Facility-Level Variation in Hospitalization, Mortality, and Costs in the 30 Days After Percutaneous Coronary Intervention

Abstract

Background— Policies to reduce unnecessary hospitalizations after percutaneous coronary intervention (PCI) are intended to improve healthcare value by reducing costs while maintaining patient outcomes. Whether facility-level hospitalization rates after PCI are associated with cost of care is unknown. Methods and Results— We studied 32 080 patients who received PCI at any 1 of 62 Veterans Affairs hospitals from 2008 to 2011. We identified facility outliers for 30-day risk-standardized hospitalization, mortality, and cost. Compared with the risk-standardized average, 2 hospitals (3.2%) had a lower-than-expected hospitalization rate, and 2 hospitals (3.2%) had a higher-than-expected hospitalization rate. We observed no statistically significant variation in facility-level risk-standardized mortality. The facility-level unadjusted median per patient 30-day total cost was $23 820 (interquartile range, $19 604–$29 958). Compared with the risk-standardized average, 17 hospitals (27.4%) had lower-than-expected costs, and 14 hospitals (22.6%) had higher-than-expected costs. At the facility level, the index PCI accounted for 83.1% of the total cost (range, 60.3%–92.2%), whereas hospitalization after PCI accounted for only 5.8% (range, 2.0%–12.7%) of the 30-day total cost. Facilities with higher hospitalization rates were not more expensive (Spearman ρ=0.16; 95% confidence interval, −0.09 to 0.39; P =0.21). Conclusions— In this national study, hospitalizations in the 30 day after PCI accounted for only 5.8% of 30-day cost, and facility-level cost was not correlated with hospitalization rates. This challenges the focus on reducing hospitalizations after PCI as an effective means of improving healthcare value. Opportunities remain to improve PCI value by reducing the variation in total cost of PCI without compromising patient outcomes.

Should We Care About Short-Term Readmissions After Percutaneous Coronary Intervention?

“…First, as the cumulative cost of PCI readmissions only represents 5.8% of the cumulative costs of all PCI episodes of care (22), efforts to reduce costs for the index hospitalization may produce a more substantial cost reduction. Second, complications of the initial PCI represent a small proportion of reasons for readmission (13,23,24).…”

A pilot study to assess the learning environment and use of reliability enhancing work practices in VHA cardiac catheterization laboratories

“…This includes variation in implementation of appropriate use criteria for elective percutaneous coronary interventions (PCI) 10 and unnecessary hospitalizations after PCI and costs of care. 11 This variation has been attributed, in part, to differences in local cath lab learning environments. 10 To understand the relationship between variation in care and the role of learning environments and REWPs in the VHA, assessment of the state of learning environments, and use of REWPs across the 81 VHA cath labs is necessary.…”

“…The CART Program has detected variation in clinical care across VHA cath labs. This includes variation in implementation of appropriate use criteria for elective percutaneous coronary interventions (PCI) 10 and unnecessary hospitalizations after PCI and costs of care 11 . This variation has been attributed, in part, to differences in local cath lab learning environments 10 .…”

Bayesian profiling for cost with zeros to decompose total cost into probability of cost and mean nonzero cost

“…Cost of care is increasingly available through electronic health records (EHRs), and cost can vary substantially across hospitals, clinics, or providers from which care is delivered. For example, risk-adjusted cost for care during the 30 days or 1 year following percutaneous coronary intervention (PCI) was seen to vary by a factor of four to five from the lowest cost to the highest cost hospitals, even in a unified health care system, such as the US Veterans Administration (VA) (Bradley et al, 2015;Ho et al, 2015). Identifying the highest and lowest cost hospitals, and understanding the nature of this variation, is important since high cost hospitals can represent opportunities for improvement, and low cost hospitals can suggest approaches to achieve this improvement.…”