title: The impact of post-procedural complications on reimbursement, length of stay and mechanical ventilation among patients undergoing transcatheter aortic valve implantation in Germany.
abstract: BACKGROUND
  The impact of various post-procedural complications after transcatheter aortic valve implantation (TAVI) on resource use and their consequences in the German reimbursement system has still not been properly quantified.
  
  
  METHODS
  In a retrospective observational study, we use data from the German DRG statistic on patient characteristics and in-hospital outcomes of all isolated TAVI procedures in 2013 (N = 9147). The impact of post-procedural complications on reimbursement, length of stay and mechanical ventilation was analyzed using both unadjusted and risk-adjusted linear and logistic regression analyses.
  
  
  RESULTS
  A total of 235 (2.57%) strokes, 583 (6.37%) bleeding events, 474 (5.18%) cases of acute kidney injury and 1428 (15.61%) pacemaker implantations were documented. The predicted reimbursement of an uncomplicated TAVI procedure was €33,272, and bleeding events were associated with highest additional reimbursement (€12,839, p < 0.001), extra length of stay (14.58 days, p < 0.001), and increased likelihood of mechanical ventilation for more than 48 h (OR 17.91, p < 0.001). A more moderate complication-related impact on resource use and reimbursement was found for acute kidney injury (additional reimbursement: €5963, p < 0.001; extra length of stay: 7.92 days, p < 0.001; ventilation >48 h: OR 6.93, p < 0.001) as well as for stroke (additional reimbursement: €4125, p < 0.001; extra length of stay: 4.68 days, p < 0.001; ventilation >48 h: OR 5.73, p < 0.001). Pacemaker implantations, in contrast, were associated with comparably small increases in reimbursement (€662, p = 0.006) and length of stay (3.54 days, p = 0.006) and no impaired likelihood of mechanical ventilation more than 48 h (OR 1.22, p = 0.156). Interestingly, these complication-related consequences remain mostly unchanged after baseline risk-adjustment.
  
  
  CONCLUSIONS
  Post procedural complications such as bleeding events, acute kidney injuries and strokes are associated with increased resource use and substantial amounts of additional reimbursement in Germany, which has important implications for decision making outside of the usual clinical sphere.
authors.affiliation: Center for Medical Biometry and Medical Informatics, Faculty of Medicine, University of Freiburg, Stefan-Meier-Str. 26, 79104, Freiburg, Germany. kaier@imbi.uni-freiburg.de.|Department of Cardiology and Angiology I, Heart Center Freiburg University, Freiburg, Germany. kaier@imbi.uni-freiburg.de.
authors.forename: Klaus
authors.identifier: http://orcid.org/0000-0003-0837-6945
authors.initials: K
authors.lastname: Kaier
authors.affiliation: Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany.
authors.forename: Holger
authors.initials: H
authors.lastname: Reinecke
authors.affiliation: LSE Health, Department of Social Policy, London School of Economics and Political Science, London, UK.
authors.forename: Huseyin
authors.initials: H
authors.lastname: Naci
authors.affiliation: Department of Cardiology, Angiology, Pulmonology, University of Heidelberg, Heidelberg, Germany.
authors.forename: Lutz
authors.initials: L
authors.lastname: Frankenstein
authors.affiliation: Department of Cardiology and Angiology I, Heart Center Freiburg University, Freiburg, Germany.|Faculty of Business Management and Social Sciences, Osnabrück University of Applied Sciences, Osnabrück, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Bode
authors.affiliation: Center for Medical Biometry and Medical Informatics, Faculty of Medicine, University of Freiburg, Stefan-Meier-Str. 26, 79104, Freiburg, Germany.
authors.forename: Werner
authors.initials: W
authors.lastname: Vach
authors.affiliation: Center for Medical Biometry and Medical Informatics, Faculty of Medicine, University of Freiburg, Stefan-Meier-Str. 26, 79104, Freiburg, Germany.
authors.forename: Philip
authors.initials: P
authors.lastname: Hehn
authors.affiliation: Department of Cardiology and Angiology I, Heart Center Freiburg University, Freiburg, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Zirlik
authors.affiliation: Department of Cardiology and Angiology I, Heart Center Freiburg University, Freiburg, Germany.
authors.forename: Manfred
authors.initials: M
authors.lastname: Zehender
authors.affiliation: Department of Cardiology and Angiology I, Heart Center Freiburg University, Freiburg, Germany.
authors.forename: Jochen
authors.initials: J
authors.lastname: Reinöhl
mesh_terms: D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis; D005260:Female; D005858:Germany; D006265:Health Care Coalitions; D006801:Humans; D007349:Insurance, Health, Reimbursement; D007902:Length of Stay; D008297:Male; D012121:Respiration, Artificial; D012189:Retrospective Studies; D012307:Risk Factors; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects* / Q000191:economics; D016896:Treatment Outcome
keywords: Excess costs; Post-procedural complications; Reimbursement; Resource use; TAVR; Transcatheter aortic valve replacement