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Objective: This manuscript aims to explore the impact of race/ethnicity and socioeconomic status on in-hospital complication rates after left atrial appendage closure (LAAC)., Methods: The US National Inpatient Sample was used to identify hospitalisations for LAAC between 1 October 2015 to 31 December 2018. These patients were stratified by race/ethnicity and quartiles of median neighbourhood income. The primary outcome was the occurrence of in-hospital major adverse events, defined as a composite of postprocedural bleeding, cardiac and vascular complications, acute kidney injury and ischaemic stroke., Results: Of 6478 unweighted hospitalisations for LAAC, 58% were male and patients of black, Hispanic and 'other' race/ethnicity each comprised approximately 5% of the cohort. Adjusted by the older Americans population, the estimated number of LAAC procedures was 69.2/100 000 for white individuals, as compared with 29.5/100 000 for blacks, 47.2/100 000 for Hispanics and 40.7/100 000 for individuals of 'other' race/ethnicity. Black patients were ~5 years younger but had a higher comorbidity burden. The primary outcome occurred in 5% of patients and differed significantly between racial/ethnic groups (p<0.001) but not across neighbourhood income quartiles (p=0.88). After multilevel modelling, the overall rate of in-hospital major adverse events was higher in black patients as compared with whites (OR: 1.60, 95% CI 1.22 to 2.10, p<0.001); however, the incidence of acute kidney injury was higher in Hispanics (OR: 2.19, 95% CI 1.52 to 3.17, p<0.001). No significant differences were found in adjusted overall in-hospital complication rates between income quartiles., Conclusion: In this study assessing racial/ethnic disparities in patients undergoing LAAC, minorities are under-represented, specifically patients of black race/ethnicity. Compared with whites, black patients had higher comorbidity burden and higher rates of in-hospital complications. Lower socioeconomic status was not associated with complication rates., Competing Interests: Competing interests: DH is on the Advisory Board for Boston Scientific, unpaid., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This study documents trends in risk-adjusted quality and cost for a variety of inpatient surgical procedures among Medicare beneficiaries from 2002 through 2015, which can provide valuable insight on future strategies to improve public health and health care., Methods: We focused on 11 classes of inpatient surgery, defined by the Agency for Health Research and Quality's (AHRQ's) Clinical Classification System. The surgical classes studied included a wide range of surgeries, including tracheostomy, heart valve procedures, colorectal resection, and wound debridement, among others. For each surgical class, we assessed trends in treatment costs and quality outcomes, as defined by 30-day survival without unplanned readmissions, among Medicare beneficiaries receiving these procedures during hospital stays. Quality and costs were adjusted for patient severity based on demographics, comorbidities, and community context. We also explored surgical innovations of these 11 classes of inpatient surgery from 2002-2015., Results: We found significant improvements in quality for 7 surgical classes, ranging from 0.08% (percutaneous transluminal coronary angioplasty) to 0.74% (heart valve procedures) per year. Changes in cost varied by surgery, the significant decrease in cost ranged from -2.59% (tracheostomy) to -0.34% (colorectal resection) per year. Treatment innovation occurred with respect to surgical procedures utilized for heart valve procedures and colorectal resection, which may be associated with the decrease in surgical cost., Conclusions: Our results suggest that there was significant quality improvement for 7 surgery categories over the 14-year study period. Costs decreased significantly for 6 surgery categories, and increased significantly for 3 other categories., Competing Interests: The authors have declared that no competing interests exist.

