Abstract
Introduction: Magnetic resonance imaging (MRI) has historically been contraindicated for patients with MRI non-conditional (i.e. legacy) cardiac implantable electronic devices (CIED). Recent trials have demonstrated safety of MRI in legacy CIED patients, with the Center for Medicare & Medicaid Services (CMS) revising MRI coverage to include these patients in 4/2018. We sought to determine the effect of this policy change on MRI utilization for legacy CIED patients with acute ischemic stroke or transient ischemic attack (AIS/TIA) and contemporary use of MRI for these patients. Methods: We performed an interrupted time series analysis of MRI utilization for AIS/TIA patients with the CMS MRI coverage revision for legacy CIED patients serving as the intervention. Using Optum claims data from 1/2012 to 7/2019, we identified AIS/TIA hospitalizations and CIED implantations and interrogations using ICD-9/10 and CPT codes, respectively. The intervention’s effect on MRI utilization for AIS/TIA was determined for patients with and without CIEDs separately. For patients treated after the CMS coverage revision, we used multivariable logistic regression to determine the association between lack of CIED and MRI utilization for AIS/TIA. Results: We identified 417,899 patients hospitalized for AIS/TIA, of which 30,425 patients (7%) had a CIED (CIED patients: age 78.0 ±10.2 years, 45% female; non-CIED patients: age 74.1 ±11.8 years, 55% female). From 2012 to 2019, MRI utilization for AIS/TIA increased from 3% to 20% for CIED patients and 58% to 66% for non-CIED patients. The CMS coverage revision was associated with a 4.2% absolute (25% relative) additional increase in MRI utilization for CIED patients with AIS/TIA. In multivariable regression, non-CIED patients treated after the CMS coverage revision, as compared to CIED patients, were substantially more likely to undergo MRI for AIS/TIA (adjusted OR 6.7, 95% CI: 6.3-7.1, p<0.001). Conclusions: Despite an increase in MRI utilization for AIS/TIA patients with CIEDs attributable to the CMS coverage revision and trials demonstrating safety, a large disparity in use of MRI for AIS/TIA patients with CIEDs persists. Identification and resolution of barriers to appropriate MRI use in AIS/TIA patients with CIEDs are needed.
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