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1.
Med Care ; 57(11): 869-874, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31634268

RESUMO

INTRODUCTION: Surgery accounts for almost half of inpatient spending, much of which is concentrated in a subset of high-cost patients. To study the effects of surgeon and hospital characteristics on surgical expenditures, a way to adjust for patient characteristics is essential. DESIGN: Using 100% Medicare claims data, we identified patients aged 66-99 undergoing elective inpatient surgery (coronary artery bypass grafting, colectomy, and total hip/knee replacement) in 2014. We calculated price-standardized Medicare payments for the surgical episode from admission through 30 days after discharge (episode payments). On the basis of predictor variables from 2013, that is, Elixhauser comorbidities, hierarchical condition categories, Medicare's Chronic Conditions Warehouse (CCW), and total spending, we constructed models to predict the costs of surgical episodes in 2014. RESULTS: All sources of comorbidity data performed well in predicting the costliest cases (Spearman correlation 0.86-0.98). Models on the basis of hierarchical condition categories had slightly superior performance. The costliest quintile of patients as predicted by the model captured 35%-45% of the patients in each procedure's actual costliest quintile. For example, in hip replacement, 44% of the costliest quintile was predicted by the model's costliest quintile. CONCLUSIONS: A significant proportion of surgical spending can be predicted using patient factors on the basis of readily available claims data. By adjusting for patient factors, this will facilitate future research on unwarranted variation in episode payments driven by surgeons, hospitals, or other market forces.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Pacientes Internados/estatística & dados numéricos , Medicare/economia , Procedimentos Cirúrgicos Operatórios/economia , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/economia , Colectomia/economia , Ponte de Artéria Coronária/economia , Cuidado Periódico , Feminino , Humanos , Masculino , Estados Unidos
2.
J Card Surg ; 34(8): 708-713, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31269297

RESUMO

BACKGROUND: The aim of this study was to identify hospital-level predictors of increased cost following index adult cardiac operations in a statewide registry. METHODS: The Pennsylvania Health Care Cost Containment Council (PHC4) database was queried for isolated coronary artery bypass grafting (CABG), isolated valve surgery, or CABG plus valve surgery performed between 2014 and 2016. Charge-to-cost ratios for each individual hospital were used to estimate cost. Expected (predicted) operative mortality and 30-day readmission were evaluated using multivariable risk models and linear regression analysis was utilized to evaluate the risk-adjusted impact of multiple hospital-level characteristics on costs. RESULTS: During the study period, 29 578 patients underwent isolated CABG (n = 16,641), isolated valve surgery (n = 8618), or CABG plus valve surgery (n = 4319) at 60 hospitals. The median cost of CABG was $61 573 (interquartile range [IQR] $50 780 to $77 482). The median cost of isolated valve surgery was $68,835 (IQR $56 039 to $89 465) and CABG plus valve surgery $83 574 (IQR $69 806 to $114 407). Hospital-level predictors of increasing costs in isolated CABG included higher predicted mortality rates, higher observed-to-expected (OE) mortality ratios, and nonteaching status. No hospital-level independent predictors of increased costs were identified for isolated valve or CABG plus valve surgery. CONCLUSIONS: Hospitals that performed higher risk cases and had higher OE ratios for operative mortality in isolated CABG were found to have increased costs. These data collectively suggest that attention to risk assessment and outcome optimization efforts in isolated CABG would likely result in programmatic advantages not only from a clinical standpoint but also economic.


Assuntos
Procedimentos Cirúrgicos Cardíacos/economia , Custos e Análise de Custo , Valva Aórtica/cirurgia , Procedimentos Cirúrgicos Cardíacos/mortalidade , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Ponte de Artéria Coronária/economia , Ponte de Artéria Coronária/estatística & dados numéricos , Bases de Dados Factuais , Feminino , Previsões , Humanos , Masculino , Readmissão do Paciente/estatística & dados numéricos , Pennsylvania/epidemiologia , Sistema de Registros
3.
Ann Thorac Surg ; 107(5): 1364-1371, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30553739

