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IIR 04-046 – HSR&D Study

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IIR 04-046
Optimal Use and Cost-Effectiveness of ICDS in the VA Health Care System
Barry M Massie MD
San Francisco VA Medical Center, San Francisco, CA
San Francisco, CA
Funding Period: July 2005 - September 2011

BACKGROUND/RATIONALE:
Until 2004, most implantable cardioverter-defibrillators (ICDs) were implanted in patients who survived episodes of sudden cardiac death (SCD) or other life-threatening arrhythmias (e.g., secondary prevention). Several subsequent trials demonstrated statistically significant, but relatively modest, improvements in survival in both myocardial infarction survivors and patients with heart failure with impaired left ventricular function without documented arrhythmias (primary prevention). These indications increased the pool of patients eligible for ICDs by 5-fold, and ICD implantation rates rose precipitously. As a consequence, ICD implantation costs are projected to grow from $1.5 billion in 2005 to $10-20 billion over 10 years.

Although statistically significant, the survival benefit in the primary prevention trials has been modest, ranging from 7-10 lives saved over 3-5 years per 100 patients implanted, with important subgroups showing no benefit. Furthermore, these clinical trials enrolled populations that differed from the "real-world patients" at high risk for SCD. Trial populations were younger, predominantly men, and had fewer comorbid conditions and less severe heart failure.

Therefore, it was critical that further studies delineate the characteristics of real-world patients who receive ICDs, the subsequent incidence of outcomes among these patients, and patient characteristics predictive of these outcomes. This information is critical to optimizing the utilization of ICDs.

OBJECTIVE(S):
We utilized the unique information available through the VA National Cardiac Device Surveillance Program (VANCDSP) based at the San Francisco VAMC to identify optimal and appropriate candidates for ICD implantation.

Specific aims were:
1. To determine the demographic and clinical characteristics of Veteran ICD recipients, the indications for ICD placement, and the appropriateness of ICD placement in relation to guideline recommendations.

2. To determine patient characteristics that predict low and high rates of appropriate ICD discharges.

3. To identify baseline characteristics that stratify patients based upon their likelihood of benefit from ICD implantation (defined as having received an appropriate ICD intervention followed by a subsequent survival period of at least 6 months) and develop a prediction model incorporating these characteristics.

4. To estimate the cost-effectiveness of ICD implantation in veterans across a broad spectrum of arrhythmia and mortality risk.

5. To compare the characteristics and outcomes of patients receiving ICDs within the VA system to those of the broader U.S. health care system, using available registry data.

METHODS:
We conducted a prospective cohort study by utilizing VA Health Information systems to phenotype the characteristics and clinical outcomes of nearly 5,000 Veterans who underwent ICD implantation and were enrolled in the VANCDSP between 2003 and 2009. This cohort was not subject to the restrictive entry criteria or selection biases of randomized clinical trials or to either the reimbursement restrictions or the financial incentives that apply to non-VA patients.

The following was collected from review of electronic medical records, periodic downloading of stored ICD data with independent adjudication, and available VA databases to track patient outcomes: information concerning patients' demographic and clinical characteristics; indication for ICD placement; ICD type, programming, and activity; clinical outcomes; and resource utilization.

Multi-predictor regression models were used to assess secular trends in patient characteristics and indications for ICD placement, as well as to determine independent predictors of clinical outcomes. Cox and tree-structured survival methods were used to develop prediction rules with potential policy implications, using generalized cross-validation methods to obtain reliable estimates of the likely prediction error of the derived rules. Cost-effectiveness will be assessed in patients across a range of indications and risk predictors by projecting life expectancy and lifetime cost of care using actual survival and cost information from the period of observation.

FINDINGS/RESULTS:
Approximately 5,000 patients met our entry criteria: namely, implantation of a first ICD within the VA system with enrollment in the VANCDSP monitoring program within 3 months of implantation. This did not include veterans whose devices were implanted at non-VA hospitals or at VA hospitals not yet participating in VANCDSP.

