title: Exploring Value in Congenital Heart Disease: An Evaluation of Inpatient Admissions.
abstract: OBJECTIVE
  Understanding value provides an important context for improvement. However, most health care models fail to measure value. Our objective was to categorize inpatient encounters within an academic congenital heart program based on clinical outcome and the cost to achieve the outcome (value). We aimed to describe clinical and nonclinical features associated with value.
  
  
  METHODS
  We defined hospital encounters based on outcome per resource utilized. We performed principal component and cluster analysis to classify encounters based on mortality, length of stay, hospital cost and revenue into six classes. We used nearest shrunken centroid to identify discriminant features associated with the cluster-derived classes. These features underwent hierarchical clustering and multivariate analysis to identify features associated with each class.
  We analyzed all patients admitted to an academic congenital heart program between September 1, 2009, and December 31, 2012.
  
  
  RESULTS
  A total of 2658 encounters occurred during the study period. Six classes were categorized by value. Low-performing value classes were associated with greater institutional reward; however, encounters with higher-performing value were associated with a loss in profitability. Encounters that included insertion of a pediatric ventricular assist device (log OR 2.5 [95% CI, 1.78 to 3.43]) and acquisition of a hospital-acquired infection (log OR 1.42 [95% CI, 0.99 to 1.87]) were risk factors for inferior health care value.
  
  
  CONCLUSIONS
  Among the patients in our study, institutional reward was not associated with value. We describe a framework to target quality improvement and resource management efforts that can benefit patients, institutions, and payers alike.
authors.affiliation: Department of Pediatrics, Stanford University, Palo Alto, Calif, USA.|Center for Quality and Clinical Effectiveness, Stanford University, Palo Alto, Calif, USA.
authors.forename: Andrew Y
authors.initials: AY
authors.lastname: Shin
authors.affiliation: Department of Surgery, Stanford University, Palo Alto, Calif, USA.
authors.forename: Zhongkai
authors.initials: Z
authors.lastname: Hu
authors.affiliation: Department of Surgery, Stanford University, Palo Alto, Calif, USA.
authors.forename: Bo
authors.initials: B
authors.lastname: Jin
authors.affiliation: Department of Pediatrics, Stanford University, Palo Alto, Calif, USA.
authors.forename: Sangeeta
authors.initials: S
authors.lastname: Lal
authors.affiliation: Department of Pediatrics, Stanford University, Palo Alto, Calif, USA.
authors.forename: David N
authors.initials: DN
authors.lastname: Rosenthal
authors.affiliation: Department of Statistics, Stanford University, Stanford, Calif, USA.
authors.forename: Bradley
authors.initials: B
authors.lastname: Efron
authors.affiliation: Department of Pediatrics, Stanford University, Palo Alto, Calif, USA.|Center for Quality and Clinical Effectiveness, Stanford University, Palo Alto, Calif, USA.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Sharek
authors.affiliation: Department of Pediatrics, Stanford University, Palo Alto, Calif, USA.
authors.forename: Scott M
authors.initials: SM
authors.lastname: Sutherland
authors.affiliation: Department of Pediatrics, Stanford University, Palo Alto, Calif, USA.
authors.forename: Harvey J
authors.initials: HJ
authors.lastname: Cohen
authors.affiliation: Department of Cardiothoracic Surgery, Stanford University, Palo Alto, Calif, USA.
authors.forename: Doff B
authors.initials: DB
authors.lastname: McElhinney
authors.affiliation: Department of Pediatrics, Stanford University, Palo Alto, Calif, USA.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Roth
authors.affiliation: Department of Surgery, Stanford University, Palo Alto, Calif, USA.
authors.forename: Xuefeng B
authors.initials: XB
authors.lastname: Ling
mesh_terms: D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006330:Heart Defects, Congenital / Q000191:economics / Q000401:mortality / Q000628:therapy*; D017721:Hospital Costs; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007297:Inpatients; D008297:Male; D010343:Patient Admission / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D014481:United States / Q000453:epidemiology
keywords: Congenital; Cost; Heart Defects; Length of Stay; Mortality; Value