Background: Institutional experience has been associated with reduced mortality after coronary artery bypass grafting and valve operations. Using a contemporary, national cohort, we examined the impact of hospital volume on hospitalization costs and postdischarge resource utilization after these operations., Methods: Adults undergoing elective coronary artery bypass grafting or valve operations were identified in the 2016 to 2017 Nationwide Readmissions Database. Institutions were grouped into volume quartiles based on annual elective cardiac surgery caseload, and comparisons were made between the lowest and highest quartiles, using generalized linear models., Results: Of an estimated 296,510 patients, 24.8% were treated at low-volume hospitals and 25.2% at high-volume hospitals. Compared with patients treated at low-volume hospitals, patients managed at high-volume hospitals were younger, had more comorbidities, and more frequently underwent combined coronary artery bypass grafting valve (13.0% vs 12.3%, P < .001) and multivalve operations (6.2% vs 3.1%, P < .001). After adjustment, operations at high-volume hospitals were associated with a $7,600 reduction (95% confidence interval $4,700-$10,500) in costs. High-volume hospitals were also associated with reduced odds of mortality, non-home discharge, and 30-day non-elective readmission compared to low-volume hospitals., Conclusion: Despite increased complexity at high-volume centers, greater operative volume was independently associated with reduced hospitalization costs and mortality after elective cardiac operations. Reduction in non-home discharge and readmissions suggests this effect to extend beyond acute hospitalization, which may guide value-based care paradigms., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: Adoption of implantable left ventricular assist devices has dramatically improved survival and quality of life in suitable patients with end-stage heart failure. In the era of value-based healthcare delivery, assessment of clinical outcomes and resource use associated with left ventricular assist devices is warranted., Methods: Adult patients undergoing left ventricular assist device implantation from 2008 to 2016 were identified using the National Inpatient Sample. Hospitals were designated as low-volume, medium-volume, or high-volume institutions based on annual institutional left ventricular assist device case volume. Multivariable logistic regression was used to evaluate adjusted odds of mortality across left ventricular assist device volume tertiles., Results: Over the study period, an estimated 23,972 patients underwent left ventricular assist device implantation with an approximately 3-fold increase in the number of annual left ventricular assist device implantations performed (P for trend <.001). In-hospital mortality in patients with left ventricular assist devices decreased from 19.6% in 2008 to 8.1% in 2016 (P for trend <.001) and was higher at low-volume institutions compared with high-volume institutions (12.0% vs 9.2%, P < .001). Although the overall adjusted mortality was higher at low-volume compared with high-volume institutions (adjusted odds ratio, 1.66; 95% confidence interval, 1.28-2.15), this discrepancy was only significant for 2008 and 2009 (low-volume 2008 adjusted odds ratio, 5.5; 95% confidence interval, 1.9-15.8; low-volume 2009 adjusted odds ratio, 2.3; 95% confidence interval, 1.4-3.8)., Conclusions: Left ventricular assist device use has rapidly increased in the United States with a concomitant reduction in mortality and morbidity. With maturation of left ventricular assist device technology and increasing experience, volume-related variation in mortality and resource use has diminished. Whether the apparent uniformity in outcomes is related to patient selection or hospital quality deserves further investigation., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Optimal methods to assess resource utilization in congenital heart surgery remain unclear. We compared traditional cost-to-charge ratio methods with newer standardized cost methods that aim to more directly assess resources consumed., Methods: Clinical data from The Society of Thoracic Surgeons Database were linked with resource use data from the Pediatric Health Information Systems Database (2010 to 2015). Standardized cost methods specific to the congenital heart surgery population were developed and compared with cost-to-charge ratio methods. Resource use in the overall population and variability across hospitals were described using hierarchical mixed effect models adjusting for case-mix., Results: Overall, 43 hospitals (65,331 patients) were included. There were minimal population-level differences in the distribution of resource use as estimated by the two methods. At the hospital level, there was less apparent variability in resource use across centers with the standardized cost vs cost-to-charge ratio method, overall (coefficient of variation 20% vs 25%) and across complexity (The Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery [STAT]) categories. When hospitals were categorized into tertiles by resource use, 33% changed classification depending on which resource use method was used (26% by one tertile and 7% by two tertiles)., Conclusions: In this first evaluation of standardized cost methodology in the congenital heart population, we found minimal differences vs traditional methods at the population level. At the hospital level, the magnitude of variation in resource use was less with standardized cost methods, and approximately one third of centers changed resource use categories depending on the methodology used. Because of these differences, care should be taken in future studies and in benchmarking and reporting efforts in selecting optimal methodology., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: This study examined postoperative heart failure (HF) and respiratory failure (RF) complications and related healthcare utilization for one year following cardiac surgery., Methods: This study identified adult patients undergoing isolated coronary artery bypass graft (CABG) and/or valve procedures from the Cerner Health Facts® database. It included patients experiencing postoperative HF or RF complications. We quantified healthcare utilization using the frequency of inpatient admissions, emergency department (ED) visits with or without hospital admission, and outpatient visits. We then determined direct hospital costs from the determined healthcare utilization. We analyzed trends over time for both HF and RF and evaluated the association between surgery type and HF complication., Results: Of 10,298 patients with HF complications, 1,714 patients (16.6%) developed persistent HF; of the 10,385 RF patients, 175 (1.7%) developed persistent RF. Healthcare utilization for those with persistent complications over the one-year period following index hospital discharge comprised an average number of the following visit types: Inpatient (1.49 HF; 1.55 RF), Outpatient (2.02, 0.51), ED without hospital admission (0.33, 0.13), ED + Inpatient (0.08, 0.06). Per patient annual costs related to persistent complications of HF and RF were $20,857 and $30,745, respectively. There was a significant association between cardiac surgical type and the incidence of HF, with risk for isolated valve procedures (adjusted OR 2.60; 95% CI: 2.35-2.88) and CABG + valve procedures (adjusted OR 2.38; 95% CI: 2.17-2.61) exceeding risk for isolated CABG procedures., Conclusions: This study demonstrates that HF and RF complication rates post cardiac surgery are substantial, and complication-related healthcare utilization over the first year following surgery results in significant incremental costs. Given the need for both payers and providers to focus on healthcare cost reduction, this study fills an important gap in quantifying the mid-term economic impact of postoperative cardiac surgical complications., Competing Interests: This work was supported financially by Edwards Lifesciences. MS is an employee of Edwards Lifesciences. ADS works as a consultant for Edwards Lifesciences. SHM works as a consultant and AVS, BLAG, XZ, and HOY as employees, for Boston Strategic Partners, Inc., who received funds from Edwards Lifesciences to perform the research. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The data that support the findings of this study are available as the Cerner Health Facts® database from the Cerner Corporation, which is available to the public through licensure with Cerner Corporation.