RESUMO

BACKGROUND: The study reports the impact of adverse events during the index coronary artery bypass graft surgery (CABG) on Medicare reimbursement for the index hospitalization and a 90-day follow-up period. METHODS: This retrospective study used 2014 Medicare claims files for hospitals, skilled nursing services, rehabilitation facilities, long-term care facilities, home health services, and outpatient visits. The study sample is 37,106 Medicare beneficiaries that survived an index CABG in a US hospital during the first three quarters of 2014. Adverse events included acute renal failure, new onset hemodialysis, postoperative respiratory failure, any infection (postoperative infection, or sepsis), postoperative shock and hemorrhage, postoperative stroke, and reoperation during index hospitalization. RESULTS: Total average Medicare reimbursement for all services consumed during index CABG hospitalization and the 90-day postdischarge period was $42,063 ± $23,284. The index CABG hospitalization accounted for $32,544 ± $14,406, 77.4% of the bundle. Medicare beneficiaries having at least one adverse event had significantly higher total average Medicare reimbursement by $15,941 ($54,280 versus $38,339) for the bundle compared with Medicare beneficiaries not having an adverse event. The risk-adjusted incremental Medicare reimbursement for the entire 90-day bundle exceeded $20,000 for four adverse events: new-onset hemodialysis, $33,250; septicemia, $32,063; postoperative stroke, $24,117; and postoperative infection, $23,801. CONCLUSIONS: Medicare beneficiaries who have adverse events during their index CABG hospitalization will significantly affect that hospital's financial risk. The challenge under the voluntary CABG bundled payment program will be to monitor and reduce adverse events and manage the services consumed by Medicare beneficiaries having adverse events delivered at all the venues of care.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Recursos em Saúde/estatística & dados numéricos , Reembolso de Seguro de Saúde/economia , Medicare , Pacotes de Assistência ao Paciente/economia , Complicações Pós-Operatórias/economia , Idoso , Idoso de 80 Anos ou mais , Ponte de Artéria Coronária/economia , Utilização de Instalações e Serviços/economia , Feminino , Recursos em Saúde/economia , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pacotes de Assistência ao Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Estados Unidos
4.
Curr Med Sci ; 38(6): 1075-1080, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30536072

RESUMO

The purpose of this study was to analyze the components of inpatient costs for coronary artery bypass graft (CABG) according to preoperative risk stratification and to provide evidence for improvement of diagnosis-related groups (DRGs) payment. All patients (n=458) receiving an isolated CABG between January 2014 and December 2016 in a tertiary referral center, in southwest China, were analyzed. Hospital mortality was predicted by the EuroSCORE II for each patient. The patients were subdivided into two groups according to the observed mortality (1.97%, 9/458): a high-risk group (group H, predicted mortality ≥1.97%) and a low-risk group (group L, predicted mortality <1.97%). Clinical outcomes, resource use, in-hospital direct costs, and reimbursement expenses were compared between the two groups. Significant differences existed between group L and group H in postoperative mortality (0.4% vs. 3.4%; P=0.02), postoperative complications (10.6% vs. 45.7%; P<0.001), postoperative length of hospital stay (17.5±4.9 days vs. 18.8±6.5 days, P=0.01), in-hospital costs ($20 256±3096 vs. $23 334±6332; P<0.001), and reimbursement expenses ($7775±2627 vs. $9639±3917; P<0.001). In general, a higher EuroSCORE II was significantly associated with a worse clinical outcome and increased costs. The CABG cost data provide evidence for improvement of DRGs payment.


Assuntos
Ponte de Artéria Coronária/economia , Tempo de Internação/economia , Grupo com Ancestrais do Continente Asiático , Feminino , Recursos em Saúde/economia , Custos Hospitalares , Mortalidade Hospitalar , Hospitais , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Período Pós-Operatório , Cuidados Pré-Operatórios/economia , Medição de Risco , Fatores de Risco
5.
J Cardiothorac Surg ; 13(1): 103, 2018 Oct 03.
Artigo em Inglês | MEDLINE | ID: mdl-30285811

