Heart failure

How do private and public hospitals compare on cardiac device outcomes?

There’s not much to choose between private and public hospitals when it comes to cardiac implantable device complication rates, Australian figures show.

An observational study that compared outcomes for more than 32,000 pacemakers and defibrillators implanted in NSW and Queensland hospitals between 2010 and 2015 found little difference in complication rates after adjusting for variables such as age, sex, co-morbidities and procedural acuity.

Overall, 8.0% of private hospital procedures and 9.6% public hospital procedures experienced at least one complication in‐hospital or within 90 days of discharge. Rates for in hospital complications (3.46% vs 4.0%) and post-discharge complications (4.86% vs 5.9%) were similar for private and public hospitals.

After adjustment for covariates, the overall device complication rate was not significantly different between private and public hospitals (Odds Ratio 0.92, p=0.58). Likewise, complication rates were comparable in private and public settings for each type of device (permanent pacemaker OR 0.93, implantable cardioverter defibrillator OR 0.92, cardiac resynchronisation therapy OR 0.85)

Rates of some complications such as in-hospital generator re-operation (OR 0.53) and post-discharge hospitalisations for infection (OR 0.61) were lower for private procedures. However, rates of in-hospital death were almost 50% higher in private hospitals (OR 1.49), mostly due to differences in deaths for acute procedures (1.3% vs 0.6% private vs public) rather than elective procedures.

Acute procedures accounted for 16.5% of cardiac device implants done in private hospitals compared to more than half (54%) of implants performed at the public hospitals.

Patients at private hospital were older (76.3 vs 73.4 years) and had a higher burden of ischaemic heart disease (27.9% vs. 26.5%) than public patients.

On the other hand, patients at private hospitals had lower incidence of heart failure (18.8% vs. 22.6%) and diabetes (14.9% vs. 20.8%) than those in public hospitals.

The findings were derived from 32,364 patients with cardiac implants , of which half the procedures (15,767) were performed at private hospitals.

The study authors said the figures added to the sparse data on comparative outcomes in public vs private hospitals in Australia. They noted that the Australian Institute of Health and Welfare has reported overall rates of adverse events during hospital admissions of 6.7% for public hospital patients, and 4.1% for private hospitals.

The higher mortality rate seen for private hospitals “points to a difference in the ability of private and public hospitals to manage acute CIED patients,” they said.

“The reasons for this are unclear, but may relate to differences in staffing, operational procedures, and infrastructure such as intensive care units between public and private hospitals to provide care for acutely unwell patients.”

The lower infective complication rates seen in private hospitals might be related to unmeasured differences in the infectious risk profile of public and private patients, or differences in infection control practices among private and public hospitals.

“Procedural factors that may impact quality and outcomes such as the use of antibiotic prophylaxis, temporary pacing and implanter experience and volume, and involvement of trainees may explain the differences observed,” the authors  added.

The findings are published in the Internal Medicine Journal.

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