Objective: Regionalization directs patients to high-volume hospitals for specialized care. We investigated regionalization trends and outcomes in pediatric cardiac surgery., Data Sources/study Setting: Statewide inpatient data from eleven states between 2000 and 2012., Study Design: Mortality, length of stay (LOS), and cost were assessed using multivariable hierarchical regression with state and year fixed effects. Primary predictor was hospital case-volume, categorized into low-, medium-, and high-volume tertiles., Data Collection/extraction Methods: We used Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) to select pediatric cardiac surgery discharges., Principal Findings: In total, 2841 (8.5 percent), 8348 (25.1 percent), and 22 099 (66.4 percent) patients underwent heart surgeries in low-, medium-, and high-volume hospitals. Mortality decreased over time, but remained higher in low- and medium-volume hospitals. High-volume hospitals had lower odds of mortality and cost than low-volume hospitals (odds ratio [OR] 0.59, P < 0.01, and relative risk [RR] 0.91, P < 0.01, respectively). LOS was longer for high- and medium-volume hospitals, compared to low-volume hospitals (high-volume: RR 1.18, P < 0.01; medium-volume: RR 1.05, P < 0.01)., Conclusions: Regionalization reduced mortality and cost, indicating fewer complications, but paradoxically increased LOS. Further research is needed to explore the full impact on health care utilization., (© Health Research and Educational Trust.)

Background The contemporary incidence of and reasons for early readmission after infective endocarditis ( IE ) are not well known. Therefore, we analyzed 30-day readmission demographics after IE from the US Nationwide Readmission Database. Methods and Results We examined the 2010 to 2014 Nationwide Readmission Database to identify index admissions for a primary diagnosis of IE with survival at discharge. Incidence, reasons, and independent predictors of 30-day unplanned readmissions were analyzed. In total, 11 217 patients (24.8%) were nonelectively readmitted within 30 days among the 45 214 index admissions discharged after IE . The most common causes of readmission were IE (20.5%), sepsis (8.7%), complications of device/graft (8.1%), and congestive heart failure (7.6%). In-hospital mortality and the valvular surgery rates during the readmissions were 8.1% and 9.1%, respectively. Discharge to home or self-care, undergoing valvular surgery, aged ≥60 years, and having private insurance were independently associated with lower rates of 30-day readmission. Length of stay of ≥10 days, congestive heart failure, diabetes mellitus, renal failure, chronic pulmonary disease, peripheral artery disease, and depression were associated with higher risk. The total hospital costs of readmission were $48.7 million per year (median, $11 267; interquartile range, $6021-$25 073), which accounted for 38.6% of the total episodes of care (index+readmission). Conclusions Almost 1 in 4 patients was readmitted within 30 days of admission for IE . The most common reasons were IE , other infectious causes, and cardiac causes. A multidisciplinary approach to determine the surgical indications and close monitoring are necessary to improve outcomes and reduce complications in in-hospital and postdischarge settings.

Medicare's Bundle Payment for Care Improvement (BPCI) Model 2 groups reimbursement for valve surgery into 90-day episodes of care, which include operative costs, inpatient stay, physician fees, postacute care, and readmissions up to 90 days postprocedure. We analyzed our BPCI patients' 90-day outcomes to understand the late financial risks and implications of the bundle payment system for valve patients. All BPCI valve patients from October 2013 (start of risk-sharing phase) to December 2015 were included. Readmissions were categorized as early (≤30 days) or late (31-90 days). Data were collected from institutional databases as well as Medicare claims. Analysis included 376 BPCI valve patients: 202 open and 174 transcatheter aortic valves (TAVR). TAVR patients were older (83.6 vs 73.8 years; P = 0.001) and had higher Society of Thoracic Surgery predicted risk (7.1% vs 2.8%; P = 0.001). Overall, 18.6% of patients (70/376) had one-or-more 90-day readmission, and total claim was on average 51% greater for these patients. Overall readmissions were more common among TAVR patients (22.4% (39/174) vs 15.3% (31/202), P = 0.052) as was late readmission. TAVR patients had significantly higher late readmission claims, and early readmission was predictive of late readmission for TAVR patients only (P = 0.04). Bundled claims for a 90-day episode of care are significantly increased in patients with readmissions. TAVR patients represent a high-risk group for late readmission, possibly a reflection of their chronic disease processes. Being able to identify patients at highest risk for 90-day readmission and the associated claims will be valuable as we enter into risk-bearing episodes of care agreements with Medicare., (Copyright © 2018 Elsevier Inc. All rights reserved.)

