1-Year Risk-Adjusted Mortality and Costs of Percutaneous Coronary Intervention in the Veterans Health Administration

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

VOL. 65, NO. 3, 2015

ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

ISSN 0735-1097/$36.00

PUBLISHED BY ELSEVIER INC.

http://dx.doi.org/10.1016/j.jacc.2014.10.048

1-Year Risk-Adjusted Mortality and Costs of Percutaneous Coronary Intervention in the Veterans Health Administration Insights From the VA CART Program P. Michael Ho, MD, PHD,*y Colin I. O’Donnell, MS,*y Steven M. Bradley, MD, MPH,*y Gary K. Grunwald, PHD,*y Christian Helfrich, PHD,z Michael Chapko, PHD,z Chuan-Fen Liu, PHD,z Thomas M. Maddox, MD, MSC,*y Thomas T. Tsai, MD, MSC,*y Robert L. Jesse, MD, PHD,x Stephan D. Fihn, MD, MPH,zk John S. Rumsfeld, MD, PHD*y

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. OBJECTIVES 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. (J Am Coll Cardiol 2015;65:236–42) © 2015 by the American College of Cardiology Foundation.

T

here is increasing interest in measuring

groups of providers assume responsibility for cost

health care value, particularly as the health

and quality of care for a patient population. Value in

care system moves toward accountable care

health care focuses on similar concepts by measuring

(1,2). Within accountable care organizations (ACOs),

outcomes achieved relative to costs for a cycle of care

From the *Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado; yDivision of Cardiology, University of Colorado Denver, Denver, Colorado; zVeterans Affairs Puget Sound Health Care System, Seattle, Washington; xDepartment of Veteran Affairs, Veterans Health Administration, Washington, DC; and the kVeterans Affairs Office of Analytics and Business Intelligence, Washington, DC. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. Drs. Bradley and Maddox are supported by Career Development Awards from VA Health Services Research and Development. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received March 28, 2014; revised manuscript received October 2, 2014, accepted October 30, 2014.

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(1). The value numerator is outcomes of care, such as

electronic health record to collect patient and

ABBREVIATIONS

mortality or morbidity; the value denominator is total

procedural data at the point-of-care for all

AND ACRONYMS

cost of care over time, not just a single episode of care

cardiac catheterization procedures and PCIs

such as hospitalization (1). Attaining high-value care,

performed in the VA system (10,11).

terest to patients, providers, health systems, and

PATIENT AND HOSPITAL INCLUSION CRITERIA.

payers. To date, value assessments have not been

Hospitals had to perform a minimum of 20

operationalized

PCIs between October 1, 2007, to September

applied

to

specific

patient

30, 2010 to be included in the study. During

populations.

these study years, patients without a history

SEE PAGE 243

ACO = accountable care organization

such as positive clinical outcomes at low costs, is of in-

and

CART = clinical assessment, reporting, and tracking

DSS = decision support system PCI = percutaneous coronary intervention

SSA = Social Security

of PCI and who underwent a PCI in the VA

Administration

Percutaneous coronary intervention (PCI) is an

system were included. Following the index

VA = Veterans Affairs

important component of care for patients with

PCI, all subsequent health care utilizations

ischemic heart disease (3). In 2010, 492,000 PCIs were

during the year were aggregated for that

performed in the United States at an mean charge of

patient, regardless of where care occurred,

$67,000 per procedure (4). Although quality of care for

either at the PCI hospital or at another VA hospital.

the PCI procedure itself has improved, 1-year re-

We attributed all patient costs and mortality to the

hospitalization and mortality rates following the pro-

index PCI hospital. We also included costs of care

cedure remain high (5–7). These findings highlight the

occurring outside of VA where VA paid for care using

VIReC = VA Information Resource Center

need to take a longitudinal approach toward evalu-

the fee basis files. As noted below, we also had

ating PCI care, including costs for this care. Accord-

Medicare utilization data for a subset of patients. Of

ingly, PCI and the longitudinal care provided to

the 64 hospitals that performed PCI, we excluded 4

patients following the procedure provide an oppor-

hospitals that performed fewer than 20 PCIs during

tune clinical scenario with which to measure 1 aspect

the study period and 57 patients (0.03%) for whom

of health care value.

