title: Facility-Level Variation in Hospitalization, Mortality, and Costs in the 30 Days After Percutaneous Coronary Intervention: Insights on Short-Term Healthcare Value From the Veterans Affairs Clinical Assessment, Reporting, and Tracking System (VA CART) Program.
abstract: BACKGROUND
  Policies to reduce unnecessary hospitalizations after percutaneous coronary intervention (PCI) are intended to improve healthcare value by reducing costs while maintaining patient outcomes. Whether facility-level hospitalization rates after PCI are associated with cost of care is unknown.
  
  
  RESULTS
  We studied 32,080 patients who received PCI at any 1 of 62 Veterans Affairs hospitals from 2008 to 2011. We identified facility outliers for 30-day risk-standardized hospitalization, mortality, and cost. Compared with the risk-standardized average, 2 hospitals (3.2%) had a lower-than-expected hospitalization rate, and 2 hospitals (3.2%) 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 cost was $23,820 (interquartile range, $19,604-$29,958). Compared with the risk-standardized average, 17 hospitals (27.4%) had lower-than-expected costs, and 14 hospitals (22.6%) had higher-than-expected costs. At the facility level, the index PCI accounted for 83.1% of the total cost (range, 60.3%-92.2%), whereas hospitalization after PCI accounted for only 5.8% (range, 2.0%-12.7%) of the 30-day total cost. Facilities with higher hospitalization rates were not more expensive (Spearman ρ=0.16; 95% confidence interval, -0.09 to 0.39; P=0.21).
  
  
  CONCLUSIONS
  In this national study, hospitalizations in the 30 day after PCI accounted for only 5.8% of 30-day cost, and facility-level cost was not correlated with hospitalization rates. This challenges the focus on reducing hospitalizations after PCI as an effective means of improving healthcare value. Opportunities remain to improve PCI value by reducing the variation in total cost of PCI without compromising patient outcomes.
authors.affiliation: From VA Eastern Colorado Health Care System, Denver (S.M.B., C.I.O., G.K.G., T.M.M., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., J.S.R., P.M.H.); University of Colorado School of Public Health, Aurora (C.I.O., G.K.G.); VA Puget Sound Health Care System, Seattle, WA (C.-F.L., P.L.H.); and Veterans Health Administration, US Department of Veteran Affairs, Washington, DC (R.L.J., S.D.F.). Steven.Bradley@va.gov.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Bradley
authors.affiliation: From VA Eastern Colorado Health Care System, Denver (S.M.B., C.I.O., G.K.G., T.M.M., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., J.S.R., P.M.H.); University of Colorado School of Public Health, Aurora (C.I.O., G.K.G.); VA Puget Sound Health Care System, Seattle, WA (C.-F.L., P.L.H.); and Veterans Health Administration, US Department of Veteran Affairs, Washington, DC (R.L.J., S.D.F.).
authors.forename: Colin I
authors.initials: CI
authors.lastname: O'Donnell
authors.affiliation: From VA Eastern Colorado Health Care System, Denver (S.M.B., C.I.O., G.K.G., T.M.M., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., J.S.R., P.M.H.); University of Colorado School of Public Health, Aurora (C.I.O., G.K.G.); VA Puget Sound Health Care System, Seattle, WA (C.-F.L., P.L.H.); and Veterans Health Administration, US Department of Veteran Affairs, Washington, DC (R.L.J., S.D.F.).
authors.forename: Gary K
authors.initials: GK
authors.lastname: Grunwald
authors.affiliation: From VA Eastern Colorado Health Care System, Denver (S.M.B., C.I.O., G.K.G., T.M.M., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., J.S.R., P.M.H.); University of Colorado School of Public Health, Aurora (C.I.O., G.K.G.); VA Puget Sound Health Care System, Seattle, WA (C.-F.L., P.L.H.); and Veterans Health Administration, US Department of Veteran Affairs, Washington, DC (R.L.J., S.D.F.).