We found that the overwhelming majority (89%) of devices were implanted for primary prevention of SCD. As anticipated, the age and level of comorbidity of VA recipients was substantially higher than that of patients entered into randomized trials. After a mean follow-up of 2.5 years, we observed a rate of all-cause mortality of 6.5 per 100 person-years. The 11% mortality we observed at two years compares well with the range of 2-year mortality observed in the major randomized trials of primary prevention ICD therapy: MADIT (12%), MADIT-2 (16%), and SCD-HeFT (11%), despite older subjects and greater burden of comorbidity among veterans with ICDs. Remarkably, the 4-year mortality rates in our cohort were less than 26%.

Mortality was much higher among patients with more severe underlying cardiac disease and comorbid conditions. Mortality by NYHA functional class ranged from 3.9 per 100 person-years (Class I) to 15.7 per 100 person-years (Class IV) (p < 0.0001). After adjusting for potential confounders, Class IV symptoms were associated with nearly four-fold greater mortality (hazard ratio 3.9; 95% CI, 1.9 - 7.8; p < 0.001) compared with Class I (very mild symptoms). Similarly, hospitalization within the preceding 6 months was associated with higher mortality (HR, 1.7; 95% CI, 1.3-2.3; p < 0.001). Patients with chronic kidney disease had a much higher risk of death (HR, 1.7; 95% CI, 1.3 - 2.1; p < 0.001).

In analyses examining guideline concordance of indications for implantation of both ICDs and cardiac resynchronization (CRT) ICDs, there was less overuse in the VA system compared with non-VA data derived from the National Cardiovascular Data Registry (NCDR, a national registry). In NCDR, 22.5% of all ICDs were found not to meet guideline indications, compared to 12.8% of ICDs implanted in the VA. Similarly, 23.7% of non-VA implanted CRT ICDs were outside clinical guidelines; "off-label" devices represented only 19.6% of VA recipients.


IMPACT:
Our findings, derived from a population-based cohort of unselected Veterans receiving ICDs with robust long-term clinical and device performance data, have confirmed that veterans receiving these expensive devices are older and have a greater burden of comorbidity than trial populations. These characteristics among veterans were associated with higher mortality, but surprisingly, overall mortality in our cohort was similar to that in trials enrolling less ill subjects. Importantly, we found that there was less overuse of these devices in the VA system than in the fee-for-service population evaluated by NCDR, and that rates of use of optimal medical therapy were extremely high, indicative of the high quality of care among veterans receiving ICDs.

Importantly, this well-phenotyped cohort has created a unique data resource that will be available for future analyses, and provides a data standard for future care of veterans with arrhythmia devices. As part of the highly successful CART-CL program that is currently employed VA-wide to document the care of greater than 30,000 cardiac catheterization and coronary intervention procedures annually, the data standard and data collection processes established in this study have already heavily informed the structure of CART-EP, the next generation VA clinical documentation platform for the comprehensive care of patients with implantable arrhythmia devices, expected to be implemented in the VA system in 2012-2013.

PUBLICATIONS:

