1-Year Risk-Adjusted Mortality and Costs of Percutaneous Coronary Intervention in the Veterans Health Administration: Insights From the VA CART Program | Journal Scan

Study Questions:

What is the variation in 1-year outcomes (risk-adjusted mortality) and risk-standardized costs of care for all patients undergoing percutaneous coronary intervention (PCI) in the Veterans Affairs’ (VA) system from 2007-2010?


This was a retrospective cohort study that used data from the national VA Clinical Assessment, Reporting, and Tracking (CART) program at 60 hospitals. By examining both outcomes and costs simultaneously, the authors framed their findings in the growing construct of healthcare value—getting more for what you pay. Primary outcomes were 1-year mortality and costs following PCI, which were standardized after adjusting for cardiac and noncardiac comorbidities.


The authors reported: “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 average cost, with risk standardized ratios ranging from 0.45 to 2.09 reflecting much larger magnitude of variability in costs compared to mortality.”


The authors concluded that variation in 1-year risk-adjusted mortality was much smaller compared to risk-standardized costs after PCI. They interpreted this to mean that there are opportunities to improve PCI “value” by reducing costs without compromising outcomes.


As a disclosure, I co-authored an editorial to this paper, published in the same issue of JACC. Our overall comments in that editorial emphasize the importance of this type of questioning in the current healthcare environment. Payers and patients are looking increasingly toward ‘value’ as a construct for deciding on healthcare services. PCI is a great example of how we can begin to ask these questions given the strength of evidence and existing databases for assessing quality and costs. This study by Mike Ho and colleagues is a great first step, but there are a number of issues that remain: Why 1-year costs (as opposed to shorter or longer outcomes assessments)? And, what about symptom relief as opposed to mortality? Also, what about the consideration of other procedures or medical therapy? These limitations aside, I think improving our understanding of ‘value’ will become a growing priority area for healthcare policy and outcomes researchers.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Cohort Studies, Comorbidity, Hospital Costs, Outcome Assessment (Health Care), Percutaneous Coronary Intervention, Risk, Veterans, Retrospective Studies

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