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.

Background: The Ruth L. Kirschstein Institutional National Research Service Award (T32) provides institutions with financial support to prepare trainees for careers in academic medicine. In 1990, the Cardiac Surgery Branch of the National Heart, Lung and Blood Institute (NHLBI) was replaced by T32 training grants, which became crucial sources of funding for cardiothoracic (CT) surgical research. We hypothesized that T32 grants would be valuable for CT surgery training and yield significant publications and subsequent funding., Methods: Data on all trainees (past and present) supported by CT T32 grants at two institutions were obtained (T32), along with information on trainees from two similarly sized programs without CT T32 funding (Non-T32). Data collected were publicly available and included publications, funding, degrees, fellowships, and academic rank. Non-surgery residents and residents who did not pursue CT surgery were excluded., Results: Out of 76 T32 trainees and 294 Non-T32 trainees, data on 62 current trainees or current CT surgeons (T32: 42 vs Control: 20) were included. Trainees who were supported by a CT T32 grant were more likely to pursue CT surgery after residency (T32: 40% [30/76] vs Non-T32: 7% [20/294], P < .0001), publish manuscripts during residency years (P < .0001), obtain subsequent NIH funding (T32: 33% [7/21] vs Non-T32: 5% [1/20], P = .02), and pursue advanced fellowships (T32: 41% [9/22] vs Non-T32: 10% [2/20], P = .02)., Conclusions: T32 training grants supporting CT surgery research are vital to develop academic surgeons. These results support continued funding by the NHLBI to effectively develop and train the next generation of academic CT surgeons., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: To reduce inefficiency and waste associated with care fragmentation, many current programs target greater clinical integration among physicians. However, these programs have led to only modest Medicare spending reductions. Most programs focus on formal integration, which often bears little resemblance to actual physician interaction patterns., Objectives: To examine how physician interaction patterns vary between health systems and to assess whether variation in informal integration is associated with care delivery payments., Design, Setting, and Participants: National Medicare data from January 1, 2008, through December 31, 2011, identified 253 545 Medicare beneficiaries (aged ≥66 years) from 1186 health systems where Medicare beneficiaries underwent coronary artery bypass grafting (CABG) procedures. Interactions were mapped between all physicians who treated these patients-including primary care physicians and surgical and medical specialists-within a health system during their surgical episode. The level of informal integration was measured in these networks of interacting physicians. Multivariate regression models were fitted to evaluate associations between payments for each surgical episode made on a beneficiary's behalf and the level of informal integration in the health system where the patient was treated., Exposures: The informal integration level of a health system., Main Outcomes and Measures: Price-standardized total surgical episode and component payments., Results: The total 253 545 study participants included 175 520 men (69.2%; mean [SD] age, 74.51 [5.75] years) and 78 024 women (34.3%; 75.67 [5.91] years). One beneficiary of the 253 545 participants did not have sex information. The low level of informal clinical integration included 84 598 patients (33.4%; mean [SD] age, 75.00 [5.93] years); medium level, 84 442 (33.30%; 74.94 [5.87] years); and high level, 84 505 (33.34%; 74.66 [5.72] years) (P < .001). Informal integration levels varied across health systems. After adjusting for patient, health-system, and community factors, higher levels of informal integration were associated with significantly lower total episode and component payments (β coefficients for informal integration were -365.87 [95% CI, -451.08 to -280.67] for total episode payments, -182.63 [-239.80 to -125.46] for index hospitalization, -43.13 [-55.53 to -30.72] for physician services, -74.48 [-103.45 to -45.51] for hospital readmissions, and -62.04 [-88.00 to -36.07] for postacute care; P < .001 for each association). When beneficiaries were treated in health systems with higher informal integration, the greatest savings of lower estimated payments were from hospital readmissions (13.0%) and postacute care services (5.8%)., Conclusions and Relevance: Informal integration is associated with lower spending. Although most programs that seek to promote clinical integration are focused on health systems' formal structures, policy makers may also want to address informal integration.

