Hospital variation in intravenous inotrope use for patients hospitalized with heart failure: insights from Get With The Guidelines.
BACKGROUND
Prior claims analyses suggest that the use of intravenous inotropic therapy for patients hospitalized with heart failure varies substantially by hospital. Whether differences in the clinical characteristics of the patients explain observed differences in the use of inotropic therapy is not known.


RESULTS
We sought to characterize institutional variation in inotrope use among patients hospitalized with heart failure before and after accounting for clinical factors of patients. Hierarchical generalized linear regression models estimated risk-standardized hospital-level rates of inotrope use within 209 hospitals participating in Get With The Guidelines-Heart Failure (GWTG-HF) registry between 2005 and 2011. The association between risk-standardized rates of inotrope use and clinical outcomes was determined. Overall, an inotropic agent was administered in 7691 of 126 564 (6.1%) heart failure hospitalizations: dobutamine 43%, dopamine 24%, milrinone 17%, or a combination 16%. Patterns of inotrope use were stable during the 7-year study period. Use of inotropes varied significantly between hospitals even after accounting for patient and hospital characteristics (median risk-standardized hospital rate, 5.9%; interquartile range, 3.7%-8.6%; range, 1.3%-32.9%). After adjusting for case-mix and hospital structural differences, model intraclass correlation indicated that 21% of the observed variation in inotrope use was potentially attributable to random hospital effects (ie, institutional preferences). Hospitals with higher risk-standardized inotrope use had modestly longer risk-standardized length of stay (P=0.005) but had no difference in risk-standardized inpatient mortality (P=0.12).


CONCLUSIONS
Use of intravenous inotropic agents during hospitalization for heart failure varies significantly among US hospitals even after accounting for patient and hospital factors.
Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora.
Larry A
LA
Allen
Gregg C
GC
Fonarow
Maria V
MV
Grau-Sepulveda
Adrian F
AF
Hernandez
Pamela N
PN
Peterson
Chohreh
C
Partovian
Shu-Xia
SX
Li
Paul A
PA
Heidenreich
Paul A
PA
Heidenrich
Deepak L
DL
Bhatt
Eric D
ED
Peterson
Harlan M
HM
Krumholz
D000368:Aged; D002316:Cardiotonic Agents / Q000008:administration & dosage*; D003430:Cross-Sectional Studies; D004305:Dose-Response Relationship, Drug; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence; D006333:Heart Failure / Q000188:drug therapy* / Q000401:mortality; D017052:Hospital Mortality / Q000639:trends; D006761:Hospitals / Q000592:standards*; D006801:Humans; D007262:Infusions, Intravenous; D007297:Inpatients; D007902:Length of Stay / Q000639:trends; D008297:Male; D017063:Outcome Assessment, Health Care; D010818:Practice Patterns, Physicians'; D012042:Registries; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D014481:United States / Q000453:epidemiology
D002316:Cardiotonic Agents
cardiotonic agents; heart failure; outcome and process assessment (health care); physician’s practice patterns