RESUMO

BACKGROUND: There is a growing interest in using negative pressure wound therapy in closed surgical incision to prevent wound complications which continue to persist following surgery despite advances in infection measures. OBJECTIVES: To estimate the cost-effectiveness of single use negative pressure wound therapy (sNPWT) compared to standard of care in patients following coronary artery bypass grafting surgery (CABG) procedure to reduce surgical site complications (SSC) defined as dehiscence and sternotomy infections. METHOD: A decision analytic model was developed from the Germany Statutory Health Insurance payer's perspective over a 12-week time horizon. Baseline data on SSC, revision operations, length of stay, and readmissions were obtained from a prospective observational study of 2621 CABG patients in Germany. Effectiveness data for sNPWT was taken from a randomised open label trial conducted in Poland which randomised 80 patients to treatment with either sNPWT or standard care. Cost data (in Euros) were taken from the relevant diagnostic related groups and published literature. RESULTS: The clinical study reported an increase in wounds that healed without complications 37/40 (92.5%) in the sNPWT compared to 30/40 (75%) patients in the SC group p = 0.03. The model estimated sNPWT resulted in 0.989 complications avoided compared to 0.952 and the estimated quality adjusted life years were 0.8904 and 0.8593 per patient compared to standard care. The estimated mean cost per patient was €19,986 for sNPWT compared to €20,572 for SC resulting in cost-saving of €586. The findings were robust to a range of sensitivity analyses. CONCLUSION: The sNPWT can be considered a cost saving intervention that reduces surgical site complications following CABG surgery compared to standard care. We however recommend that additional economic studies should be conducted as new evidence on the use of sNPWT in CABG patients becomes available to validate the results of this economic analysis.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Tratamento de Ferimentos com Pressão Negativa/métodos , Padrão de Cuidado/estatística & dados numéricos , Infecção da Ferida Cirúrgica/prevenção & controle , Bandagens , Ponte de Artéria Coronária/economia , Análise Custo-Benefício , Feminino , Alemanha , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Tratamento de Ferimentos com Pressão Negativa/efeitos adversos , Tratamento de Ferimentos com Pressão Negativa/economia , Readmissão do Paciente/estatística & dados numéricos , Polônia , Estudos Prospectivos , Anos de Vida Ajustados por Qualidade de Vida , Reoperação/estatística & dados numéricos , Padrão de Cuidado/economia , Infecção da Ferida Cirúrgica/epidemiologia
7.
Circ Cardiovasc Qual Outcomes ; 11(9): e004818, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30354549

RESUMO

Background Postoperative pneumonia is the most common healthcare-associated infection in cardiac surgical patients, yet their impact across a 90-day episode of care remains unknown. Our objective was to examine the relationship between pneumonia and 90-day episode payments and outcomes among Medicare beneficiaries undergoing cardiac surgery. Methods and Results Medicare claims were used to identify beneficiaries with episodes of coronary artery bypass grafting (CABG; n=56 728) and valve surgery (n=56 377) across 1045 centers between April 2014 and March 2015. Using a published diagnosis code-based algorithm, we identified pneumonia in 6.4% CABG episodes and 6.6% of valve surgery episodes. We compared price-standardized 90-day episode payments and outcome measures (postoperative length of stay, discharge to postacute care, mortality, and readmission) between beneficiaries with and without pneumonia using hierarchical regression models, adjusting for patient factors and hospital random effects. Pneumonia was associated with 24.5% higher episode payments for CABG ($46 723 versus $37 496; P<0.001) and 26.5% higher episode payments for valve surgery ($61 544 versus $48 549; P<0.001). For both cohorts, pneumonia was significantly associated with longer postoperative length of stay (CABG: +4.1 days, valve: +5.6 days), more frequent discharge to postacute care (CABG: odds ratio [OR]=1.99, valve: OR=2.17), and higher rates of 30-day mortality (CABG: OR=2.42, valve: OR=2.57) and 90-day readmission (CABG: OR=1.20, valve: OR=1.25), all P<0.001. We compared episode payments and outcomes across terciles of pneumonia rates and found that high pneumonia rate hospitals had higher episode payments and poorer outcomes compared with episodes at low pneumonia rate hospitals in both CABG and valve surgery cohorts. Conclusions Postoperative pneumonia was associated with significantly higher 90-day episode payments and inferior outcomes at the patient and hospital level. Future work should examine whether reducing pneumonia after cardiac surgery reduces episode spending and improves outcomes, which could facilitate hospital success in value-based reimbursement programs.


Assuntos
Procedimentos Cirúrgicos Cardíacos/economia , Infecção Hospitalar/economia , Infecção Hospitalar/terapia , Cuidado Periódico , Planos de Pagamento por Serviço Prestado/economia , Custos de Cuidados de Saúde , Benefícios do Seguro/economia , Medicare/economia , Pneumonia/economia , Pneumonia/terapia , Demandas Administrativas em Assistência à Saúde , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/economia , Análise Custo-Benefício , Infecção Hospitalar/diagnóstico , Infecção Hospitalar/mortalidade , Bases de Dados Factuais , Feminino , Valvas Cardíacas/cirurgia , Humanos , Tempo de Internação/economia , Masculino , Alta do Paciente/economia , Readmissão do Paciente/economia , Pneumonia/diagnóstico , Pneumonia/mortalidade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
8.
Am Heart J ; 204: 178-185, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30077336

