title: Cost, quality, and value in coronary artery bypass grafting.
abstract: OBJECTIVE
  Pay-for-performance measures, part of the Affordable Care Act, aim to reduce health care costs by linking value with Medicare payments, but until now the concept of value has not been applied to specific procedures. We sought to define value in coronary artery bypass grafting (CABG) and provide a framework to identify high-value centers.
  
  
  METHODS
  In a multiinstitutional statewide database, clinical patient-level data from 42,839 patients undergoing CABG were matched with cost data. Hierarchical models adjusting for relevant preoperative patient characteristics and comorbidities were used to estimate center-specific risk-adjusted costs and risk-adjusted postoperative length of stay. Variation in value across centers was assessed by the correlation between risk-adjusted measures of quality (mortality, morbidity/mortality) and resource use (costs and length of stay).
  
  
  RESULTS
  There were no significant correlations between risk-adjusted costs and risk-adjusted mortality (r = 0.20, P = .45) or morbidity/mortality (r = 0.15, P = .57) across centers. Risk-adjusted costs and length of stay were not significantly associated (r = 0.23, P = .37) because of cost accounting differences across centers. This may explain the lack of correlation between risk-adjusted quality and risk-adjusted cost measures. When risk-adjusted length of stay and morbidity/mortality were used for the framework, there was a strong positive correlation (r = 0.67, P = .003), indicating that higher risk-adjusted quality is associated with shorter risk-adjusted length of stay.
  
  
  CONCLUSIONS
  Risk-adjusted length of stay and risk-adjusted combined morbidity/mortality are important outcome measures for assessing value in cardiac surgery. The proposed framework can be used to define value in CABG and identify high-value centers, thereby providing information for quality improvement and pay-for-performance initiatives.
authors.affiliation: Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Ruben L
authors.initials: RL
authors.lastname: Osnabrugge
authors.affiliation: Inova Heart and Vascular Institute, Fairfax, Va.
authors.forename: Alan M
authors.initials: AM
authors.lastname: Speir
authors.affiliation: Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Head
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, Mo.
authors.forename: Philip G
authors.initials: PG
authors.lastname: Jones
authors.affiliation: University of Virginia Health System, Charlottesville, Va.
authors.forename: Gorav
authors.initials: G
authors.lastname: Ailawadi
authors.affiliation: ARMUS Corporation, San Mateo, Calif; Virginia Cardiac Surgery Quality Initiative, Falls Church, Va.
authors.forename: Clifford E
authors.initials: CE
authors.lastname: Fonner
authors.affiliation: Virginia Cardiac Surgery Quality Initiative, Falls Church, Va.
authors.forename: Edwin
authors.initials: E
authors.lastname: Fonner
authors.affiliation: Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: A Pieter
authors.initials: AP
authors.lastname: Kappetein
authors.affiliation: Sentara Heart Hospital, Norfolk, Va. Electronic address: jeffrich2014@cox.net.
authors.forename: Jeffrey B
authors.initials: JB
authors.lastname: Rich
mesh_terms: D000368:Aged; D015897:Comorbidity; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000191:economics / Q000401:mortality / Q000592:standards; D003362:Cost-Benefit Analysis; D005260:Female; D017048:Health Care Costs / Q000592:standards; D006801:Humans; D007902:Length of Stay / Q000191:economics; D008297:Male; D008875:Middle Aged; D018803:Models, Economic; D058996:Quality Improvement / Q000191:economics; D019984:Quality Indicators, Health Care / Q000191:economics / Q000592:standards; D012042:Registries; D012052:Reimbursement, Incentive / Q000191:economics; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014768:Virginia