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Use of pulmonary artery catheter decreases
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CHICAGO—Use of the pulmonary artery catheter decreased by 65 percent in the U.S. between 1993 and 2004, possibly due to growing evidence that this invasive procedure does not reduce the risk of death for hospitalized patients, according to a study in the July 25 issue of JAMA.

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The pulmonary artery (PA) catheter (a thin, flexible tube that is inserted into a pulmonary artery) first became available as a practical diagnostic tool in 1970 and was rapidly embraced by critical care physicians, according to background information in the article. The PA catheter made measurements such as cardiac output and pressure within the small vessels in the lungs accessible to physicians at the bedside. "Many physicians assumed that these numbers could guide treatment and ultimately reduce mortality in critically ill patients. Within several years, PA catheterization was widely used throughout the United States. In the 1980s, 20 percent to 43 percent of seriously ill patients who were hospitalized were reported to undergo the procedure," the authors write.

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 microorganism s 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.


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.

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