RESUMO

IMPORTANCE: Although percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are both commonly employed in the treatment of stable ischemic heart disease (SIHD), their ability to reduce subsequent heart attacks and death is currently in question. These procedures will come under increasing scrutiny as the healthcare reimbursement system moves away from the traditional fee for service model in favor of "pay for value". OBSERVATION: Both international and domestic data show wide variability in the use of PCI and CABG in patients with SIHD. There is evidence of ongoing quality improvement over the last 5 years in reducing the use of inappropriate procedures, but there is still room for improvement. We present ideas regarding health policy interventions that might help manage the transition to value-based payments in this area, including improvements in national registries, more rapid revision of appropriate use criteria, shared decision making, and evidence-based management of PCI in SIHD. CONCLUSIONS AND RELEVANCE: The use of revascularization procedures in patients with SIHD is potentially a model for how care might be improved with health care policy intervention. We suggest that the status quo, although apparently improved over the last 5 years, is still unacceptable when 25% of hospitals have a rate of unnecessary PCI in patients with SIHD that approaches 25%.


Assuntos
Ponte de Artéria Coronária , Política de Saúde , Isquemia Miocárdica/cirurgia , Intervenção Coronária Percutânea , Seguro de Saúde Baseado em Valor , Ponte de Artéria Coronária/economia , Ponte de Artéria Coronária/estatística & dados numéricos , Custos e Análise de Custo , Tomada de Decisões , Medicina Baseada em Evidências , Humanos , Isquemia Miocárdica/epidemiologia , Intervenção Coronária Percutânea/economia , Intervenção Coronária Percutânea/estatística & dados numéricos , Utilização de Procedimentos e Técnicas , Sistema de Registros , Mecanismo de Reembolso , Estados Unidos/epidemiologia , Procedimentos Desnecessários/economia
9.
Innovations (Phila) ; 13(4): 282-286, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30130263

RESUMO

OBJECTIVE: Totally endoscopic coronary artery bypass (TECAB) with robotic distal anastomosis and robotic-assisted minimally invasive coronary artery bypass (RA-MIDCAB) with robotic internal mammary artery harvest and direct hand-sewn distal anastomosis via an anterior thoracotomy have both been reported as safe and efficacious. We compared hospital cost and short-term outcomes between these techniques. METHODS: Patients who underwent robotic-assisted minimally invasive single-vessel Coronary artery bypass grafting (2011-2014) were retrospectively reviewed. One hundred consecutive patients underwent either TECAB (n = 50) or RA-MIDCAB (n = 50). The two groups were sequential with TECAB performed by one surgeon in the first portion of the study interval and RA-MIDCAB by another surgeon in the latter. Demographics, short-term outcomes, and hospital cost data were compared between the two groups. RESULTS: Patient demographics and preoperative risk factors were similar between the TECAB and RA-MIDCAB groups, as total operating room time. Cardiopulmonary bypass was used for 56% of TECAB and 0% of RA-MIDCAB cases (P < 0.001). Intensive care unit and hospital lengths of stay, along with postoperative morbidities, were similar between the two groups. Operative mortality was 2% in the TECAB and 0% in the RA-MIDCAB group (P = NS). Total hospital cost was significantly higher with TECAB compared with RA-MIDCAB (US $33,769 vs. $22,679, P < 0.001), which was primarily driven by operative costs (US $17,616 vs. $26,803, P < 0.001). CONCLUSIONS: Totally endoscopic coronary artery bypass and RA-MIDCAB both demonstrated excellent short-term clinical outcomes. However, TECAB was associated with significantly higher hospital costs. Further comparisons, including long-term outcomes, patient satisfaction, and functional status, are needed to evaluate whether this additional cost is justified.


Assuntos
Ponte de Artéria Coronária/economia , Custos Hospitalares/estatística & dados numéricos , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Robóticos/economia , Idoso , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/estatística & dados numéricos , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Resultado do Tratamento
10.
Am J Surg ; 216(6): 1037-1045, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30060911

RESUMO

BACKGROUND: Our objective was to determine the association between indicators of surgical quality - incidence of major complications and failure-to-rescue - and hospital market concentration in light of differences in costs of care. METHODS: Patients undergoing coronary artery bypass graft (CABG), colon resection, pancreatic resection, or liver resection in the 2008-2011 Nationwide Inpatient Sample were identified. The effect of hospital market concentration on major complications, failure-to-rescue, and inpatient costs was estimated at the lowest and highest mortality hospitals using multivariable regression techniques. RESULTS: A weighted total of 527,459 patients were identified. Higher market concentration was associated with between 4% and 6% increased odds of failure-to-rescue across all four procedures. Across procedures, more concentrated markets had decreased inpatient costs (average marginal effect ranging from -$3064 (95% CI: -$5812 - -$316) for CABG to -$4876 (-$7773 - -$1980) for liver resection. CONCLUSION: In less competitive (more concentrated) hospital markets, higher overall risk of failure-to-rescue after complications was accompanied by lower inpatient costs, on average. These data suggest that market controls may be leveraged to influence surgical quality and costs.


