Disparities in Time Spent Seeking Medical Care in the United States.

recommendation for their use. Despite the lack of guidelinebasedrecommendationsandlittleevidencetosupport IABPuse, the studyby Inoharaet al2 finds that IABPs continue tobeused frequently and that their use is associated with increased inhospital mortality. Although there has been enthusiasm about newer PVADs (eg, ImpellaLP2.5 [AbiomedEuropeGmbH]andTandemHeart [CardiacAssist]), initial studies regarding their use to treat cardiogenic shockhavenot shownanysignificant survival benefit compared with IABPs and observed increased bleeding and a tendency toward more limb ischemia from the use of larger sheaths with PVADs.7 Similar to IABPs, no net benefit was demonstrated in hemodynamically stable patients with an implanted PVAD undergoing high-risk angioplasty, another common clinical scenario for the use of PVADs.8 Why is there reluctance toabandon these invasive, expensive, andseemingly ineffective therapies?Theanswermightbe multifactorial. Cardiogenic shock complicatingmyocardial infarction remains a formidable foe and is associatedwith 40% to50% in-hospitalmortality.9 In this setting, only early revascularizationhasshownimprovedsurvival. Insomeofthesecritically ill patients, itmayseemreasonable tousemechanical circulatory supportdevices as salvage therapy.However, theyoffer littlebenefit in reducingclinical events, andhavehighcosts and significant complication rates. Inohara et al2 confirmpreviousfindingsthat IABPsandPVADsarebeing increasinglyused inpatientswithout indications for their use.Although theprecisereasonsforsuchexcessiveuseremaintobeestablished,misalignedfinancial incentivesmighthavearole.Furthermore,continueduseof IABPsmaybedue toestablishedroutinesor treatment protocols, with commission bias tending toward action rather than inaction.10 Based on available data, the use of these invasive and expensive mechanical circulatory support devices should be critically appraised and limited because of significant complication rates associated with their use and a lack of evidence demonstrating any benefit. In the use of IABPs and PVADs, it seems appropriate to conclude that perhaps less is more.