0.113 for any inotrope) indicated that a noteworthy proportion of the observed variation was related to an individual institutional effect. Hospital rates or patterns of use were not associated with differences in length of stay or risk-standardized mortality rates.
  
  
  CONCLUSIONS
  We found marked differences in the use of inotropic agents for heart failure patients among a diverse group of hospitals. This variability, occurring in the context of little clinical evidence, indicates an urgent need to define the appropriate use of these medications.
authors.affiliation: Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut 06510, USA.
authors.forename: Chohreh
authors.initials: C
authors.lastname: Partovian
authors.forename: Scott R
authors.initials: SR
authors.lastname: Gleim
authors.forename: Purav S
authors.initials: PS
authors.lastname: Mody
authors.forename: Shu-Xia
authors.initials: SX
authors.lastname: Li
authors.forename: Haiyan
authors.initials: H
authors.lastname: Wang
authors.forename: Kelly M
authors.initials: KM
authors.lastname: Strait
authors.forename: Larry A
authors.initials: LA
authors.lastname: Allen
authors.forename: Tara
authors.initials: T
authors.lastname: Lagu
authors.forename: Sharon-Lise T
authors.initials: SL
authors.lastname: Normand
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
mesh_terms: D002316:Cardiotonic Agents / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D006333:Heart Failure / Q000188:drug therapy* / Q000401:mortality; D017052:Hospital Mortality / Q000639:trends; D006761:Hospitals / Q000592:standards*; D006801:Humans; D007902:Length of Stay / Q000639:trends; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D014481:United States / Q000453:epidemiology
chemical_list: D002316:Cardiotonic Agents