Journal Articles

  1. Sung RK, Massie BM, Varosy PD, Moore H, Rumsfeld J, Lee BK, Keung E. Long-term electrical survival analysis of Riata and Riata ST silicone leads: National Veterans Affairs experience. Heart Rhythm. 2012 Dec 1; 9(12):1954-61.
  2. Schuller JL, Olson MD, Zipse MM, Schneider PM, Aleong RG, Wienberger HD, Varosy PD, Sauer WH. Electrocardiographic characteristics in patients with pulmonary sarcoidosis indicating cardiac involvement. Journal of Cardiovascular Electrophysiology. 2011 Nov 1; 22(11):1243-8.
  3. Massie BM. Novel targets for the treatment of heart failure: perspectives from a heart failure clinician and trialist. Journal of molecular and cellular cardiology. 2011 Oct 1; 51(4):438-40.
  4. Steinman MA, Harlow JB, Massie BM, Kaboli PJ, Fung KZ, Heidenreich PA. Age and receipt of guideline-recommended medications for heart failure: a nationwide study of veterans. Journal of general internal medicine. 2011 Oct 1; 26(10):1152-9.
  5. Dewland TA, Pellegrini CN, Wang Y, Marcus GM, Keung E, Varosy PD. Dual-chamber implantable cardioverter-defibrillator selection is associated with increased complication rates and mortality among patients enrolled in the NCDR implantable cardioverter-defibrillator registry. Journal of the American College of Cardiology. 2011 Aug 30; 58(10):1007-13.
  6. Heath RR, Schuller JL, Sauer WH, Varosy PD, Nguyen DT, Aleong RG. Images in cardiovascular medicine: a mobile tubular mass visualized by transesophageal echocardiography after successful lead extraction. Circulation. 2011 May 17; 123(19):e590-1.
  7. Heath RR, Varosy PD, Katz DF, Schuller JL, Aleong RG, Sauer WH, Nguyen DT. Life-threatening ST-segment elevation without coronary artery disease. Archives of internal medicine. 2011 May 9; 171(9):801, 802-3.
  8. Haass M, Kitzman DW, Anand IS, Miller A, Zile MR, Massie BM, Carson PE. Body mass index and adverse cardiovascular outcomes in heart failure patients with preserved ejection fraction: results from the Irbesartan in Heart Failure with Preserved Ejection Fraction (I-PRESERVE) trial. Circulation. Heart failure. 2011 May 1; 4(3):324-31.
  9. Jiang S, Tabas J, Varosy PD, Goldschlager N. Tachycardia in a patient with a dual-chamber pacemaker. Archives of internal medicine. 2011 Mar 14; 171(5):379-81.
  10. Sauer WH, Lowery CM, Bargas RL, Schuller JL, Stees CS, Aleong RG, Varosy PD. Utility of postoperative testing of implantable cardioverter-defibrillators. Pacing and Clinical Electrophysiology. 2011 Feb 1; 34(2):186-92.
  11. Burjonroppa SC, Varosy PD, Rao SV, Ou FS, Roe M, Peterson E, Singh M, Shunk KA. Survival of patients undergoing rescue percutaneous coronary intervention: development and validation of a predictive tool. JACC. Cardiovascular interventions. 2011 Jan 1; 4(1):42-50.
  12. Ghali JK, Massie BM, Mann DL, Rich MW. Heart failure guidelines, performance measures, and the practice of medicine: mind the gap. Journal of cardiac failure. 2011 Jan 1; 17(1):90.e1-4.
  13. Krum H, Massie B, Abraham WT, Dickstein K, Kober L, McMurray JJ, Desai A, Gimpelewicz C, Kandra A, Reimund B, Rattunde H, Armbrecht J, ATMOSPHERE Investigators. Direct renin inhibition in addition to or as an alternative to angiotensin converting enzyme inhibition in patients with chronic systolic heart failure: rationale and design of the Aliskiren Trial to Minimize Outcomes in Patients with HEart failuRE (ATMOSPHERE) study. European journal of heart failure : journal of the Working Group on Heart Failure of the European Society of Cardiology. 2011 Jan 1; 13(1):107-14.
  14. Schuller JL, Lowery CM, Zipse M, Aleong RG, Varosy PD, Weinberger HD, Sauer WH. Diagnostic utility of signal-averaged electrocardiography for detection of cardiac sarcoidosis. Annals of Noninvasive Electrocardiology. 2011 Jan 1; 16(1):70-6.
  15. Ghali JK, Massie BM, Mann DL, Rich MW. Heart failure guidelines, performance measures, and the practice of medicine: mind the gap. Journal of the American College of Cardiology. 2010 Dec 14; 56(25):2077-80.