Assuntos
Setor de Assistência à Saúde/organização & administração , Custos Hospitalares , Hospitalização/economia , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Qualidade da Assistência à Saúde , Colectomia/efeitos adversos , Colectomia/economia , Colectomia/estatística & dados numéricos , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/economia , Ponte de Artéria Coronária/estatística & dados numéricos , Hepatectomia/efeitos adversos , Hepatectomia/economia , Hepatectomia/estatística & dados numéricos , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Hospitais , Humanos , Pancreatectomia/efeitos adversos , Pancreatectomia/economia , Pancreatectomia/estatística & dados numéricos , Estados Unidos
11.
Int J Cardiol ; 273: 63-68, 2018 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-30158068

RESUMO

BACKGROUND: Recent trials have reported similar clinical outcomes between on-pump and off-pump coronary artery bypass graft (CABG). However, long-term cost-effectiveness of these strategies is unknown. METHODS: A prespecified economic study was performed based on the MASS III trial. Costs were estimated for all patients based on observed healthcare resource usage over a 5-year follow-up. Health state utilities were evaluated with the SF-6D questionnaire. Cost-effectiveness was assessed as cost per quality-adjusted life-year (QALY) gained using a Markov model. Probabilistic sensitivity analysis with the Monte-Carlo simulation and cost-effectiveness acceptability curve were used to address uncertainty. RESULTS: Quality of life improved significantly in both groups during follow-up compared with baseline. At 5 years, when comparing on-pump and off-pump CABG groups, no differences were found in cumulative life-years (4.851 and 4.766 years, P = .319) and QALY gained (4.150 and 4.105 QALYs, P = .332). Mean cost in US dollars per patient during the trial did not differ significantly between the on-pump and off-pump groups ($5890.29 and $5674.75, respectively, P = .409). Over a lifetime horizon, the incremental cost-effectiveness ratio of on-pump versus off-pump CABG was $12,576 per QALY gained, which is above the suggested cost-effectiveness threshold range (from $3210 to 10,122). In the sensitivity analysis, the probability that on-pump CABG is cost-effective compared to off-pump surgery for a willingness-to-pay threshold of $3212 per QALY gained was <1%. For the $10,122 per QALY threshold, the same probability was 35%. CONCLUSION: This decision-analytic model suggests that on-pump CABG is not cost-effective when compared to off-pump CABG from a public health system perspective.


Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea/economia , Ponte de Artéria Coronária/economia , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/cirurgia , Análise Custo-Benefício/métodos , Brasil/epidemiologia , Ponte de Artéria Coronária/tendências , Ponte de Artéria Coronária sem Circulação Extracorpórea/tendências , Doença da Artéria Coronariana/epidemiologia , Análise Custo-Benefício/tendências , Feminino , Seguimentos , Humanos , Masculino , Cadeias de Markov
12.
Appl Health Econ Health Policy ; 16(5): 661-674, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29998450

RESUMO

BACKGROUND: There are limited economic evaluations comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multi-vessel coronary artery disease (MVCAD) in contemporary, routine clinical practice. OBJECTIVE: The aim was to perform a cost-effectiveness analysis comparing CABG and PCI in patients with MVCAD, from the perspective of the Australian public hospital payer, using observational data sources. METHODS: Clinical data from the Melbourne Interventional Group (MIG) and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) registries were analysed for 1022 CABG (treatment) and 978 PCI (comparator) procedures performed between June 2009 and December 2013. Clinical records were linked to same-hospital admissions and national death index (NDI) data. The incremental cost-effectiveness ratios (ICERs) per major adverse cardiac and cerebrovascular event (MACCE) avoided were evaluated. The propensity score bin bootstrap (PSBB) approach was used to validate base-case results. RESULTS: At mean follow-up of 2.7 years, CABG compared with PCI was associated with increased costs and greater all-cause mortality, but a significantly lower rate of MACCE. An ICER of $55,255 (Australian dollars)/MACCE avoided was observed for the overall cohort. The ICER varied across comparisons against bare metal stents (ICER $25,815/MACCE avoided), all drug-eluting stents (DES) ($56,861), second-generation DES ($42,925), and third-generation of DES ($88,535). Moderate-to-low ICERs were apparent for high-risk subgroups, including those with chronic kidney disease ($62,299), diabetes ($42,819), history of myocardial infarction ($30,431), left main coronary artery disease ($38,864), and heart failure ($36,966). CONCLUSIONS: At early follow-up, high-risk subgroups had lower ICERs than the overall cohort when CABG was compared with PCI. A personalised, multidisciplinary approach to treatment of patients may enhance cost containment, as well as improving clinical outcomes following revascularisation strategies.