authors.forename: Chuan-Fen
authors.initials: CF
authors.lastname: Liu
authors.affiliation: From VA Eastern Colorado Health Care System, Denver (S.M.B., C.I.O., G.K.G., T.M.M., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., J.S.R., P.M.H.); University of Colorado School of Public Health, Aurora (C.I.O., G.K.G.); VA Puget Sound Health Care System, Seattle, WA (C.-F.L., P.L.H.); and Veterans Health Administration, US Department of Veteran Affairs, Washington, DC (R.L.J., S.D.F.).
authors.forename: Paul L
authors.initials: PL
authors.lastname: Hebert
authors.affiliation: From VA Eastern Colorado Health Care System, Denver (S.M.B., C.I.O., G.K.G., T.M.M., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., J.S.R., P.M.H.); University of Colorado School of Public Health, Aurora (C.I.O., G.K.G.); VA Puget Sound Health Care System, Seattle, WA (C.-F.L., P.L.H.); and Veterans Health Administration, US Department of Veteran Affairs, Washington, DC (R.L.J., S.D.F.).
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Maddox
authors.affiliation: From VA Eastern Colorado Health Care System, Denver (S.M.B., C.I.O., G.K.G., T.M.M., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., J.S.R., P.M.H.); University of Colorado School of Public Health, Aurora (C.I.O., G.K.G.); VA Puget Sound Health Care System, Seattle, WA (C.-F.L., P.L.H.); and Veterans Health Administration, US Department of Veteran Affairs, Washington, DC (R.L.J., S.D.F.).
authors.forename: Robert L
authors.initials: RL
authors.lastname: Jesse
authors.affiliation: From VA Eastern Colorado Health Care System, Denver (S.M.B., C.I.O., G.K.G., T.M.M., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., J.S.R., P.M.H.); University of Colorado School of Public Health, Aurora (C.I.O., G.K.G.); VA Puget Sound Health Care System, Seattle, WA (C.-F.L., P.L.H.); and Veterans Health Administration, US Department of Veteran Affairs, Washington, DC (R.L.J., S.D.F.).
authors.forename: Stephan D
authors.initials: SD
authors.lastname: Fihn
authors.affiliation: From VA Eastern Colorado Health Care System, Denver (S.M.B., C.I.O., G.K.G., T.M.M., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., J.S.R., P.M.H.); University of Colorado School of Public Health, Aurora (C.I.O., G.K.G.); VA Puget Sound Health Care System, Seattle, WA (C.-F.L., P.L.H.); and Veterans Health Administration, US Department of Veteran Affairs, Washington, DC (R.L.J., S.D.F.).
authors.forename: John S
authors.initials: JS
authors.lastname: Rumsfeld
authors.affiliation: From VA Eastern Colorado Health Care System, Denver (S.M.B., C.I.O., G.K.G., T.M.M., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., J.S.R., P.M.H.); University of Colorado School of Public Health, Aurora (C.I.O., G.K.G.); VA Puget Sound Health Care System, Seattle, WA (C.-F.L., P.L.H.); and Veterans Health Administration, US Department of Veteran Affairs, Washington, DC (R.L.J., S.D.F.).
authors.forename: P Michael
authors.initials: PM
authors.lastname: Ho
mesh_terms: D000368:Aged; D015331:Cohort Studies; D005260:Female; D017721:Hospital Costs / Q000592:standards* / Q000639:trends; D006760:Hospitalization / Q000191:economics / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D010355:Patient Identification Systems / Q000191:economics / Q000592:standards* / Q000639:trends; D062645:Percutaneous Coronary Intervention / Q000191:economics / Q000401:mortality*; D013997:Time Factors; D014481:United States / Q000453:epidemiology; D014493:United States Department of Veterans Affairs / Q000191:economics / Q000592:standards* / Q000639:trends; D014728:Veterans
keywords: costs and cost analysis; hospitalization; outcome assessment (health care); percutaneous coronary intervention