‘Value’ of PCI Varies Widely Across VA Hospitals

While risk-standardized mortality is similar among VA hospitals 1 year after PCI, costs of care exhibit substantial variability, according to an observational study published in the January 27, 2015, issue of the Journal of the American College of Cardiology. 

“These findings highlight the fact that although there may be selective opportunities to improve patient outcomes following PCI, there appear to be greater opportunities to reduce costs for longitudinal PCI care,” the study authors say.

Researchers led by P. Michael Ho, MD, PhD, of the Denver Veteran Affairs Medical Center (Denver, CO), looked at more than 19,000 patients (mean age 65.1 years) undergoing PCI at 60 VA hospitals tracked through the VA CART program from October 2007 through September 2010. The median number of procedures performed per hospital was 60 and 43% were for ACS. Comorbidities were common, with 21.6% of patients having heart failure, 42.6% diabetes, and 39.7% obesity.

Hospital-level unadjusted median mortality was 1.29% at 30 days and 6.13% at 1 year (primary clinical outcome). In a risk-standardized model, 4 hospitals reported rates about one-quarter higher than the median and no hospitals reported rates lower than the median.

Cost varied much more substantially. The median unadjusted 1-year costs per patient were $46,302, but risk-standardized costs were above the median in 16 hospitals—up to 209% higher—and below the median in 19 hospitals—up to 55% lower. Adjusting for patient costs in the 6 months prior to PCI did not change the results.

Almost half (41.7%) of 1-year costs (66.2% inpatient; 32.6% outpatient) came from the index procedure. For subsequent costs, the top 3 primary diagnoses for hospitalization were other forms of chronic ischemic heart disease (19.5%), heart failure (7.2%), and care involving rehabilitation procedures (2.3%). The top contributor to outpatient costs was cardiac-related care (18.0%).

There was no overall correlation between hospital standardized mortality and cost (P = .97). However, there was a relationship between the volume of outpatient visits and inpatient admissions and cost in a sensitivity analysis (P < .001), which, the authors say, supports “the fact that higher costs at hospitals reflect higher utilization.”

A New Healthcare Model?

“The study findings may inform current discussions of healthcare value measurement and may be a model for other systems or [accountable care organizations] attempting to measure and improve value,” Dr. Ho and colleagues write.

Inconsistent costs accompanied by minimal disparity in mortality “suggest[s] there may be significant differences in processes and structures of care during the index procedure and in the year following PCI,” they say, referencing a previous VA study that found 28% variability in risk-adjusted costs despite modest differences in efficiency.

Future studies should focus on patient health status outcomes, particularly for those with chronic stable angina as well as extend beyond PCI to include outcomes and costs for all patients with ischemic heart disease, the authors suggest. Additionally, they suggest improvements to be made within the VA system, such as ongoing efforts toward negotiating a system-wide purchasing contract to ensure the price of all stents remains consistent throughout the country.

PCI Appropriateness an Underlying Issue

In an editorial accompanying the study, Daniel M. Alyeshmerni, MD, Andrew Ryan, PhD, and Brahmajee K. Nallamothu, MD, MPH, all of the University of Michigan Health System (Ann Arbor, MI), say that PCI “was an excellent procedure on which to focus” as it is common and costly. “On the other hand, other data indicate PCI (and coronary revascularization in general) is overprovided in the United States and is not related to improved outcomes in many patients.”

They observe that optimal medical therapy plays a role in mortality and resource use over the study period. “[S]hould value be assessed for short-term gains of PCI or its long-term implications for patients over 1 year (or even a lifetime)? This is especially important and difficult to determine for a procedure like PCI, where alternative treatments frequently exist,” note the editorialists, adding that timelines for measuring cost should be guided by clinical context.

Additionally, the editorial tasks policy makers with deciding the proper context—whether for a given procedure, specific disease, or target population—for assessing value in healthcare.

These “challenges” aside, Dr. Alyeshmerni and colleagues write, the study is “a positive step forward [and] informs the national discussion of value in an important population of patients undergoing PCI, particularly highlighting the need to evaluate both costs and quality of care for populations over time.”

 

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Sources:
1. Ho PM, O’Donnell CI, Bradley SM, et al. 1-year risk-adjusted mortality and costs of percutaneous coronary intervention in the Veterans Health Administration: insights from the VA CART program. J Am Coll Cardiol. 2015;65:236-242.

2. Alyeshmerni DM, Ryan A, Nallamothu BK. Defining value in percutaneous coronary intervention: “the price of everything and the value of nothing [editorial].” J Am Coll Cardiol. 2015;65:243-245.

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