Objective: To evaluate whether participation in Medicare's Acute Care Episode (ACE) Demonstration Program-an early, small, voluntary episode-based payment program-was associated with a change in expenditures or quality of care., Data Sources/study Setting: Medicare claims for patients who underwent cardiac or orthopedic surgery from 2007 to 2012 at ACE or control hospitals., Study Design: We used a difference-in-differences approach, matching on baseline and pre-enrollment volume, risk-adjusted Medicare payments, and clinical outcomes to identify controls., Principal Findings: Participation in the ACE Demonstration was not significantly associated with 30-day Medicare payments (for orthopedic surgery: -$358 with 95 percent CI: -$894, +$178; for cardiac surgery: +$514 with 95 percent CI: -$1,517, +$2,545), or 30-day mortality (for orthopedic surgery: -0.10 with 95 percent CI: -0.50, 0.31; for cardiac surgery: -0.27 with 95 percent CI: -1.25, 0.72). Program participation was associated with a decrease in total 30-day post-acute care payments (for cardiac surgery: -$718; 95 percent CI: -$1,431, -$6; and for orthopedic surgery: -$591; 95 percent CI: $-$1,161, -$22)., Conclusions: Participation in Medicare's ACE Demonstration Program was not associated with a change in 30-day episode-based Medicare payments or 30-day mortality for cardiac or orthopedic surgery, but it was associated with lower total 30-day post-acute care payments., (© Health Research and Educational Trust.)

Background: Increasing hospital market concentration (with concomitantly decreasing hospital market competition) may be associated with rising hospital prices. Hospital markup - the relative increase in price over costs - has been associated with greater hospital market concentration., Methods: Patients undergoing a cardiothoracic or gastrointestinal procedure in the 2008-2011 Nationwide Inpatient Sample (NIS) were identified and linked to Hospital Market Structure Files. The association between market concentration, hospital markup and hospital for-profit status was assessed using mixed-effects log-linear models., Results: A weighted total of 1,181,936 patients were identified. In highly concentrated markets, private for-profit status was associated with an 80.8% higher markup compared to public/private not-for-profit status (95%CI: +69.5% - +96.9%; p < 0.001). However, private for-profit status in highly concentrated markets was associated with only a 62.9% higher markup compared to public/private not-for-profit status in unconcentrated markets (95%CI: +45.4% - +81.1%; p < 0.001)., Conclusion: Hospital for-profit status modified the association between hospitals' market concentration and markup. Government and private not-for-profit hospitals employed lower markups in more concentrated markets, whereas private for-profit hospitals employed higher markups in more concentrated markets., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To evaluate and describe resource use and perioperative morbidities among those patients with genetic conditions undergoing cardiac surgery., Study Design: Using the Pediatric Health Information System database, we identified patients ≤18 years old with cardiac surgery classified by Risk Adjustment for Congenital Heart Surgery (RACHS) during 2003-2014. A total of 95 253 patients met study criteria and included no genetic conditions (84.6%), trisomy 21 (9.9%), trisomy 13 or 18 (0.2%), 22q11 deletion (0.8%), Turner syndrome (0.4%), and "other" genetic conditions (4.2%). We compared perioperative complications and procedures in each genetic condition with patients without genetic conditions using regression analysis., Results: All groups with genetic conditions, excluding trisomy 21 RACHS 3-5, experienced increased length of stay and cost among survivors. Complications varied by genetic condition, with patients with trisomy 21 having increased odds of pulmonary hypertension and nosocomial infections. Patients with 22q11 only had increased odds of infection. Patients with Turner syndrome had increased odds of acute renal failure (OR 2.35). Patients with trisomy 13 or 18 had increased odds of pulmonary hypertension (OR 3.13), acute renal failure (OR 2.93), cardiac arrest (OR 2.84), and nosocomial infections (OR 3.53), and those with "other" genetic conditions had increased odds of all complications., Conclusions: Children with congenital heart disease and genetic conditions, except trisomy 21 RACHS 3-5, had increased costs and length of stay. Perioperative morbidities were more common and differed across genetic condition subgroups. Patient-specific risk factors are important for risk stratification, benchmarking, and counseling with families., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Policymakers have proposed risk-adjusted bundled payment as the single most promising method of linking reimbursement to value rather than to quantity of service. Our objective was to assess the relationship between risk and cost to develop a model for forecasting the costs of cardiac operations under a bundled payment scheme., Methods: All patients undergoing adult cardiac operations for which there was a Society of Thoracic Surgeons (STS) risk score over a 5-year period (2008 to 2013) at a tertiary care, university hospital were reviewed. Patients were stratified into five groups based on preoperative risk as a basis for negotiating risk-adjusted bundles. A multivariable regression model was developed to analyze the relationship between risk and log-transformed costs. Monte Carlo simulation was performed to validate the model by comparing predicted with actual fiscal year 2013 costs., Results: Among the 2,514 patients analyzed, preoperative risk was strongly correlated with costs (p < 0.001) but was able to explain only 28% (R(2) = 0.28) of the variation in costs between individual patients. The use of bundling to diffuse and adjust for risk improved prediction to only 33% (R(2) = 0.33). Actual costs