Use of pulmonary artery catheter decreases substantially in US

In the mid and late 1980s, there were challenges to the benefits of this procedure. A turning point occurred in September 1996 when a multicenter observational study suggested an increased risk of death with PA catheterization, with an editorial calling for a moratorium on PA catheter use until a randomized controlled trial could be conducted. In the past 5 years multiple randomized trials and a meta-analysis have shown that this technology has no impact on the risk of death in diverse populations of critically ill patients. But it is not known how this information has changed the use of this procedure.

Renda Soylemez Wiener, M.D., and H. Gilbert Welch, M.D., M.P.H., of the Department of Veterans Affairs Medical Center, White River Junction, Vt., examined the trends in the utilization of PA catheterization from 1993-2004 using data from all U.S. states contributing to the Nationwide Inpatient Sample.

The researchers found that utilization of PA catheterization in the United States from 1993 to 2004 for all medical admissions decreased by 65 percent, from 5.66 to 1.99 per 1,000 medical admissions. Among patients who died during hospitalization, a group whose disease severity may be consistent across time, the relative decline was similar (67 percent). A significant change in trend occurred following the 1996 study that suggested an increased risk of death with PA catheterization. Among common diagnoses associated with PA catheterization, the decline was most prominent for heart attack, which decreased by 81 percent, and least prominent for septicemia (a disease caused by toxic microorganisms in the bloodstream), which decreased by 54 percent.

“We found that PA catheterization use in both medical and surgical admissions has declined substantially across the United States over the study period,” the authors write. “… the national decrease in PA catheter utilization suggests that many physicians have responded appropriately to the evidence that PA catheterization does not reduce mortality.”

(JAMA. 2007;298(4):423-429. Available pre-embargo to the media at www.jamamedia.org)

Editor’s Note: Please see the article for additional information, including author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: The Pulmonary Artery Catheter, 1967–2007; Rest in Peace?

In an accompanying editorial, Gordon D. Rubenfeld, M.D., M.Sc., of the University of Toronto, and colleagues write that hospitals should consider several options to address the increasingly rare procedure of PA catheterization.

“First, centers performing only a few PA catheterization procedures should consider not doing any. Because it is likely that centers that use PA catheters infrequently will derive even less benefit than the published studies that show no benefit, low-volume centers should carefully consider whether there is greater risk from performing only a few PA catheterizations than doing none. … Second, if PA catheterization use is continued, the procedure should be limited to a small number of skilled clinicians. Specialized teams of clinicians devoted to specific tasks have demonstrated value in critical care.”

“Third, consider alternate hemodynamic monitoring tools, but consider them skeptically until convincing outcome data are available. … Fourth, continued use of PA catheterization demands intensive evaluation and education,” the authors write. “In the waning years of PA catheterization when the risks of infrequent use may outweigh any unproven benefit, it is more important than ever to remain vigilant for common errors in PA catheter placement and data interpretation. Passive education may not be sufficient and hospitals that choose to continue to use PA catheters will need to invest in simulation experiences, hands-on training, and quality monitoring to maintain a vanishing skill.”

(JAMA. 2007;298(4):458-461. Available pre-embargo to the media at www.jamamedia.org)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.