cost data were not captured. The final dataset con-

Accordingly, we evaluated 1-year outcomes (risk-

sisted of 60 hospitals and 19,148 patients. The Colo-

adjusted mortality) and 1-year risk-standardized

rado Multiple Institutional Review Board approved

costs of care for all patients who underwent PCI in

the current analysis.

the U.S. Department of Veterans Affairs (VA) health

OUTCOMES. The

care system from 2007 to 2010. We compared risk-

all-cause mortality during the year following the

standardized mortality and costs for VA hospitals

index PCI procedure. Death was ascertained from the

that performed PCI and evaluated the proportion of

VA Information Resource Center (VIReC) Vital Status

costs attributable to the index procedure compared

File, which compiles data from the BIRLS (Beneficiary

with the follow-up period. It is hoped that the findings

Identification Records Locator Subsystem) Death file,

will inform the discussion of how to measure and move

the VA Medicare Vital Status File, and the Social

toward achieving high-value PCI care and also serve as

Security Administration (SSA) Death Master File.

a potential model for similar assessments in non-VA

primary

clinical

outcome

was

The primary cost outcome was total cost during the year after PCI. Costs for each patient were collected

settings.

from DSS and adjusted for regional variations, using

METHODS

the Medicare wage index. Total costs were divided

STUDY SETTING. The Veterans Health Administra-

costs within 7 days of PCI; and 2) subsequent costs,

into 2 periods: 1) index procedural costs, defined as all tion is the largest integrated health care system in the

defined as all costs from days 8 to 365. Within these

United States (8). The VA has a financial management

categories, we further divided costs into inpatient,

system (Decision Support System [DSS]) that uses a

outpatient, and/or fee basis costs. All inpatient costs

cost accounting method to track costs rather than

were further broken down into 6 unique DSS-defined

charges and payments. This system is the primary

categories: nursing, pharmacy, radiology, surgery,

financial data source for VA health care operations

laboratory, and all other costs. All outpatient costs

and the source of cost data for these analyses (8,9).

were aggregated for each patient and then to the PCI

The

VA

Clinical

237

Variation in Mortality and Costs of PCI Care

Assessment,

Reporting,

and

Tracking (CART) program is the clinical quality pro-

hospital. Outpatient costs were matched to internal VA codes that identified the purpose of visit.

gram for 76 cardiac catheterization laboratories, 64

STATISTICAL ANALYSIS. Statistical analyses were

of which perform PCI. The CART program uses a

performed using SAS version 9.3 software (SAS Insti-

clinical software application integrated with the VA

tute Inc., Cary, North Carolina), R version 2.15.1

238

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Variation in Mortality and Costs of PCI Care

software (R Foundation for Statistical Computing, Vienna, Austria), and WinBUGS version 1.4.3 software (Imperial College and MRC, Cambridge, United Kingdom). Bayesian profiling of standardized mortality risk

T A B L E 1 Baseline Characteristics of Hospitals (n ¼ 60) and

Patients (n ¼ 19,148 Patients)

Age, yrs*

65.1  9.5

Alcohol abuse

10.0

Anemia

14.0

(SMR) and standardized cost risk (SCR) was modeled

Blood loss anemia*

following Markov chain Monte Carlo (MCMC) methods

Cardiogenic shock*

0.8

(14). Logistic regression was used for mortality, and

Congestive heart failure

21.6

Chronic kidney disease†

11.0

cost was logged prior to modeling. To adjust for both cardiac and noncardiac comorbidities, we included variables from the National Cardiovascular Data Registry risk prediction mortality model and from the

0.4

Coagulation deficiency†

3.2

Chronic pulmonary disease

29.5

Depression

27.4

Diabetes

Elixhauser comorbidities scale (12,13). The resulting

With complications

17.4

dataset contained more than 35 adjustment covariates.

