Increasing use of dual-chamber pacemakers raises hospital costs

Although permanent dual-chamber pacemaker device use is increasing in the U.S., single-chamber ventricular pacemaker use is decreasing. These trends have resulted in a 45 percent increase in hospital charges, driven by the cost of dual-chamber devices, and have “healthcare policy implications,” according to authors of a study published online Sept. 19 in the Journal of the American College of Cardiology.

Implantation of cardiac pacemakers in the U.S. has increased (Pacing Clin Electrophysiol 2010;33:705-711). “Pacemaker technology has advanced from fixed-rate single-chamber pacemakers to dual-chamber pacemakers with pacing algorithms to enhance rate response and to minimize ventricular pacing,” according to the study authors, who also noted that the National Coverage Determination for Cardiac Pacemakers from the Centers for Medicare & Medicaid Services has not changed “significantly” since 1985.

Thus, Arnold J. Greenspon, MD, cardiac electrophysiologist at the Jefferson Heart Institute in Philadelphia, and colleagues evaluated cardiac pacemaker implantation trends in the U.S. to assess the disparity between National Coverage Determination policies, which emphasized the role of single-chamber pacing and contemporary medical practice.

To accomplish this goal, the researchers queried the Nationwide Inpatient Sample (NIS) to identify permanent pacemaker implants between 1993 and 2009 using the ICD-9 Clinical Modification procedure codes for dual-chamber, single-ventricular, single-atrial or biventricular devices. They also analyzed the annual permanent pacemaker implantation rates and patient demographics.

Between 1993 and 2009, 2.9 million U.S. patients received permanent pacemakers. Overall use increased by 55.6 percent.

By 2009, dual-chamber device use increased from 62 percent to 82 percent, whereas single-chamber ventricular pacemaker use fell from 36 percent to 14 percent. The researchers reported that the use of dual-chamber devices was higher in urban, non-teaching hospitals (79 percent) compared with urban teaching hospitals (76 percent) and rural hospitals (72 percent).

Greenspon et al reported that patients with private insurance (83 percent) more commonly received dual-chamber devices than Medicaid (79 percent) or Medicare (75 percent) recipients.

Also, patient age and Charlson comorbidity index increased over time.

Hospital charges increased 45.3 percent—driven by the increased cost of dual-chamber devices—from $53,693 in 1993 to $78,015 in 2009. “We observed that hospital charges are increasing, despite a decrease in the length of stay,” wrote the study authors. “Improvements in technology, often associated with dual-chamber pacing, come at a higher cost. It is unclear whether these costs will continue to rise and to what extent the healthcare system can withstand this financial burden.”

Acknowledging the study’s limitations, Greenspon et al said that the analysis used the NIS, a U.S. survey of hospital discharges, which may underestimate total pacemaker implantation rate because it does not capture outpatient procedures. In addition, the NIS suffers from the absence of clinical data. 

However, they added that these findings "have important implications for future healthcare policy decisions."