  16. Cheng A, Wang Y, Curtis JP, Varosy PD. Acute lead dislodgements and in-hospital mortality in patients enrolled in the national cardiovascular data registry implantable cardioverter defibrillator registry. Journal of the American College of Cardiology. 2010 Nov 9; 56(20):1651-6.
  17. Ponikowski P, Mitrovic V, O'Connor CM, Dittrich H, Cotter G, Massie BM, Givertz MM, Chen E, Murray M, Weatherley BD, Fujita KP, Metra M. Haemodynamic effects of rolofylline in the treatment of patients with heart failure and impaired renal function. European journal of heart failure : journal of the Working Group on Heart Failure of the European Society of Cardiology. 2010 Nov 1; 12(11):1238-46.
  18. Massie BM, O'Connor CM, Metra M, Ponikowski P, Teerlink JR, Cotter G, Weatherley BD, Cleland JG, Givertz MM, Voors A, DeLucca P, Mansoor GA, Salerno CM, Bloomfield DM, Dittrich HC, PROTECT Investigators and Committees. Rolofylline, an adenosine A1-receptor antagonist, in acute heart failure. The New England journal of medicine. 2010 Oct 7; 363(15):1419-28.
  19. Al-Khatib SM, Calkins H, Eloff BC, Kowey P, Hammill SC, Ellenbogen KA, Marinac-Dabic D, Waldo AL, Brindis RG, Wilbur DJ, Jackman WM, Yaross MS, Russo AM, Prystowsky E, Varosy PD, Gross T, Pinnow E, Turakhia MP, Krucoff MW. Developing the Safety of Atrial Fibrillation Ablation Registry Initiative (SAFARI) as a collaborative pan-stakeholder critical path registry model: a Cardiac Safety Research Consortium "Incubator" Think Tank. American heart journal. 2010 Oct 1; 160(4):619-26.
  20. Franciosa JA, Ferdinand KC, Yancy CW, Consensus Statement on Heart Failure in African Americans Writing Group. Treatment of heart failure in African Americans: a consensus statement. Congestive Heart Failure (Greenwich, Conn.). 2010 Jan 1; 16(1):27-38.
  21. Haywood LJ, Ford CE, Crow RS, Davis BR, Massie BM, Einhorn PT, Williard A, ALLHAT Collaborative Research Group. Atrial fibrillation at baseline and during follow-up in ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial). Journal of the American College of Cardiology. 2009 Nov 24; 54(22):2023-31.
  22. Lee KW, Everett TH, Wilson EE, Guerra JM, Varosy PD, Olgin JE. Safety profiles and lesion size of different radiofrequency ablation technologies: a comparison of large tip, open and closed irrigation catheters. Journal of Cardiovascular Electrophysiology. 2009 Mar 1; 20(3):325-35.
  23. Benjamin EJ, Chen PS, Bild DE, Mascette AM, Albert CM, Alonso A, Calkins H, Connolly SJ, Curtis AB, Darbar D, Ellinor PT, Go AS, Goldschlager NF, Heckbert SR, Jalife J, Kerr CR, Levy D, Lloyd-Jones DM, Massie BM, Nattel S, Olgin JE, Packer DL, Po SS, Tsang TS, Van Wagoner DR, Waldo AL, Wyse DG. Prevention of atrial fibrillation: report from a national heart, lung, and blood institute workshop. Circulation. 2009 Feb 3; 119(4):606-18.
  24. Tseng ZH, Aouizerat BE, Pawlikowska L, Vittinghoff E, Lin F, Whiteman D, Poon A, Herrington D, Howard TD, Varosy PD, Hulley SB, Malloy M, Kane J, Kwok PY, Olgin JE. Common beta-adrenergic receptor polymorphisms are not associated with risk of sudden cardiac death in patients with coronary artery disease. Heart Rhythm. 2008 Jun 1; 5(6):814-21.
  25. Kohlwes RJ, Shunk RL, Avins A, Garber J, Bent S, Shlipak MG. The PRIME curriculum. Clinical research training during residency. Journal of general internal medicine. 2006 May 1; 21(5):506-9.
  26. Massie BM, Fabi MR. Clinical trials in diastolic heart failure. Progress in Cardiovascular Diseases. 2005 May 1; 47(6):389-95.
  27. Packer M, McMurray J, Massie BM, Caspi A, Charlon V, Cohen-Solal A, Kiowski W, Kostuk W, Krum H, Levine B, Rizzon P, Soler J, Swedberg K, Anderson S, Demets DL. Clinical effects of endothelin receptor antagonism with bosentan in patients with severe chronic heart failure: results of a pilot study. Journal of cardiac failure. 2005 Feb 1; 11(1):12-20.
Journal Other

