3099 — Facility-level variation in hospitalization, mortality, and costs in the 30-days following percutaneous coronary intervention

Bradley SM, VA Eastern Colorado Health Care System; O'Donnell CI, VA Eastern Colorado Health Care System; Grunwald GK, VA Eastern Colorado Health Care System; Liu CF, VA Puget Sound Health Care System; Hebert PL, VA Puget Sound Health Care System; Maddox TM, VA Eastern Colorado Health Care System; Jesse RL, Veterans Health Administration; Fihn SD, Veterans Health Administration; Rumsfeld JS, VA Eastern Colorado Health Care System; Ho PM, VA Eastern Colorado Health Care System

Objectives:
Policies have been proposed to reduce hospitalization rates after percutaneous coronary intervention (PCI) in hopes of improving healthcare value by reducing costs while maintaining patient outcomes. Although these policies are targeted at facilities, whether facility-level rates of hospitalization after PCI are associated with outcomes and costs of care is unknown.

Methods:
We studied 32,080 patients who received PCI at one of 62 VA hospitals from 2008 to 2011. Using Bayesian methods, we identified facility outliers for 30-day risk-standardized hospitalization, mortality and cost.

Results:
The facility-level unadjusted median 30-day hospitalization rate after PCI was 10.8% (IQR 8.8% to 12.2%). 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 costs 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 hospitalization accounted for 83.1% of total costs (range 60.3-92.2%) while hospitalization after PCI accounted for only 5.8% (range 2.0-12.7%) of the 30-day total costs. Facilities with higher hospitalization rates were not significantly more expensive (Spearman ? = 0.16; 95% confidence interval, -0.09 to 0.39; p value = 0.21).

Implications:
In this national study, hospitalizations in the 30-days after PCI accounted for only 5.8% of 30-day costs and facility-level costs were not correlated with hospitalization rates. These findings challenge the focus on reducing hospitalizations after PCI as an effective means of improving healthcare value.

Impacts:
These findings suggest opportunities to achieve higher value for PCI care by reducing variation in the cost of PCI without compromising patient outcomes.