Without complications

42.6

To reduce the number of covariates used in MCMC, a

eGFR

single backward elimination using maximal likelihood

Fluid and electrolyte disorders

was used to obtain the most significant 24 covariates,

HIV AIDS†

respectively (Table 1). We used the univariate method of Timbie and

3.5 0.7

Neurologic disorders

6.0

iterations with 2,000 burn-in iterations to obtain an

Obesity*

SMR and an SCR and their associated credibility

Paralysis

intervals for each hospital. These adjusted ratios are

Psychoses†

Bayesian analogs to observed to expected ratios. SMRs

Pulmonary circulation disorders

and SCRs for each hospital were used to quantify

Peripheral vascular disease†

95% credibility interval did not contain 1. To examine the association between mortality and cost at the

0.6

Metastatic cancer NYHA functional class IV

identify significantly unusual hospitals as those whose

10.6

Liver disease

Normand (14) in WinBUGS with a single chain of 10,000

variation in mortality and cost across hospitals and to

76.1  26.6

1.0 39.7 2.0 14.6 2.4 17.5

Status Elective Emergent

61.2 7.6

Urgent

27.0

Salvage

0.2

hospital level, each hospital’s SCR was plotted against

STEMI*

8.1

the SMR, and Pearson correlation was used.

Solid tumor without metastasis

11.8

Prior valve disease

8.3

Weight Loss

2.4

We performed several sensitivity analyses. First, despite a national cost accounting system, we evaluated potential variations in cost coding across hospitals by assessing Pearson’s correlation coefficient between costs and utilization after PCI discharge. We

Values are mean  SD or %. *Mortality model only. †Cost model only. eGFR ¼ estimated glomerular filtration rate; HIV ¼ human immunodeficiency virus; NYHA ¼ New York Heart Association; STEMI ¼ ST-segment elevation myocardial infarction.

derived a mean utilization per hospital on the basis of number of unique outpatient visits and inpatient admissions by number of patients undergoing PCI. A positive correlation would suggest that higher costs at hospitals reflect higher utilization and not necessarily variations in cost coding. Second, VA patients who are 65 years of age or older may obtain care outside of VA by using Medicare benefits. To address this, we evaluated the correlation between hospital

high-cost patients prior to the PCI between hospitals. Fourth, we stratified our cohort by acute coronary syndrome (ACS) versus non-ACS indication for the PCI procedure and assessed variations in 1-year mortality and costs across the hospitals.

RESULTS

readmissions in Medicare and VA hospital costs. A negative correlation would suggest that VA hospitals

The median number of PCIs performed in the 60

are low cost because their patients are rehospitalized

hospitals was 261, and the mean was 319 (inter-

outside of VA and that these readmissions are not

quartile range [IQR]: 195 to 357) (Table 1). Almost one-

accounted for in VA costs. Medicare readmission data

half (43.0%) of PCIs were performed for ACS.

were available for the cohort through December 31,

Comorbidities were common: 21.6% heart failure,

2010. Third, we also adjusted for patient costs in the

17.5% peripheral vascular disease, 29.5% chronic

6 months prior to the PCI in the assessment of vari-

pulmonary disease, 11.0% renal failure, 42.6% dia-

ation in hospital costs to account for differences in

betes, and 39.7% obesity.

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At the hospital level, the 30-day unadjusted median mortality rate after PCI was 1.29% (IQR:

Variation in Mortality and Costs of PCI Care

F I G U R E 1 Standard 1-Year Mortality With Significant

95% Credibility Intervals

0.85% to 2.22%). One-year unadjusted median mortality was 6.13% (IQR: 4.51% to 7.34%). With risk-

1.6

hospitals had credibility intervals above 1.0 (Figure 1). These hospitals had mortality rates approximately 23.2% to 28.5% higher than the median. There were no hospitals with credibility intervals below the riskstandardized median ratio. There was substantially greater variation in total costs. The median unadjusted total 1-year costs were $46,302 (IQR: $37,291 to $57,886) per patient (Figure 2). Risk-standardized 1-year total costs demonstrated that 16 hospitals had credibility intervals above the riskstandardized median, up to 2.09 (95% confidence in-

Standardized Mortality Ratio

standardized median 1-year mortality ratio of 1.00, 4 1.4 1.2 1.0 0.8 0.6 0.4 0

terval [C]I: 1.84 to 2.36) or 209% higher costs than median, and 19 hospitals were below, with the lowest