  1. Massie BM. Globalization of clinical trials how should we interpret differences in outcomes? Journal of the American College of Cardiology. 2011 Aug 23; 58(9):923-4.
  2. Ghali JK, Massie BM, Mann DL, Rich MW. Guidelines are merely guidelines. [Editorial]. Journal of cardiac failure. 2011 Mar 1; 17(3):208-9.
Conference Presentations

  1. Schneider PM, Pelligrini CN, Yang Y, Heidenreich PA, Rumsfeld JS, Masoudi FA, Massie BM, Varosy PD. Adherence to Guideline-Based Indications and Prevalence of Optimal Medical Therapy Among Patients Receiving Cardiac Resynchronization Therapy Defibrillators in the Outcomes Among Veterans with Implantable Devices Registry. Paper presented at: American Heart Association Annual Scientific Sessions; 2011 Nov 1; Orlando, FL.
  2. Massie BM. How will heart failure therapy change? Paper presented at: Heart Failure Society of America Annual Scientific Meeting; 2011 Sep 19; Boston, MA.
  3. Katz DF, Aleong RG, Pointer L, Pelligrini CN, Sauer WH, Heath RR, Schuller J, Nguyen DT, Heidenreich PA, Massie BM, Varosy PD. Characteristics of Implantable Cardioverter-defibrillator Recipients for the Primary and Secondary Prevention of Sudden Cardiac Death in the Outcomes Among Veterans With Implantable Defibrillators (OVID) Registry. Paper presented at: Heart Failure Society of America Annual Scientific Meeting; 2011 Sep 1; Boston, MA.
  4. Massie BM. Update on anticoagulation in chronic heart failure. Paper presented at: European Society of Cardiology Heart Failure Congress; 2011 May 22; Goteborg, Sweden.
  5. Massie BM. New medical therapies for acute heart failure. Paper presented at: European Society of Cardiology Heart Failure Congress; 2011 May 22; Goteborg, Sweden.
  6. Massie BM. Difficult cases in heart failure with preserved ejection fraction. Paper presented at: European Society of Cardiology Heart Failure Congress; 2011 May 22; Goteborg, Sweden.
  7. Massie BM. President’s debate: Heart rate reduction beyond a beta-blocker effect is not beneficial in heart failure. Paper presented at: European Society of Cardiology Heart Failure Congress; 2011 May 22; Goteborg, Sweden.
  8. Massie BM. Advanced pharmacological therapy for heart failure. Paper presented at: American College of Cardiology Annual Scientific Session; 2011 Apr 2; New Orleans, LA.
  9. Massie BM. New insights into the pathophysiology of cardiorenal syndrome. Paper presented at: American College of Cardiology Annual Scientific Session; 2011 Apr 2; New Orleans, LA.
  10. Massie BM. Is there really a good drug for diastolic heart failure? Paper presented at: American College of Cardiology Annual Scientific Session; 2011 Apr 2; New Orleans, LA.
  11. Massie BM. Management of volume overload in advanced heart failure. Paper presented at: American College of Cardiology Annual Scientific Session; 2011 Apr 2; New Orleans, LA.
  12. Massie BM. New insights into the mechanism of cardiorenal syndrome. Paper presented at: American Heart Association Annual Scientific Sessions; 2010 Nov 14; Chicago, IL.
  13. Massie BM. Is there a role for positive inotropic drugs in the management of acute heart failure? Paper presented at: American Heart Association Annual Scientific Sessions; 2010 Nov 14; Chicago, IL.
  14. Aleong R, Sauer WH, Pellegrini CN, Yang Y, Keung E, Heidenreich P, Rumsfeld JS, Massie BM, Varosy PD. Clinical Subtype of Atrial Fibrillation at the Time of Implantation and Subsequent Mortality Among Veterans with Implantable Defibrillators. Paper presented at: Heart Failure Society of America Annual Scientific Meeting; 2010 Sep 1; San Diego, CA.
  15. Olson MD, Zipse M, Schuller JL, Belardi DF, Bargas RL, Lowery CM, Aleong RG, Varosy PD, Sauer WH. Symptomatic Heart Failure Is an Uncommon Presentation of Cardiac Sarcoidosis and is Associated with a Higher Rate of Ventricular Arrhythmias. Paper presented at: Heart Failure Society of America Annual Scientific Meeting; 2010 Sep 1; San Diego, CA.
