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Pacemakers (PM) are life-saving and quality-of-life-enhancing devices for the treatment of patients with symptomatic bradyarrhythmia. Guidelines for PM implantation are well established and have changed little over the past 20 years. Preliminary reports suggest that regional variability exists with respect to implant rates and device type. This study examines geographic variations and the impact of patient age on PM utilization and survival in BC.
Methods
This study analyzed data from the Cardiac Services BC Registry and included BC residents ≥ 20 years of age who underwent PM implantation from 1997 to 2013. The age-sex-standardized per capita rates were calculated (per 100,000) and regions were defined by patient residence. Chi-square test was used for comparisons of implant rates and the Cochran-Armitage test was applied to analyze the trend over time of age at initial implant and the trend of dual vs. single-chamber PM implantation rates. The probabilities of survival and time to replacement were estimated by Kaplan-Meier method.
Results
47,327 PM implants (new or generator replacement) took place in BC from 1997 to 2013. The average age at initial implant increased from 74.2 ± 11.2 years in 1997 to 77.4 ± 10.7 years in 2013 (p<0.01) (Table 1). Implant rates grew steadily over time, from 76.28 per 100,000 in 2007 to 92.13 in 2013 and there was an increased preference for dual-chamber PM (p<0.01). Significant regional variation of PM utilization was revealed (Figure 1). The rate of implant for residents of the Northern Health Authority was substantially lower than the BC average for single-chamber PMs (p<0.01). For the Fraser Health Authority (FHA) residents, the rate steadily increased until 2008. Since 2009, this rate has leveled off but remains above the BC average. A higher rate of dual-chamber PM implants occurred for FHA (p<0.01) and a lower-than-average rate in the Interior (p<0.01). Based on Kaplan-Meier estimates, long-term and short-term survival after initial implant was significantly lower in the elderly (≥75 years of age) (p<0.01). In addition, the estimated average time to replacement was 5.6 years for elderly and 8.3 years for younger patients (20-74).
Conclusion
Pacemaker implantation volume doubled in BC from 1997 to 2013, with approximately 2% per capita growth every 5 years. Marked regional variability exists in implant rates and device selection. Age was shown to impact the time to device replacement and survival following implantation. Future provincial initiatives will focus on the quality and sustainability of PM care.
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