title: 1-year risk-adjusted mortality and costs of percutaneous coronary intervention in the Veterans Health Administration: insights from the VA CART Program.
abstract: BACKGROUND
  There is significant interest in measuring health care value, but this concept has not been operationalized in specific patient cohorts. The longitudinal outcomes and costs for patients after percutaneous coronary intervention (PCI) provide an opportunity to measure an aspect of health care value.
  
  
  OBJECTIVE
  This study evaluated variations in 1-year outcomes (risk-adjusted mortality) and risk-standardized costs of care for all patients undergoing PCI in the Veterans Affairs (VA) system from 2007 to 2010.
  
  
  METHODS
  This retrospective cohort study evaluated all veterans undergoing PCI at any of 60 hospitals in the VA health care system, using data from the national VA Clinical Assessment, Reporting, and Tracking (CART) program. Primary outcomes were 1-year mortality and costs following PCI. Risk-standardized mortality and cost ratios were calculated, adjusting for cardiac and noncardiac comorbidities.
  
  
  RESULTS
  A median of 261 PCIs were performed in the 60 hospitals during the study period. Median 1-year unadjusted hospital mortality rate was 6.13%. Four hospitals were significantly above the 1-year risk-standardized median mortality rate, with median mortality ratios ranging from 1.23 to 1.28. No hospitals were significantly below median mortality. Median 1-year total unadjusted hospital costs were $46,302 per patient. There were 16 hospitals above and 19 hospitals below the risk-standardized median cost, with risk-standardized ratios ranging from 0.45 to 2.09, reflecting a much larger magnitude of variability in costs than in mortality.
  
  
  CONCLUSIONS
  There is much smaller variation in 1-year risk adjusted mortality than in risk-standardized costs after PCI in the VA. These findings suggest that there are opportunities to improve PCI value by reducing costs without compromising outcomes. This approach to evaluating outcomes and costs together may be a model for other health systems and accountable care organizations interested in operationalizing value measurement.
authors.affiliation: Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado; Division of Cardiology, University of Colorado Denver, Denver, Colorado. Electronic address: michael.ho@va.gov.
authors.forename: P Michael
authors.initials: PM
authors.lastname: Ho
authors.affiliation: Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado; Division of Cardiology, University of Colorado Denver, Denver, Colorado.
authors.forename: Colin I
authors.initials: CI
authors.lastname: O'Donnell
authors.affiliation: Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado; Division of Cardiology, University of Colorado Denver, Denver, Colorado.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Bradley
authors.affiliation: Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado; Division of Cardiology, University of Colorado Denver, Denver, Colorado.
authors.forename: Gary K
authors.initials: GK
authors.lastname: Grunwald
authors.affiliation: Veterans Affairs Puget Sound Health Care System, Seattle, Washington.
authors.forename: Christian
authors.initials: C
authors.lastname: Helfrich
authors.affiliation: Veterans Affairs Puget Sound Health Care System, Seattle, Washington.
authors.forename: Michael
authors.initials: M
authors.lastname: Chapko
authors.affiliation: Veterans Affairs Puget Sound Health Care System, Seattle, Washington.
authors.forename: Chuan-Fen
authors.initials: CF
authors.lastname: Liu
authors.affiliation: Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado; Division of Cardiology, University of Colorado Denver, Denver, Colorado.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Maddox
authors.affiliation: Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado; Division of Cardiology, University of Colorado Denver, Denver, Colorado.
authors.forename: Thomas T
authors.initials: TT
authors.lastname: Tsai
authors.affiliation: Department of Veteran Affairs, Veterans Health Administration, Washington, DC.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Jesse
authors.affiliation: Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Veterans Affairs Office of Analytics and Business Intelligence, Washington, DC.
authors.forename: Stephan D
authors.initials: SD
authors.lastname: Fihn
authors.affiliation: Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado; Division of Cardiology, University of Colorado Denver, Denver, Colorado.
authors.forename: John S
authors.initials: JS
authors.lastname: Rumsfeld
mesh_terms: D054058:Acute Coronary Syndrome / Q000453:epidemiology / Q000628:therapy; D000368:Aged; D000553:Ambulatory Care / Q000191:economics; D017721:Hospital Costs / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006787:Hospitals, Veterans / Q000191:economics*; D006801:Humans; D008390:Markov Chains; D009010:Monte Carlo Method; D062645:Percutaneous Coronary Intervention / Q000191:economics* / Q000401:mortality* / Q000706:statistics & numerical data; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology; D014493:United States Department of Veterans Affairs; D014728:Veterans
keywords: PCI; costs; health care delivery; ischemic heart disease; outcomes; value