  16. Varosy PD, Pellegrini CN, Yang Y, Keung E, Heidenreich P, Rumsfeld JS, Massie BM. History of heart failure and mortality among veterans with implantable cardioverter-defibrillators. Paper presented at: Heart Failure Society of America Annual Scientific Meeting; 2010 Sep 1; San Diego, CA.
  17. Massie BM. Do ICDs work for patients in everyday life? Presented at: European Society of Cardiology Heart Failure Congress; 2010 May 31; Berlin, Germany.
  18. Yang Y, Pellegrini CN, Wang N, Keung E, Heidenreich P, Rumsfeld JS, Massie BM, Varosy PD. Agreement between Clinical and Adjudicated Indications for ICD Implantation at Veterans Affairs Medical Centers. Paper presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2010 May 20; Washington, DC.
  19. Massie BM. Real-world incidence of long-term surgical and mechanical complications among Veterans enrolled in the VA National ICD Surveillance Center. Paper presented at: Heart Rhythm Society Annual Scientific Sessions; 2010 May 14; Denver, CO.
  20. Pellegrini CN, Yang Y, Slomiak S, Heidenreich PA, Massie BM, Varosy PD. Application of the MADIT II Clinical Risk Score to Cohort of Veterans with Defibrillators. Presented at: Heart Rhythm Society Annual Scientific Sessions; 2010 May 12; Denver, CO.
  21. Bargas RL, Stees CS, Schuller JL, Belardi DF, Aleong RG, Varosy PD, Khoo MC, Sauer WH, Lowery CM. Typical Flutter in an Atypical Patient: Ablation of “Clockwise” Atrial Flutter in a Patient with Situs Inversus Totalis and Limited Venous Access. Paper presented at: Heart Rhythm Society Annual Scientific Sessions; 2010 May 1; Denver, CO.
  22. Heath R, Kao D, Belardi D, Varosy PD. Mortality and Complication Rates of Catheter-Based Ablation Procedures are Lower at High Volume Centers. Paper presented at: Heart Rhythm Society Annual Scientific Sessions; 2010 May 1; Denver, CO.
  23. Lowery CM, Bargas RL, Stees CS, Schuller JL, Belardi DF, Aleong RG, Khoo MC, Varosy PD, Sauer WH. Induction of Ventricular Fibrillation is not necessary for Successful Ablation in Patients with Structural Heart Disease and Severe Heart Failure. Paper presented at: Heart Rhythm Society Annual Scientific Sessions; 2010 May 1; Denver, CO.
  24. Schuller JL, Zipse MM, Bargas R, Stees CS, Aleong RG, Khoo MC, Lowery CM, Varosy PD, Gottschall EB, Maier L, Rose C, Hamzeh N, Weinberger H, Sauer WH. Patients with Cardiac Sarcoidosis and an Implanted Cardioverter-Defibrillator can have Late Reduction in Measured R-waves Requiring Lead Revision. Paper presented at: Heart Rhythm Society Annual Scientific Sessions; 2010 May 1; Denver, CO.
  25. Schuller JL, Zipse MM, Bargas R, Stees CS, Aleong RG, Khoo MC, Lowery CM, Varosy PD, Gottschall EB, Maier L, Rose C, Hamzeh N, Weinberger H, Sauer WH. Patients with Cardiac Sarcoidosis and a Primary Prevention ImplantableCardioverter Defibrillator Have a Higher Incidence of Ventricular Tachycardia Storm Compared to Patients with Non-Sarcoidosis Cardiomyopathies. Paper presented at: Heart Rhythm Society Annual Scientific Sessions; 2010 May 1; Denver, CO.
  26. Varosy PD, Pellegrini CN, Yang Y, Heidenreich PA, Singh R, Rumsfeld JS, Massie BM. Real-world incidence of long-term surgical and mechanical complications among veterans with implantable cardioverter-defibrillators (ICDs). Paper presented at: Heart Rhythm Society Annual Scientific Sessions; 2010 May 1; Denver, CO.
  27. Zipse MM, Schuller JL, Bargas R, Stees CS, Aleong RG, Khoo MC, Lowery CM, Varosy PD, Gottschall EB, Maier L, Rose C, Hamzeh N, Weinberger H, Sauer WH. Signal Averaged Electrocardiography can Accurately Detect Cardiac Involvement of Sarcoidosis in Patients with a Narrow QRS Complex. Paper presented at: Heart Rhythm Society Annual Scientific Sessions; 2010 May 1; Denver, CO.
  28. Massie BM. Implantable cardioverter-defibrillators: How many lives are we really saving and at what cost? Paper presented at: American College of Cardiology New York Cardiovascular Annual Symposium; 2009 Dec 11; New York, NY.