in 2013 were $21.6M compared with predicted costs of $19.3M (±$350K), which is well outside the forecast's 95% confidence interval., Conclusions: Even among the most routine cardiac operations and with use of the most widely validated surgical risk score available, much of the variation in costs cannot be explained by preoperative risk or surgeon. Consequently, policymakers should reexamine whether individual practices or insurers are best suited to manage the residual financial risk., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Importance: As robotic-assisted cardiac surgical procedures increase nationwide, surgeons need to be educated on the safety of the new modality compared with that of open technique., Objective: To compare complications, length of stay (LOS), actual cost, and mortality between nonrobotic and robotic-assisted cardiac surgical procedures., Design, Setting, and Participants: Weighted data on cardiac patients who had undergone operations involving the valves or septa and vessels, as well as other heart and pericardium procedures, from January 1, 2008, to December 31, 2011, were obtained from the Nationwide Inpatient Sample via the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. Propensity score matching was used to match each robotic-assisted case to 2 nonrobotic cases on 14 characteristics., Main Outcomes and Measures: Complications, median LOS, actual cost, and mortality., Results: Exploratory analysis found a total of 1,374,653 cardiac cases (1,369,454 [99.6%] nonrobotic and 5199 [0.4%] robotic-assisted cases). After propensity score matching, there were 10,331 (66.5%) nonrobotic cases and 5199 (33.5%) robotic-assisted cases. Cardiac operations included 1630 (10.5%) involving the valves or septa, 6616 (42.6%) involving the vessels, and 7284 (46.9%) other heart and pericardium procedures. Robotic-assisted compared with nonrobotic surgery had a higher median cost ($39,030 vs $36,340; P < .001) but lower LOS (5 vs 6 days; P < .001) and lower mortality (1.0% vs 1.9%; P < .001). Robotic-assisted surgery had significantly fewer complications for all operation types (30.3% vs 27.2%; P < .001)., Conclusions and Relevance: Overall, robotic-assisted surgery has significantly reduced median LOS, complications, and mortality compared with nonrobotic surgery. Results of this study support the contention that robotic-assisted surgery is as safe as nonrobotic surgery and offers the surgeon an additional technique for performing cardiac surgery.

Background: There are very sparse data on patient outcomes related to the use of extracorporeal membrane oxygenation (ECMO) prior to heart operation in children with congenital heart disease. This study was designed to evaluate this association using the Pediatric Health Information System (PHIS) database., Hypothesis: We hypothesize that patients receiving ECMO prior to heart operation will have worse outcomes, including mortality, compared with patients receiving ECMO after heart operation., Methods: Patients age ≤18 years receiving ECMO before or after pediatric heart operation (with or without cardiopulmonary bypass) at a PHIS-participating hospital from 2004 to 2013 were included. Multivariable logistic regression or Cox proportional-hazards models were fitted to study the effect of timing of ECMO initiation in relation to cardiac surgery on study outcomes., Results: A total of 3498 patients from 42 hospitals qualified for inclusion. Of these, 494 (14%) received ECMO prior to heart operation (presurgery ECMO) and 3004 (86%) received ECMO after heart operation (postsurgery ECMO). Unadjusted mortality was significantly lower in the presurgery ECMO group compared with the postsurgery ECMO group (30% vs 45%; P < 0.0001). After adjusting for patient and center characteristics, odds of mortality were significantly lower in the presurgery ECMO group (odds ratio: 0.46, 95% confidence interval: 0.36-0.59, P < 0.0001). There were no significant differences in ECMO duration, length of hospital stay, and hospital charges between the 2 groups in adjusted models., Conclusions: This study suggests that ECMO can be used with satisfactory outcomes prior to heart operation in children with congenital heart disease., (© 2014 Wiley Periodicals, Inc.)

Hospital volume has been associated with improved outcomes in congenital cardiac surgery. However, the relationship between hospital volume and hospitalization cost remains unclear. This study examines the relationship between hospital surgical volume and hospitalization costs, while accounting for measures of quality, in children undergoing congenital heart surgery. A retrospective, repeated cross-sectional analysis was performed, using discharges from the 2006 and 2009 Kids' Inpatient Database. All pediatric admissions (<18 years) with a Risk Adjustment for Congenital Heart Surgery procedure and hospitalization cost/charge data were included. Multivariate, linear mixed regression models were run on hospitalization costs, with and without adjustment for indicators of quality (hospital mortality rate and complication rate). Both medium and high-volume hospitals (200-400 cases/year and >400 cases/year, respectively) were associated with lower odds of mortality but not occurrence of a complication. Hospital mortality was associated with the largest increase in hospitalization costs. High-volume hospitals (>400 cases/year) were associated with the lowest hospitalization costs per discharge ($37,775, p < 0.01) when compared to low-($43,270) and medium($41,085)-volume hospitals, prior to adjusting for quality indicators. However, when adjusting for hospital mortality rate, high-volume hospitals no longer demonstrated significant cost savings. When adjusting for hospital complication rate, high-volume hospitals continued to have the lowest hospitalization costs. High-volume hospitals are associated with a reduction in hospitalization costs that appear to be mediated through improvements in quality.