10

20

30 40 Hospital

50

60

being 0.45 (95% CI: 0.39 to 0.51) or 55% lower costs than median (Figure 3). Adjusting for patient costs in the 6 months prior to PCI did not change the number of

Risk-standardized 1-year mortality ratios with 95% credibility interval for each hospital. Salmon lines represent hospitals (n ¼ 4) with standardized mortality ratios significantly above 1.0.

outlier hospitals. The index procedural costs accounted for 41.7% of total 1-year costs. Of these index costs, 66.2% were inpatient, 32.6% were outpatient, and 1.2% were fee basis costs. Index inpatient costs were attributed to the following categories: nursing, 31.6%; surgery, 2.8%; laboratory, 2.6%; radiology, 2.2%; pharmacy, 6.6%; and all others, 54.2%. Following the index procedure, subsequent costs accounted for 58.3% of total 1-year costs and were attributable to inpatient (28.2%), outpatient (64.3%),

In sensitivity analyses, there was significant and strong correlation between utilization on the basis of outpatient visits and inpatient admissions and costs (r ¼ 0.87; 95% CI: 0.79 to 0.92; p < 0.001), supporting the fact that higher costs at hospitals reflect higher utilization. Next, the correlation between hospital readmissions in Medicare and VA hospitals costs

and fee basis costs (7.5%). The top 3 primary diagnoses for inpatient costs were: 1) other forms of chronic ischemic heart disease; 2) heart failure; and 3) care involving rehabilitation procedures (Table 2

F I G U R E 2 Patient Mean 7-Day Cost and Follow-Up Cost

100,000

lists the top 10 diagnoses). For outpatient costs, cardiac-related care was the largest cost category (18.0% of all outpatient costs), followed by pharmacy (15.2%), prosthetics (14.9%), outpatient procedures

75,000

(7.8%), screening and laboratory (7.2%), primary care (6.5%), and radiology (3.3%). The remaining outpatient costs were attributed to a variety of reasons (26.7%).

50,000

Next, we plotted standardized mortality and total cost ratios for each hospital (Central Illustration). There were 4 hospitals with risk-standardized credibility intervals above 1.0, (Central Illustration, blue

25,000

dots and lines). There were 35 hospitals with riskstandardized 1-year total costs either above or below 1.0 (Central Illustration, red dots and lines). Overall, there was no correlation between hospital standard-

0 7 Day

8-365 Day

ized mortality and costs (r ¼ 0.004; 95% CI: 0.24 to 0.26; p ¼ 0.97). One hospital had both mortality and

Stacked bars of costs of care at individual hospitals are shown for the first 7 days (salmon)

cost ratios that were above the standardized risks,

and for days 8 to 365 of follow-up (blue).

suggesting that this hospital was “low” value.

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Variation in Mortality and Costs of PCI Care

was small and not statistically significant (r ¼ 0.11; p ¼ 0.40), suggesting that the reason for lower-cost

F I G U R E 3 Standardized 1-Year Cost With Significant

95% Credibility Intervals

VA hospitals was not related to greater Medicare use by their patients. Finally, similar to the primary analysis, variations at the hospital level in 1-year 2.0

mortality for ACS were similar to those for non-ACS indications for the procedure. For 1-year costs, significant variations remained, with 14 hospitals above and 16 hospitals below the risk-standardized median for ACS indications for the procedure and 16 above and 20 hospitals below the risk-standardized median for non-ACS indications for the procedure.