Assuntos
Implante de Prótese Vascular/economia , Ponte de Artéria Coronária/economia , Doença das Coronárias/economia , Stents/economia , Idoso , Implante de Prótese Vascular/mortalidade , Ponte de Artéria Coronária/mortalidade , Doença das Coronárias/mortalidade , Doença das Coronárias/cirurgia , Análise Custo-Benefício , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pontuação de Propensão , Fatores de Risco
13.
J Thorac Cardiovasc Surg ; 156(4): 1436-1448.e2, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30017448

RESUMO

OBJECTIVE: The objective of this study was to determine if the implementation of a value-driven outcomes tool comprising modifiable quality and utilization metrics lowers cost and improves value of coronary artery bypass grafting (CABG) postoperative care. METHODS: Ten metrics were defined for CABG patients in 2 temporally separated phases. Clinical care protocols were designed and implemented to increase compliance with these metrics. Clinical outcomes and cost data were harvested from the electronic medical record using a proprietary value-driven outcomes tool and verified by a data management team. "Perfect care" was defined as achieving all 10 metrics per patient episode. RESULTS: Over a 45-month period, data of 467 consecutive patients who underwent isolated CABG were analyzed. "Perfect care" was successfully achieved in 304 patients (65.1%). There were no observed differences in mortality between patient groups. Linear regression analysis showed a negative correlation between percent compliance with "perfect care" and mean cost. When multivariate analysis was used to adjust for preoperative risk score, mean cost for patients with "perfect care" was 37.0% less than for those without "perfect care." CONCLUSIONS: In the context of focused institution-specific interventions to target quality and utilization metrics for CABG care, clinical care pathways and protocols informed by innovative tools that link automated tracking of these metrics to cost data might simultaneously promote quality and decrease costs, thereby enhancing value. This descriptive study provides preliminary support for a systematic approach to define, measure, and modulate the drivers of value for cardiothoracic surgery patients.


Assuntos
Ponte de Artéria Coronária , Cuidados Pós-Operatórios , Qualidade da Assistência à Saúde , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos Clínicos/normas , Ponte de Artéria Coronária/economia , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/normas , Análise Custo-Benefício , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/normas , Qualidade da Assistência à Saúde/economia , Qualidade da Assistência à Saúde/normas , Estudos Retrospectivos
14.
JAMA Cardiol ; 3(8): 761-766, 2018 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-29955882

RESUMO

Importance: Medicare's Bundled Payments for Care Improvement (BPCI) is a voluntary pilot program evaluating bundled payments for several common cardiovascular conditions. Evaluating the external validity of this program is important for understanding the effects of bundled payments on cardiovascular care. Objective: To determine whether participants in BPCI cardiovascular bundles are representative of US acute care hospitals and identify factors associated with participation. Design, Setting, and Participants: Retrospective cross-sectional study of hospitals participating in BPCI model 2 bundles for acute myocardial infarction (AMI), congestive heart failure (CHF), coronary artery bypass graft, and percutaneous coronary intervention and nonparticipating control hospitals (October 2013 to January 2017). The BPCI participants were identified using data from the Centers for Medicare and Medicaid Services, and controls were identified using the 2013 American Hospital Association's Survey of US Hospitals. Hospital structural characteristics and clinical performance data were obtained from the American Heart Association survey and Centers for Medicare and Medicaid Services. One hundred fifty-nine hospitals participating in BPCI model 2 cardiac bundles and 1240 nonparticipating control hospitals were compared, and a multivariable logistic regression was estimated to identify predictors of BPCI participation. Exposures: Bundled payments. Main Outcomes and Measures: Hospital-level structural characteristics and 30-day risk-adjusted readmission and mortality rates for AMI and CHF. Results: Compared with nonparticipants, BPCI participants were larger, more likely to be privately owned or teaching hospitals, had lower Medicaid bed day ratios (ratio of Medicaid inpatient days to total inpatient days: 17.0 vs 19.3; P < .001), and were less likely to be safety net hospitals (2.5% vs 12.3%; P < .001). The BPCI participants had higher AMI and CHF discharge volumes, were more likely to have cardiac intensive care units and catheterization laboratories, and had lower risk-standardized 30-day mortality rates for AMI (13.7% vs 16.6%; P = .001) and CHF (11.3 vs 12.4; P = .005). In multivariable analysis, larger hospital size and access to a cardiac catheterization laboratory were positively associated with participation. Being a safety net hospital was negatively associated with participation (odds ratio, 0.3; 95% CI, 0.1-0.7; P = .001). Conclusions and Relevance: Hospitals participating in BPCI model 2 cardiac bundles differed in significant ways from nonparticipating hospitals. The BPCI outcomes may therefore have limited external validity, particularly among small and safety net hospitals with limited clinical cardiac services.