  29. Cheng A, Wang Y, Curtis JP, Varosy PD. Acute lead dislodgements and in-hospital mortality in patients enrolled in the National Cardiovascular Data Registry Implantable Cardioverter Defibrillator Registry. Paper presented at: American Heart Association Annual Scientific Sessions; 2009 Nov 1; Orlando, FL.
  30. Fein AS, Wang Y, Curtis JP, Masoudi FA, Varosy PD, Reynolds MR. Prevalence and predictors of off-label use of cardiac resynchronization therapy in patients enrolled in the National Cardiovascular Data Registry Implantable Cardiac-Defibrillator Registry. Paper presented at: American Heart Association Annual Scientific Sessions; 2009 Nov 1; Orlando, FL.
  31. Varosy PD. Quality Improvement for Implantable Cardioverter-Defibrillator Use. Paper presented at: American Heart Association Annual Scientific Sessions; 2009 Nov 1; Orlando, FL.
  32. Massie BM. Pathophysiology of Cardiorenal Syndrome. Paper presented at: Heart Failure Society of America Annual Scientific Meeting; 2009 Sep 13; Boston, MA.
  33. Massie BM. Cardiorenal Syndrome. Paper presented at: Toronto International Annual Heart Summit; 2009 Jun 12; Toronto, Canada.
  34. Massie BM. Cardiorenal Syndrome. Paper presented at: Columbia University Department of Medicine Grand Rounds Daniel L. Macken Visiting Lectureship; 2009 May 12; New York, NY.
  35. Massie BM. Implantable Cardioverter Defibrillators: Appropriate use or abuse? Paper presented at: Columbia University Department of Medicine Grand Rounds Daniel L. Macken Visiting Lectureship; 2009 May 12; New York, NY.
  36. Massie BM. Heart Failure with Preserved Ejection Fraction. Paper presented at: Columbia University Department of Medicine Grand Rounds Daniel L. Macken Visiting Lectureship; 2009 May 11; New York, NY.
  37. Massie BM. The effect of race on mortality among veterans with implantable cardioverter-defibrillators. Paper presented at: American College of Physicians Annual Meeting; 2009 Apr 24; Philadelphia, PA.
  38. Massie BM. Implantable cardioverter defibrillators: Disparities between evidence and use. Paper presented at: University of California San Diego Grand Rounds; 2009 Apr 15; San Diego, CA.
  39. Massie BM. Comorbidity and survival after implantation of a first cardioverter-defibrillator among Veterans enrolled in the VA National ICD Surveillance Center. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 11; Baltimore, MD.
  40. Massie BM. Late Breaking Clinical Trial Session: Irbesartan for Heart Failure with Preserved Ejection Fraction. Paper presented at: American Heart Association Annual Scientific Sessions; 2008 Nov 11; New Orleans, LA.
  41. Massie BM. Heart failure as a cause and consequence of atrial fibrillation. Paper presented at: National Heart, Lung, and Blood Institute Workshop on Prevention of Atrial Fibrillation; 2008 Apr 16; Bethesda, MD.
  42. Sahay, Massie BM, Heidenreich PA. Heart Failure Network of VA Providers: An Innovative Strategy for Implementation. Presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD.
  43. Dewland TA, Pellegrini CN, Wang Y, Marcus GM, Varosy PD, Massie BM. Dual chamber ICD selection is associated with racial and socioeconomic disparities and increased complication rates among patients enrolled in the NCDR ICD Registry. Paper presented at: American Heart Association Annual Scientific Sessions; 2007 Nov 4; Orlando, FL.
  44. Aleong RG, Sauer WH, Pellegrini CN, Yang Y, Massie BM, Turakhia M, Heidenreich PA, Mulkerin JL, Rumsfeld JS, Varosy PD. Clinical Subtype of Atrial Fibrillation at the Time of Implantation and Subsequent Heart Failure Admissions Among Veterans with Implantable Defibrillators. Paper presented at: Heart Rhythm Society Annual Scientific Sessions; 2001 May 1; San Francisco, CA.


DRA: Health Systems, Cardiovascular Disease
DRE: Treatment - Observational, Technology Development and Assessment
Keywords: Cardiac procedures, Cardiovascular Disease, Cost, Effectiveness, Guideline Development and Implementation, Research measure, Risk Factors
MeSH Terms: none

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