Background: Anesthesiologists are frequently involved in efforts to meet perioperative quality metrics. The degree to which hospitals compete on publicly reported quality measures, however, is unclear. We hypothesized that hospitals in more competitive environments would be more likely to compete on quality and thus perform better on such measures. To test our hypothesis, we studied the relationship between competition and quality in hospitals providing procedural cardiac care and participating in a national quality database., Methods: For hospitals performing heart valve surgery (HVS) and delivering acute myocardial infarction (AMI) care in the Hospital Compare database, we assessed the degree of intrahospital competition using both geographical radius and federally defined metropolitan statistical area (MSA) to determine the degree of intrahospital competition. For each hospital, we then correlated the degree of competition with quality measure performance, mortality, patient volume, and per-patient Medicare costs for both HVS and AMI., Results: Six hundred fifty-three hospitals met inclusion criteria for HVS and 1898 hospitals for AMI care. We found that for both definitions of competition, hospitals facing greater competition did not demonstrate better quality measure performance for either HVS or AMI. For both diagnoses, competition by number of hospitals correlated positively with cost: partial correlation coefficients = 0.40 (0.42 for MSA) (P < 0.001) for HVS and 0.52 (0.47 for MSA) (P < 0.001) for AMI., Conclusions: An analysis of the Hospital Compare database found that competition among hospitals correlated overall with increased Medicare costs but did not predict better scores on publicly reported quality metrics. Our results suggest that hospitals do not compete meaningfully on publicly reported quality metrics or costs.

Introduction: Advances in highly active antiretroviral therapy have dramatically improved the lifespan of patients infected with human immunodeficiency virus (HIV). We sought to examine the impact of HIV status on outcomes in patients undergoing cardiovascular surgery., Methods: We identified 5,621,817 patients who underwent coronary artery bypass graft (CABG), valve, aortic, or other cardiovascular surgery between 1998 and 2009 from the Nationwide Inpatient Sample. Of these, 9771 (0.17%) patients were seropositive for HIV. Using multivariable logistic regression modeling and 1:1 propensity-score matching, we determined the influence of HIV infection on outcomes., Results: The percentage of HIV+ patients undergoing cardiovascular surgery increased significantly from 0.09% to 0.23%. HIV+ patients were more often male, black, younger than 55 years of age, and on Medicaid, and they were more likely to undergo valve and other cardiovascular surgeries, but less likely to have CABG. Among propensity-matched pairs, patients with HIV were at no increased risk for in-patient mortality. HIV+ patients were more likely to receive a blood transfusion and have any postoperative complication. Patients with HIV were less likely to have a postoperative stroke. Rates of pneumonia, renal complications, and wound infection were similar between the groups. The median length of stay and mean total cost were not different between the groups. Factors that predicted in-hospital death in HIV+ patients included metastatic cancer, coagulopathy, renal failure, and aortic, other, or combined surgical procedure., Conclusions: Cardiovascular surgery can be performed safely on patients with HIV with no increased hospital mortality and only minimal increased need for blood transfusion., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Small series of thoracotomy for mitral valve repair have demonstrated clinical benefit. This multi-institutional administrative database analysis compares outcomes of thoracotomy and sternotomy approaches for mitral repair., Methods: The Premier database was queried from 2007 to 2011 for mitral repair hospitalizations. Premier contains billing, cost, and coding data from more than 600 US hospitals, totaling 25 million discharges. Thoracotomy and sternotomy approaches were identified through expert rules; robotics were excluded. Propensity matching on baseline characteristics was performed. Regression analysis of surgical approach on outcomes and costs was modeled., Results: Expert rule analysis positively identified thoracotomy in 847 and sternotomy in 566. Propensity matching created 2 groups of 367. Mortalities were similar (thoracotomy 1.1% vs sternotomy 1.9%). Sepsis and other infections were significantly lower with thoracotomy (1.1% vs 4.4%). After adjustment for hospital differences, thoracotomy carried a 17.2% lower hospitalization cost (-$8289) with a 2-day stay reduction. Readmission rates were significantly lower with thoracotomy (26.2% vs 35.7% at 30 days and 31.6% vs 44.1% at 90 days). Thoracotomy was more common in southern and northeastern hospitals (63% vs 37% and 64% vs 36%, respectively), teaching hospitals (64% vs 36%) and larger hospitals (>600 beds, 78% vs 22%)., Conclusions: Relative to sternotomy, thoracotomy for mitral repairs provides similar mortality, less morbidity, fewer infections, shorter stay, and significant cost savings during primary admission. The markedly lower readmission rates for thoracotomy will translate into additional institutional cost savings when a penalty on hospitals begins under the Affordable Care Act's Hospital Readmissions Reduction Program., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: While there is an increasing emphasis on both optimizing quality of care and reducing health care costs, there are limited data regarding how to best achieve these goals for common and resource-intense conditions such as congenital