Assuntos
Ponte de Artéria Coronária/economia , Insuficiência Cardíaca/economia , Hospitais/estatística & dados numéricos , Medicare , Infarto do Miocárdio/economia , Intervenção Coronária Percutânea/economia , Mecanismo de Reembolso , Cateterismo Cardíaco , Estudos Transversais , Tamanho das Instituições de Saúde , Humanos , Análise Multivariada , Razão de Chances , Readmissão do Paciente , Melhoria de Qualidade , Provedores de Redes de Segurança , Estados Unidos
16.
Semin Cardiothorac Vasc Anesth ; 22(4): 353-358, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29790423

RESUMO

BACKGROUND: Results of a previous study revealed an over-ordering of blood products for cardiac surgery and led to the creation of a new blood ordering algorithm. This follow-up study has been conducted to evaluate improvement in ordering practices. METHODS: Retrospective data were collected for 171 patients who underwent coronary artery bypass grafting or valve surgery from March 2015 to March 2016 to determine the crossmatch-to-transfusion ratio (C:tx) and potential cost savings. Results were compared with pre-algorithm values and considered statistically significant if the 95% confidence interval did not include zero. RESULTS: Prior to the algorithm, 100% of patients undergoing cardiac surgery were crossmatched. After instituting the algorithm, this decreased to 15%. The overall C:tx decreased from 7.97 to 2.14. Cost savings were calculated as $114.79 (coronary artery bypass grafting) and $129.05 (valve surgery) per patient. CONCLUSIONS: The creation of a new algorithm to guide ordering practices has significantly improved the C:tx, reduced unnecessary crossmatching, and lowered costs.


Assuntos
Algoritmos , Transfusão de Sangue/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte de Artéria Coronária/métodos , Adulto , Tipagem e Reações Cruzadas Sanguíneas/métodos , Transfusão de Sangue/economia , Procedimentos Cirúrgicos Cardíacos/economia , Ponte de Artéria Coronária/economia , Redução de Custos , Análise Custo-Benefício , Seguimentos , Humanos , Estudos Retrospectivos
17.
Int J Surg ; 54(Pt A): 7-17, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29678620

RESUMO

BACKGROUND: Hospital readmissions contribute substantially to the overall healthcare cost. Coronary artery bypass graft (CABG) is of particular interest due to its relatively high short-term readmission rates and mean hospital charges. METHODS: A retrospective review was performed on 2007-2011 data from California, Florida, and New York from the State Inpatient Databases, Healthcare Cost and Utilization Project. All patients ≥18 years of age who underwent isolated CABG and met inclusion/exclusion criteria were included. Insurance status was categorized by Medicaid, Medicare, Private Insurance, Uninsured, and Other. Primary outcomes were unadjusted rates and adjusted odds of readmission at 30- and 90-days. Secondary outcomes included diagnosis at readmission. RESULTS: A total of 177,229 were included in the analyses after assessing for exclusion criteria. Overall 30-day readmission rate was 16.1%; rates were highest within Medicare (18.4%) and Medicaid (20.2%) groups and lowest in the private insurance group (11.7%; p < 0.0001). Similarly, 90-day rates were highest in Medicare (27.3%) and Medicaid (29.8%) groups and lowest in the private insurance group (17.6%), with an overall 90-day rate of 24.0% (p < 0.0001). The most common 30-day readmission diagnoses were atrial fibrillation (26.7%), pleural effusion (22.5%), and wound infection (17.7%). Medicare patients had the highest proportion of readmissions with atrial fibrillation (31.7%) and pleural effusions (23.3%), while Medicaid patients had the highest proportion of readmissions with wound infections (21.8%). Similar results were found at 90 days. Risk factors for readmission included non-private insurance, age, female sex, non-white race, low median household income, non-routine discharge, length of stay, and certain comorbidities and complications. CONCLUSIONS: CABG readmission rates remain high and are associated with insurance status and racial and socioeconomic markers. Further investigation is necessary to better delineate the underlying factors that relate racial and socioeconomic disparities to CABG readmissions. Understanding these factors will be key to improving healthcare outcomes and expenditure.