DISCUSSION We evaluated hospital variations in 1-year riskstandardized mortality and 1-year costs of care

Standardized Cost Ratio

240

1.5 1.0 0.5 0.0

0

10

20

30

40

50

60

Hospital

following PCI at 60 VA hospitals (Central Illustration). Variations in 1-year mortality were low overall, and there were only 4 outliers, which had median standardized mortality ratios up to 28% above the median. In contrast, there was substantially greater

Risk-standardized 1-year total cost ratios with 95% credibility intervals. Salmon lines represent hospitals with standardized cost ratios above or below 1.0.

variability in 1-year costs following PCI. Following risk adjustment, costs ranged from 55% below to 209% above the mean standardized costs. These

Overall, patients receiving PCI in the VA achieved

findings highlight the fact that although there may be

good 1-year outcomes, as shown by mortality rates

selective opportunities to improve patient outcomes

comparable to randomized controlled clinical trials

following PCI, there appear to be greater opportu-

and statewide registries of PCI (7,16–19). The VA out-

nities to reduce costs for longitudinal PCI care. The

comes may be related to improvements in cardiovas-

results of this study suggest that the value of PCI care

cular care delivery. Beginning in 2004, VA invested

for the VA system may be enhanced through reducing

heavily in improving cardiac care by upgrading infra-

unnecessary variation in costs of care while con-

structure, developed national performance metrics to

tinuing to achieve good patient outcomes.

assess cardiac care quality, and reorganized cardiac

To our knowledge, this is one of the first studies

care into a hub-and-spoke model. Furthermore, the VA

to operationalize and measure both longitudinal out-

CART program, started in 2004, is a national quality

comes and costs for a specific patient cohort and from a

improvement program that proactively monitors care

system perspective. The study findings may inform

and outcomes for all VA cardiac catheterization labo-

current discussions of health care value measurement

ratories (10).

and may be a model for other systems or ACOs

In contrast to mortality, there was significantly

attempting to measure and improve value. It has been

greater variation in health care costs in the year

recommended that in a health care system structured

following PCI. Although absolute costs are important

around value for patients, care should be organized

in any discussion of health care value, our main

around longitudinal care and outcomes rather than

purpose was to compare relative costs spent by indi-

single episodes of care like hospitalization (1,15).

vidual hospitals. These variations suggest there may

Accordingly, we focused our assessment on 1-year

be significant differences in processes and structures

outcomes and costs of care for patients who had un-

of care during the index procedure and in the year

dergone PCI, consistent with the approach advocated

following PCI. A previous VA study found modest

by Porter (1) and Porter et al. (15). Future studies should

variations in efficiency as defined by quality of care

also capture patient health status outcomes as these

indicators for inpatient care, 30-day mortality, and

are also critical outcomes of PCI, particularly for pa-

costs, without focusing on a specific condition (8).

tients undergoing PCI in the setting of chronic stable

They found the least efficient VA hospitals had nearly

angina. Future studies should also expand beyond PCI

28% higher risk-adjusted costs than the most efficient

care to more broadly include the outcomes and costs

hospitals, and one-half of hospitals were 5% to 11%

for patients with ischemic heart disease.

less efficient than ideal. Furthermore, a previous

Ho et al.

JACC VOL. 65, NO. 3, 2015 JANUARY 27, 2015:236–42

study of the Medicare population found that complications following coronary artery bypass procedure,

T A B L E 2 Top 10 Diagnoses for Hospitalization After the Index PCI

total hip replacement surgery, abdominal aortic

ICD-9 Code

aneurysm repair, or colectomy procedures were

414

Other forms of chronic ischemic heart disease

2,313 (19.5)

associated with higher costs but not with mortality

786

Symptoms involving respiratory system and other chest symptoms

1,001 (8.4)

(20). In contrast to the previous study in which there

428

Heart failure

was an association between clinical outcomes and

410

Acute myocardial infarction

478 (4.0)

costs, we did not demonstrate such an association

427

Cardiac dysrhythmias

409 (3.4)

between 1-year risk-standardized mortality and costs.

