Research Letter
Trends in Utilization of Microaxial Flow Pump and Intra-Aortic Balloon Pump Across 3 Countries
Dennis T. Ko, Sharon Ayayo, Amitava Banerjee, et al
JAMA Intern Med Published Online: August 11, 2025
doi: 10.1001/jamainternmed.2025.3881
Rising health care spending is threatening the sustainability of health systems in many high-income countries.1While health technology assessment (HTA) is used in the UK and Canada to guide payment decisions for new technologies, the US has historically lacked a formal national HTA process. However, the Centers for Medicare & Medicaid Services have begun working toward incorporating HTA in certain circumstances through national coverage determination policies.2 Microaxial flow pumps (MAFPs) (eg, Impella) and intra-aortic balloon pumps (IABPs) are costly cardiac devices frequently used to provide hemodynamic support in complex percutaneous coronary interventions (PCIs) and patients with myocardial infarction with cardiogenic shock.3 Despite widespread use in the US and other countries, effectiveness data remain limited.4,5 We aimed to evaluate the adoption and deadoption of MAFP and IABP in patients undergoing PCI in the US, UK, and Canada to understand how utilization patterns vary across countries.
Methods
We conducted a cross-sectional study using clinical and administrative data for patients 65 years and older who underwent PCIs between January 1, 2012, and December 31, 2021. Information on ethics review and approval and statistical analysis is presented in the eMethods in Supplement 1. The STROBE reporting guideline was followed.
MAFP or IABP use was identified using administrative codes in the US and prespecified data fields in the UK and Canada. Utilization rates for each procedure were calculated annually in each country, standardized per 10 000 PCI procedures performed per year. Linear regression models were used to evaluate significant temporal changes in procedure utilization.
Results
From 2012 to 2021, 2.15 million PCIs were performed in the US, 493 279 in the UK, and 130 579 in Canada in patients 65 years and older. There were 52 637 MAFPs in the US, 264 in the UK, and 112 in Canada. Median (IQR) age of recipients was 75 (70-82) years, and 30% were female. MAFP use in the US increased from 60/10 000 PCIs in 2012 to 443/10 000 in 2021, a 7-fold increase. Conversely, utilization remained low in the UK and Canada (Figure 1), with 2021 rates of 9.2 and 7.3/10 000 PCIs, respectively. Among MAFP recipients, 17.5% had a primary diagnosis of ST-segment elevation myocardial infarction with cardiogenic shock in the US, compared to 9.1% in the UK, and 17.9% in Canada.
Figure 1. Trends in Utilization of Microaxial Flow Pump (MAFP) in the US, UK, and Canada
The rate of MAFP use per 10 000 percutaneous coronary intervention (PCI) procedures is plotted from 2012 to 2021 in the US, UK, and Canada.
For IABP, the utilization rate was 328/10 000 PCIs in the US in 2012 and 356/10 000 PCIs in 2021 (P for trend = .66) (Figure 2). However, IABP utilization decreased significantly in the UK and Canada. In the UK, IABP utilization was 206/10 000 PCIs in 2012 and declined to 66/10 000 in 2021 (68% reduction; P < .001). In Canada, the rate decreased from 261/10 000 in 2012 to 185/10 000 in 2021 (29% reduction; P = .002).
Figure 2. Trends in Utilization of Intra-Aortic Balloon Pump (IABP) in the US, UK, and Canada
The rate of IABP use per 10 000 percutaneous coronary intervention (PCI) procedures is plotted from 2012 to 2021 in the US, UK, and Canada.
Discussion
This study assessed trends in mechanical support use among older patients undergoing PCI from 2012 to 2021, when practice guidelines downgraded their support for IABP, and MAFP was emerging as a potential adjunctive treatment despite limited evidence of effectiveness.3,6 In our comparison across different health systems using nationally representative patient-level data, several key insights emerged. MAFP was adopted faster in the US, with over 40-fold higher utilization than in the UK and Canada in 2021, while IABP deadoption patterns varied substantially: utilization declined by 68% in the UK and 29% in Canada but remained stable in the US. MAFP was not primarily adopted as a replacement therapy for IABP in the US but resulted in expanded use among patients undergoing elective PCIs. This study was limited because only patients 65 years and older who were hospitalized between 2012 and 2022 were included. The superior hemodynamic support provided by MAFP compared to IABP has generated enthusiasm but divergence in clinical guidelines across countries.3 Our findings underscore that health care financing structures and HTA processes may play a dominant role in shaping the adoption and deadoption of cardiac technologies across countries, often outweighing clinical efficacy considerations alone.2