Assuntos
Ponte de Artéria Coronária/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Idoso , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/etiologia , California , Comorbidade , Grupos de Populações Continentais/estatística & dados numéricos , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/economia , Feminino , Florida , Custos de Cuidados de Saúde , Humanos , Masculino , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , New York , Alta do Paciente , Readmissão do Paciente/economia , Derrame Pleural/epidemiologia , Derrame Pleural/etiologia , Estudos Retrospectivos , Fatores de Risco , Fatores Socioeconômicos , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Estados Unidos
18.
J Cardiovasc Surg (Torino) ; 59(6): 817-829, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29616525

RESUMO

INTRODUCTION: Cardiac rehabilitation (CR) is recommended for all cardiac patients including patients after cardiac surgery. Since the effect of CR after cardiac surgery has not been well established yet, we conducted a systematic review on the effects of CR for patients after cardiac surgery compared to treatment as usual. EVIDENCE ACQUISITION: A systematic review of randomized clinical trials (RCTs), quasi-randomized and prospective observational studies in The Cochrane Library, PubMed/MEDLINE and EMBASE was undertaken until October 18th, 2017. Adults after any kind of cardiac surgery were included. Primary outcome was all-cause mortality, other outcomes were serious adverse events, health-related quality of life, work participation, functioning and costs/cost-effectiveness. Risk of bias was evaluated, and the quality of evidence was assessed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. EVIDENCE SYNTHESIS: Eighteen RCTs and 15 observational studies were included. Low risk of bias was only observed in one observational study. Meta-analysis of RCTs suggested no significant difference of CR compared to control on mortality (random-effects relative risk (RR) 0.93 (95% CI: 0.40-1.81), while observational studies suggested statistically significant beneficial effect associated with CR (random-effects RR=0.49, 95% CI: 0.35 - 0.68). CR did not significantly affect any of the other outcomes. Due to the limited data TSA could not be performed. CONCLUSIONS: The body of evidence does not allow us to reach any reliable conclusions about the effectiveness of CR following cardiac surgery. Future trials need to be conducted with low risks of bias and clearly defined outcomes.


Assuntos
Reabilitação Cardíaca/métodos , Ponte de Artéria Coronária/reabilitação , Implante de Prótese de Valva Cardíaca/reabilitação , Reabilitação Cardíaca/efeitos adversos , Reabilitação Cardíaca/economia , Reabilitação Cardíaca/mortalidade , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/economia , Ponte de Artéria Coronária/mortalidade , Análise Custo-Benefício , Custos de Cuidados de Saúde , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/economia , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Qualidade de Vida , Recuperação de Função Fisiológica , Retorno ao Trabalho , Fatores de Risco , Resultado do Tratamento
20.
Ann Thorac Surg ; 106(2): 454-459, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29596822

RESUMO

BACKGROUND: A statewide database identified prolonged ventilation (PV) and acute renal failure (RF) as the biggest cost drivers after isolated coronary artery bypass grafting. Reducing these complications through regional collaboration should improve outcomes and lower health care costs. METHODS: A total of 27,978 patients who underwent isolated coronary artery bypass grafting were divided into pre- and post-quality improvement initiative groups (early era: 2008 to 2011, n = 15,176; later era: 2012 to 2015, n = 12,802). Focused learning sessions on PV and postoperative RF were undertaken in the earlier era. Incidence of death, PV, and RF in the two groups was analyzed using one-way analysis of variance and Fisher exact tests. RESULTS: The Society of Thoracic Surgeons (STS) predicted risk of mortality and predicted risk of mortality/morbidity were significantly higher in the later era (p < 0.01), as were STS predicted PV (10.1% vs 11.3%) and RF (3.4% vs 3.8%). Despite these increased risks, STS observed-to-expected ratios for mortality and mortality/morbidity fell. Observed rates for PV (10.5% vs 8.8%, p < 0.01) and RF (3.6% vs 2.3%, p < 0.01) were associated with STS observed-to-expected ratios of PV (1.04 vs 0.78) and RF (1.03 vs 0.60). Adjusting for case volume in the two eras, 271 cases of PV and 170 of RF were avoided, with estimated cost savings of $10,212,637 and $8,519,630, respectively. CONCLUSIONS: A regional collaboration using a statewide STS and an all-payor database with focused quality improvement is a powerful tool for change. Despite rising risks for mortality and morbidity, outcomes for PV and RF improved and produced significant cost savings. Applying these efforts nationally can enormously affect patient care and health care costs.


Assuntos
Ponte de Artéria Coronária/economia , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Redução de Custos , Pesquisas sobre Serviços de Saúde , Melhoria de Qualidade , Idoso , Estudos de Coortes , Angiografia Coronária/métodos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
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