996

Complications peculiar to certain specified procedures

278 (2.3)

Subsequent evaluations will be needed to identify

V57

Care involving use of rehabilitation procedures

270 (2.3)

specific reasons for the cost variations identified, 1 of

491

Chronic bronchitis

250 (2.1)

780

General symptoms

224 (1.9)

486

Pneumonia

200 (1.7)

which may be regional differences in practice patterns. Research is needed to understand the magnitude of variation for each inpatient cost category as well as

Diagnosis

Patient Count (%)

858 (7.2)

ICD-9 ¼ International Classification of Diseases-9th revision; PCI ¼ percutaneous coronary intervention.

what types of costs are included in the “all other” cost category. There may be structural factors related to staffing of cardiac catheterization laboratories and/or

the variation in costs persists. Third, although we

supply costs (e.g., coronary stents), which are negoti-

were able to account for absolute costs, VA has its

ated by individual hospitals. For outpatient care, there

own cost accounting system, which may not be

will be opportunities to explore differences in follow-

applicable to other health care systems or payers and

up care, some of which may be related to the in-

may limit generalizability. However, it is the com-

tensity of care provided, frequency of cardiac testing,

parison within the system such as the one we did

and/or a need for noncardiac-related care. Qualitative research, such as structured interviews, may help identify reasons for cost variations. Following these results, we will work with VA operational partners to-

C EN T RA L IL LUSTR AT I ON Variation in Mortality and Costs of PCI Care: Standardized 1-Year Cost and 1-Year Mortality

ward implementing interventions to reduce unnecessary variations. For example, in previous work, we have found wide variations in costs of stents across VA cardiac catheterization laboratories and are now pursuing a national purchasing contract to make stent costs uniform across VA (Dr. John Rumsfeld, National Program Director for Cardiology, Department of Veterans Health Administration, personal communication, June 2013). STUDY

LIMITATIONS. First,

as

an

observational

study, we cannot exclude unmeasured confounding. However,

we

used

241

Variation in Mortality and Costs of PCI Care

robust

risk

adjustment

for

observable variables related to both mortality and cost outcomes. The goal was to evaluate variation jointly in outcome and cost in actual clinical practice, and hence, the observational study design is the only one possible. Second, there is likely some variation in attributing specific costs to a cost category at a hospital. However, this should not influence the overall cost comparisons (as the VA has a national cost accounting system), and these differences in methods would not explain the large variability in total costs spent at each hospital. Furthermore, there was strong correlation between utilization and costs, suggesting that variability in costs cannot be solely

Standardized 1-year mortality rates and costs for each of the 60 Veterans Affairs hospitals are shown, with significant 95% credibility intervals. Blue lines represent hospitals with standardized mortality ratios above 1.0 (n ¼ 4). Salmon lines represent hospitals

attributed to differences in cost accounting methods.

with standardized costs above (n ¼ 16) or below (n ¼ 19) 1.0. PCI ¼ percutaneous

However, it will also be important that future studies

coronary intervention.

apply standard costs to utilization to assess whether

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Variation in Mortality and Costs of PCI Care

which provides valuable information to identify opportunities for quality improvement. This is particu-

REPRINT REQUESTS AND CORRESPONDENCE: Dr.

larly relevant given the push toward ACOs, where

P. Michael Ho, Denver Veteran Affairs Medical Center,

there will be increasing pressure to improve quality

University of Colorado, Denver, Section of Cardio-

at lower costs. Finally, we assessed 1-year mortality

logy, 1055 Clermont Street (111B), Denver, Colorado

and costs after PCI, which is a common duration

80220. E-mail: [email protected].

of follow-up for clinical trials and registries of PCI. Although future studies should assess different lengths of follow-up, it is likely that variations in costs will persist.

COMPETENCY IN MEDICAL KNOWLEDGE: Most variation of longitudinal PCI care occurs as a result of

CONCLUSIONS

differences in costs with much less variation in patient

We assessed variations in both 1-year mortality and costs of care among all VA hospitals that perform PCI. We found substantial variations in costs, with much less variation in patient mortality. This suggests that value of PCI care for the VA may be enhanced through reducing unnecessary variation in costs of care without

compromising

PERSPECTIVES

patient

outcomes.

This

approach to the assessment of mortality and costs for the VA system may be useful for other health care

outcomes. This suggests that value of PCI care for the VA may be enhanced through reducing unnecessary variation in costs of care, without compromising patient outcomes. TRANSLATIONAL OUTLOOK: Future evaluation will be needed to identify specific reasons for the cost variations. Qualitative research such as structured interviews may help identify reasons for cost variations.

systems and ACOs.

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KEY WORDS costs, health care delivery, ischemic heart disease, PCI, outcomes, value