Facility-Level Variation in Hospitalization, Mortality, and Costs in the 30 Days Following Percutaneous Coronary Intervention: Insights on Short-Term Healthcare Value from the VA CART Program
Background—Policies to reduce unnecessary hospitalizations after 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 one of 62 VA 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 (3.2%) hospitals had a lower than expected hospitalization rate and 2 (3.2%) hospitals 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 (IQR $19,604 to $29,958). Compared with the risk-standardized average, 17 (27.4%) hospitals had lower than expected costs and 14 (22.6%) hospitals had higher than expected costs. At the facility level, the index PCI accounted for 83.1% of total cost (range 60.3-92.2%) while hospitalization after PCI accounted for only 5.8% (range 2.0-12.7%) of 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 value=0.21).
Conclusions—In this national study, hospitalizations in the 30-days 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 variation in total cost of PCI without compromising patient outcomes.
- Received January 6, 2015.
- Revision received April 27, 2015.
- Accepted May 1, 2015.