Elective percutaneous coronary intervention without on-site cardiac surgery: clinical and economic implications.
BACKGROUND
Low procedural complication rates, barriers to access, and patient preference have encouraged the development of percutaneous coronary intervention (PCI) programs at centers that are often closer to home but without on-site cardiac surgical capability.


OBJECTIVE
We compared clinical and economic outcomes associated with performing low-risk elective PCI at a community hospital without on-site cardiac surgery with those obtained at a more remote tertiary care center with on-site cardiac surgery.


METHODS
We matched 257 patients undergoing low-risk, elective PCI at a community hospital (Immanuel St. Joseph's Hospital [ISJ] between January 27, 2000, and July 31, 2002) to 514 PCI patients treated at a tertiary care hospital (Saint Marys Hospital [SMH] between January 27, 2000, and April 30, 2002) based on clinical and lesion criteria. Clinical outcomes (in-hospital procedural success and target vessel failure during long-term follow up) and economic outcomes (direct medical costs, billed charges, and hospital length of stay [LOS]) were compared between groups. The Mayo Clinic PCI Registry (containing clinical, angiographic, and follow-up data) and administrative data were used in matching and outcomes assessment.


RESULTS
Procedural success was achieved more often among ISJ-treated patients (99% vs. 95%; P = 0.02); however, no difference in target vessel failure rates was observed during a median follow-up time of 3.1 years (estimated 1-year event rate: 15.2% vs. 14.8%; P = 0.46). ISJ-treated patients incurred, on average, $3024 more in estimated total costs ($13,771 vs. $10,746; P < 0.001) and $6084 more in billed charges (P < 0.001), but incurred similar LOS post procedure (1.53 days).


CONCLUSIONS
Similar clinical outcomes were achieved at a community hospital without on-site cardiac surgery but at significantly increased direct medical cost. Patients, providers, hospitals, payers, and policymakers should consider whether the benefits associated with locally provided specialized cardiovascular services warrant this additional cost.
Long
Kirsten Hall
KH
Department of Health Sciences Research, Division of Health Care Policy & Research, Mayo Clinic, Rochester, Minnesota 55905, USA. long.kirsten@mayo.edu
McMurtry
Erin K
EK
Lennon
Ryan J
RJ
Chapman
Anne C
AC
Singh
Mandeep
M
Rihal
Charanjit S
CS
Wood
Douglas L
DL
Holmes
David R
DR
Ting
Henry H
HH
D002300:Cardiac Care Facilities / Q000191:economics / Q000706:statistics & numerical data; D006348:Cardiac Surgical Procedures / Q000191:economics / Q000706:statistics & numerical data; D017115:Catheter Ablation / Q000191:economics* / Q000706:statistics & numerical data*; D015331:Cohort Studies; D003327:Coronary Disease / Q000601:surgery*; D017558:Elective Surgical Procedures / Q000191:economics* / Q000706:statistics & numerical data*; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006764:Hospitals, Community / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D010043:Outcome and Process Assessment, Health Care; D016019:Survival Analysis