Implantable cardioverter-defibrillators (ICDs) are class-IA-guideline-recommended therapies for patients with chronic heart failure (CHF) and reduced left ventricular ejection fraction. As CHF is common among veterans over age 65, a large number of veterans who are simultaneously enrolled in both VA and Medicare are eligible for ICDs, yet it is unknown how many VHA-enrolled veterans with CHF have received an ICD. It is also uncertain how ICDs implanted outside VHA among dually enrolled veterans impacted VA costs of care.
Our specific aims were to (1) identify the total number of dual-enrolled (i.e., Medicare- and VHA-enrolled) veterans who received ICDs during 2001-08; (2) quantify the fraction of veterans with an ICD who received their device at VA versus outside VA; (3) determine the number of veterans living with an ICD who receive ongoing device care at VA; (4) determine the costs of VA health care attributable to the ICD; and (5) determine whether there were substantial racial or socioeconomic differences in VA's ICD implant rates.
We used administrative data from 2001-2010 on ICD implantations, device continuity care, and device-related complications as recorded in the VA's national Medical SAS datasets (including fee-basis care). These data were merged with VA Information Resource Center's (VIReC's) Medicare claims data from patients dually enrolled in VHA and Medicare who received an ICD in calendar years 2001-2008 (2009-2010 data were not yet available). Costs of VA health care were estimated using the VA's Health Economics Resource Center's (HERC's) Average Cost Datasets. We used race data as reported in both VA and Medicare, as well as ZIP-code linked socioeconomic data as reported in the 2000 U.S. Census, to determine the race and estimate the socioeconomic status of each dual-eligible ICD recipient from 2001-2008. We hypothesized that the number of enrolled veterans with an ICD increased substantially between 2001 and 2010. We further hypothesized that a substantial proportion of veterans who received ICDs during these years received their devices outside VHA, yet a large number of those veterans received subsequent device monitoring within VHA. Finally, we hypothesized that minority and low-socioeconomic status veterans received ICDs at lower rates than other veterans.
The number of dual-enrolled veterans receiving an ICD in the VA nearly tripled between 2001 (799 implants) and 2010 (2284 implants). Among all dual-eligible veterans receiving ICD implants either in the VA or in a non-VA hospital via a Medicare-covered procedure, the percentage of implants delivered by VA fell from 10.3% in 2001 to 8.2% in 2002-2003, but then increased to 9.7% as of 2008. The total number of dual-enrolled veterans receiving ICD-related healthcare in the VA increased even more markedly (360%) between 2001 (n=5,775) and 2010 (26,556).
Among veterans receiving ICD continuity care in the VA from 2006-2008, 26% had originally received their ICD in VA, 34% had received their ICD outside VA and covered by Medicare, and 40% of had no ICD implantation record either in VA or Medicare data. Among veterans in 2006-2008 who originally had received their ICD at a VAMC, 83% continued to obtain all device care in VA, 13% received some device care at VA and some outside VA, and 4% received device care entirely outside VA. Among veterans in 2006-2008 who originally had received their ICD outside VA (paid for by Medicare), 88% continued to obtain all device care outside of VA, 9% received some device care at VA and some outside VA, and 2% received device care entirely outside VA. We estimated that VA "inherited" on net the care of approximately 3,000 veterans during 2006-2008 who had ICDs implanted under Medicare coverage.
The average cost of ICD implantation within VA increased significantly (p<0.001) from a mean of $50,536 (2010 dollars) recipient in 2001 to $64,552 per recipient in 2010. Conversely, the mean costs of continuity care for veterans did not change significantly with time; the 2001-2010 average ICD-attributable cost per device recipient was $762. Based on our findings that 74% of dual-eligible veterans received their ICDs outside of VA, we estimated that $13.9 million in VA healthcare costs resulted from device continuity care for veterans who had received their devices outside VA.
Between 2001 and 2008, a growing proportion (10.6% rising to 13.4%, p=0.001) of VA ICD implants were among black veterans. The percentage of black ICD recipients in 2008 was comparable to the percentage of black VA-hospitalized heart failure patients (12%). The percentage of black ICD recipients within VA greatly exceeds the national percentage of black ICD recipients among all dual-enrolled veterans (6.2% in 2008). The percentage of ICD recipients who were from low-SES ZIP codes was higher in the VA (28% in 2008) than among all dual-eligible veterans nationwide (20% in 2008, p<0.001). The percentage of low-SES ICD recipients in VA was comparable to the percentage of low-SES VA-hospitalized heart failure patients (30% in 2008).
ICD implantation rates and the number of veterans who receive routine defibrillator care have risen dramatically in the VA during the past decade. VA ICD-related health care costs have increased by $123 million from 2001 to 2010, with nearly $14 million of this increase attributable to device care for veterans who had received their devices outside VA. The VA's ICD implant rate among black and low-SES veterans is much higher than the national average, suggesting VA is providing an essential service to these historically disadvantaged populations.
Our study identified recent VA utilization and cost trends in ICD utilization among dual-enrolled veterans, and our results may inform future VA policymaking, the design of clinical operations, and projecting fiscal burden of cardiovascular device therapy on the Veterans Health Administration (VHA), as implantable devices increasingly become essential components of high-quality cardiovascular care.
- Groeneveld PW. Implantable cardioverter-defibrillators in VHA and healthcare cost growth: 2001-2010. [Cyberseminar]. 2013 Jul 9.
- Groeneveld PW. Implantable cardioverter-defibrillators in VHA and healthcare cost growth: 2001-2010 [HERC Health Economics Seminar]. [Cyberseminar]. 2012 Jun 20.
- Epps KC, Holper EM, Gualano SK, Vlachos HA, Selzer F, Abbott JD, Jacobs AK, Marroquin OC, Naidu SS, Srinivas VS, Groeneveld PW, Wilensky RL. Higher rates of repeat coronary revascularizations in young women. Poster session presented at: Transcatheter Cardiovascular Therapeutics Annual Scientific Conference; 2013 Oct 29; San Francisco, CA.
- Groeneveld PW, Medvedeva E, Roberts C, Navaline HA, Richardson DM. Increasing use of implantable cardioverter-defibrillators in the Veterans Health Administration: 2001-2010. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; Washington, DC.