Improving affordability through innovation in the surgical treatment of mitral valve disease.

OBJECTIVE: To determine whether technically innovative cardiac surgical platforms (ie, robotics) deployed in conjunction with surgical process improvement (systems innovation) influence total hospital costs to address the concern that expanding adoption might increase health care expenses. PATIENTS AND METHODS: We studied 185 propensity-matched patient pairs (370 patients) undergoing isolated conventional open vs robotic mitral valve repair with identical repair techniques and care teams between July 1, 2007, and January 31, 2011. Two time periods were considered, before the implementation of system innovations (pre-July 2009) and after implementation. Generalized linear mixed models were used to estimate the effect of the type of surgery on cost while adjusting for a time effect. RESULTS: Baseline characteristics of the study patients were similar, and all patients underwent successful mitral valve repair with no early deaths. Median length of stay (LOS) for patients undergoing open repair was unchanged at 5.3 days (P=.636) before and after systems innovation implementation, and was lower for robotic patients at 3.5 and 3.4 days, respectively (P=.003), throughout the study. The overall median costs associated with open and robotic repair were $31,838 and $32,144, respectively (P=.32). During the preimplementation period, the total cost was higher for robotic ($34,920) than for open ($32,650) repair (P<.001), but during the postimplementation period, the median cost of robotic repair ($30,606) became similar to that of open repair ($31,310) (P=.876). The largest decrease in robotic cost was associated with more rapid ventilator weaning and shortened median intensive care unit LOS, from 22.7 hours before July 2009 to 9.3 hours after implementation of systems innovations (P<.001). CONCLUSION: Following the introduction of systems innovation, the total hospital cost associated with robotic mitral valve repair has become similar to that for a conventional open approach, while facilitating quicker patient recovery and diminished utilization of in-hospital resources. These data suggest that innovations in techniques (robotics) along with care systems (process improvement) can be cost-neutral, thereby improving the affordability of new technologies capable of improving early patient outcomes.

Pre-operative CT coronary angiography in patients with mitral valve prolapse referred for surgical repair: comparison of accuracy, radiation dose and cost versus invasive coronary angiography.

BACKGROUND: The aims of this study are to evaluate the accuracy of low dose multidetector computed tomography coronary angiography (MDCT) versus invasive coronary angiography (ICA) in ruling out CAD in patients with mitral valve prolapse and severe mitral regurgitation (MVP) before cardiac surgery and to compare the overall effective radiation dose (ED) and cost of a diagnostic approach in which conventional ICA should be performed only in patients with significant CAD as detected by MDCT. METHODS: Eighty patients with MVP and without history of CAD were randomized to MDCT (Group 1) or ICA (Group 2) to rule out CAD before surgery. However, ICA was also performed as gold standard reference in Group 1 to test the diagnostic accuracy of MDCT. A diagnostic work-up A in whom all patients underwent low-dose MDCT as initial diagnostic test and those with positive findings were referred for ICA was compared with work-up B in which all patients were referred for ICA according to the standard of care in terms of ED and cost. RESULTS: The two groups were homogeneous in terms of gender, age and body mass index. The overall feasibility and accuracy in a patient-based model were 99% and 93%, respectively. The overall ED and costs were significantly lower in diagnostic work-up A compared to diagnostic work-up B. CONCLUSIONS: The accuracy of low dose MDCT for ruling out the presence of significant CAD in patients undergoing elective valve surgery for mitral valve prolapse is excellent with a reduction of overall radiation dose exposure and costs.

Cost-effectiveness of echocardiography for evaluation of children with murmurs.

Echocardiography is widely accepted as an accurate diagnostic test to evaluate heart murmurs in children, however its costs, and the ubiquity of murmurs in children, discourage its universal application. The purpose of this article is to identify some clinical circumstances in which the cost of echocardiography is justified for the evaluation of heart murmurs in infants and children. Eight common clinical problems were selected in which a heart murmur is present and a diagnosis is called for. Effectiveness of echocardiography and less costly clinical diagnostic methods in these settings were compared. In some circumstances, echocardiography is worth the cost, because clinical evaluation is unacceptably insensitive to important disease (the premature infant with a murmur which might represent a patent ductus arteriosus, the infant with a dysmorphic syndrome and a murmur). In others, the expert clinical examination is highly accurate (the asymptomatic child with a heart murmur) and is preferred over the echocardiogram as the initial diagnostic approach on the grounds of cost. When the expert clinical examination suggests minor structural heart disease, a continuum of echocardiographic cost-effectiveness relative to the expert clinical examination exists between these extremes depending on the working diagnosis. A threshold has not yet been defined at any point on this continuum above which the public will demand the greater diagnostic detail available echocardiographically, and below which the public will refuse to accept its greater cost. Quantitative formal cost-effectiveness analysis of echocardiography for evaluation of heart murmur in infants and children is not yet feasible because the benefits of echocardiography are indirect, dependent upon the as yet unmeasured benefits of correct management of congenital heart defects. To go beyond simple comparison of efficacy of echocardiography with less costly methods, further work is required in outcomes research in congenital heart disease.