Most costs tied to index PCI, not 30-day hospitalizations

Efforts to reduce healthcare costs by targeting 30-day readmissions after PCI may be misguided. An analysis of Veterans Affairs (VA) hospitals attributed the majority of costs to the index procedure.

Payment models such as bundling and accountable care organizations focus on episodes of care, with 30 days after discharge often seen as the window for determining quality and value. The VA system includes a number of resources that can be leveraged to track usage, outcomes and care, Steven M. Bradley, MD, MPH, of the VA Eastern Colorado Health Care System in Denver, and colleagues pointed out in their study. It was published online May 7 in Circulation.

Those resources include the Decision Support System, which provides data on utilization and cost, and the VA Clinical Assessment, Reporting and Tracking clinical quality program, which covers all VA cardiac catheterization laboratories. Data can be linked through the VA’s EHR.   

Bradley et al identified 32,080 patients who underwent PCI procedures at 62 hospitals between 2008 and 2011. Each of the hospitals had performed at least 10 PCIs annually during the study period. The median mortality rate in unadjusted analyses was 1.5 percent, with little variability among hospitals.

At the facility level, the median 30-day hospitalization rate was 10.8 percent in unadjusted analyses. Risk-standardized hospitalization ratios varied significantly, from 0.82 to 1.24. They determined that 3.2 percent of the hospitals were significantly above the risk-standardized median and 3.2 percent were significantly below.

The unadjusted median cost at 30 days after discharge was $23,820, with hospital risk-standardized ratios varying from 0.44 to 2.31. In the cost analysis, 27.4 percent of hospitals achieved lower than expected costs compared with the risk-standardized average and 22.6 percent accrued higher than expected costs.

Overall at the facility level, the index PCI accounted for a median 83.1 percent of total costs and hospitalization within 30 days of discharge only 5.8 percent.

These findings remained similar in sensitivity analyses for patients who were younger than 65 to ensure the variation wasn’t due to dual use with Medicare and for hospitals that perform more than 100 PCIs annually.

The index PCI may provide an opportunity to reduce costs and improve care, they proposed.    

“The current analysis adds to concerns that emphasizing hospitalization rates after PCI may not be an ideal target for improving healthcare value given that facility-level variation in hospitalization rates after PCI was modest, hospitalizations after PCI were a small component of facility-level 30-day total cost, and facility-level hospitalization rates were not clearly related to variation in 30-day total cost,” Bradley et al wrote.