VA Study Examines Variability of Costs and Mortality of Stent Surgery

Dr. P. Michael Ho, MD PhD Denver Veteran Affairs Medical Center, University of Colorado, Denver, Section of Cardiology Denver, Colorado Interview with:
Dr. P. Michael Ho, MD PhD
Denver Veteran Affairs Medical Center,
University of Colorado, Denver, Section of Cardiology
Denver, Colorado 80220.

Medical Research: What is the background for this study? What are the main findings?

Dr. Ho: There is increasing interest in measuring health care value, particularly as the healthcare system moves towards accountable care. Value in health care focuses on measuring outcomes achieved relative to costs for a cycle of care. Attaining high value care – good clinical outcomes at low costs – is of interest to patients, providers, health systems, and payers. To date, value assessments have not been operationalized and applied to specific patient populations. We focused on percutaneous coronary intervention (PCI) because it is an important aspect of care for patients with ischemic heart disease, is commonly performed and is a costly procedure. In this study, we evaluated 1-year risk-adjusted mortality and 1-year risk-standardized costs of care for all patients who underwent PCI in the VA healthcare system from 2008 to 2010.

We found that median one-year unadjusted hospital mortality rate was 6.13% (interquartile range 4.51% to 7.34% across hospitals). Four hospitals were significantly above the one-year risk standardized median mortality rate, with median mortality ratios ranging from 1.23 to 1.28; no hospitals were significantly below median mortality. Median 1-year total unadjusted hospital costs were $46,302 (IQR of $37,291 to $57,886) per patient. There were 16 hospitals above and 19 hospitals below the risk standardized average cost, with risk standardized ratios ranging from 0.45 to 2.09 reflecting much larger magnitude of variability in costs compared to mortality. These findings suggest that there are opportunities to improve PCI healthcare by reducing costs without compromising outcomes. This approach of evaluating outcomes and costs together may be a model for other health systems and accountable care organizations interested in operationalizing value measurement.

Medical Research: What should clinicians and patients take away from your report?

Dr. Ho: These findings are more relevant to hospitals, health care systems, and policy makers. Most of the variation across hospitals of longitudinal PCI care occurs as a result of differences in costs with much less variation in patient outcomes. This suggests that value of PCI care for the VA may be enhanced through reducing unnecessary variation in costs of care, without compromising patient outcomes.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Ho: Future research will be needed to identify specific reasons for the cost variations identified, one of which may be regional differences in practice patterns. For inpatient care, there may be structural factors related to staffing of cath labs and/or supply costs (e.g., coronary stents) which are negotiated by individual hospitals. For outpatient care, there will be opportunities to explore differences in follow-up care, some of which may be related to intensity of care provided, frequency of cardiac testing and/or need for non-cardiac related care. We are planning on conducting qualitative interviews at hospitals to identify reasons for the cost variations found in this study.


1-Year Risk-Adjusted Mortality and Costs of Percutaneous Coronary Intervention in the Veterans Health Administration: Insights From the VA CART Program

P. Michael Ho, MD, PhD, Colin I. O’Donnell, MS, Steven M. Bradley, MD, MPH Gary K. Grunwald, PhD Christian Helfrich, PhD Michael Chapko, PhD Chuan-Fen Liu, PhD Thomas M. Maddox, MD, MSc Thomas T. Tsai, MD, MSc Robert L. Jesse, MD, PhD, Stephan D. Fihn, MD, MPH John S. Rumsfeld, MD, PhD

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