heart disease. We evaluated excess costs associated with complications and prolonged length of stay (LOS) after congenital heart surgery in a large multicenter cohort., Methods: Clinical data from The Society of Thoracic Surgeons Database were linked to estimated costs from the Pediatric Health Information Systems Database (2006 to 2010). Excess cost per case associated with complications and prolonged LOS was modeled for 9 operations of varying complexity adjusting for patient baseline characteristics., Results: Of 12,718 included operations (27 centers), average excess cost per case in those with any complication (versus none) was $56,584 (+$132,483 for major complications). The 5 highest cost complications were tracheostomy, mechanical circulatory support, respiratory complications, renal failure, and unplanned reoperation or reintervention (ranging from $57,137 to $179,350). Patients with an additional day of LOS above the median had an average excess cost per case of $19,273 (+$40,688 for LOS 4 to 7 days above median). Potential cost savings in the study cohort achievable through reducing major complications (by 10%) and LOS (by 1 to 3 days) were greatest for the Norwood operation ($7,944,128 and $3,929,351, respectively) and several other commonly performed operations of more moderate complexity., Conclusions: Complications and prolonged LOS after congenital heart surgery are associated with significant costs. Initiatives able to achieve even modest reductions in these morbidities may lead to both improved outcomes and cost savings across both moderate and high complexity operations., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Clostridium difficile infections (CDIs) have increased during the past 2 decades, especially among cardiac surgical patients, who share many of the comorbidity risk factors for CDI. Our objectives were to use a large national database to identify the regional-, hospital-, patient-, and procedure-level risk factors for CDI; and determine mortality, resource usage, and cost of CDIs in cardiac surgery., Methods: Using the Nationwide Inpatient Sample database, we identified 349,122 patients who had undergone coronary artery bypass, valve, or thoracic-aortic surgery from 2004 to 2008. Of these, 2581 (0.75%) had been diagnosed with CDI. Multivariable regression analysis and the propensity method were used for risk adjustment., Results: Compared with the West, CDIs were more likely to occur in the Northeast (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.12-1.47) and Midwest (OR, 1.27, 95% CI, 1.11-1.46) and less likely in the South (OR, 0.80; 95% CI, 0.70-0.90). Medium-size hospitals (OR, 0.88; 95% CI, 0.78-0.99) had a lower risk of CDI than did large hospitals. Older age (>75 years; OR, 2.59; 95% CI, 1.93-3.49), longer preoperative length of stay (OR, 1.51; 95% CI, 1.43-1.60), Medicare (OR, 1.21; 95% CI, 1.05-1.39) and Medicaid (OR, 1.60; 95% CI, 1.31-1.96) coverage, and more comorbidities were associated with CDI. Among the matched pairs, patients with CDIs had greater mortality (302 [12%] vs 187 [7.2%], P<.001), a longer median length of stay (21 vs 11 days, P<.001), and greater median hospital charges ($193,330 vs $112,245, P<.001). The cumulative incremental cost of CDIs was an estimated $212 million annually., Conclusions: Our results have shown that CDI is associated with increased morbidity and resource usage. Additional work is needed to better understand the complex interplay among regional-, hospital-, and patient-level factors., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: While neonates account for a significant proportion of health care expenditures related to inpatient care for congenital heart disease, key drivers of resource utilization among this population are poorly defined., Methods: Data from 2005 through 2011 were extracted from the Pediatric Health Information System for patients assigned a discharge All Patient Refined Diagnosis Related Group of 630 (neonates with birthweight >2499 g undergoing a major cardiovascular procedure). Mortality risk adjustment for patients undergoing operative interventions was performed with the Risk Adjusment in Congenital Heart Surgery (RACHS-1) score., Results: A total of 13 156 cases were included in the analysis. Despite only a 3% increase in case mix index and no significant change in operative acuity over the study period (RACHS classifications of 3 or greater 67% in 2005 vs. 66% in 2011, P = .64), there were inflation-adjusted increases in both total estimated cost per case of (50% to $151 760 in 2011, P < .001), and mean charge per case (33% to $433 875 in 2011, P < .001). Pharmacy charges increased by 16% (P < .001), with agents including chlorothiazide and albumin accounting for the highest patient charges over the study period. Imaging charges increased by 42% (P < .001), with an average of 5.7 echocardiograms and $6517 in associated charges per case by 2011. While the proportion of patients receiving nitric oxide remained consistent, mean duration of administration increased by 25% to 6.6 days by 2011, accounting for average charges of $52 141 per patient exposed., Conclusions: Among neonates with serious congenital heart disease, increases in both institutional costs and charges to the patient are associated with relatively consistent utilization practices in recent years. Multiinstitutional collaboration may prove useful in aligning evidence-based reductions in practice variation with limitations in resource utilization without compromising the quality of care., (© 2013 Wiley Periodicals, Inc.)

Objectives: This study sought to examine the impact of surgical timing on major morbidity and hospital reimbursement for late preterm and term infants with dextrotransposition of the great arteries (d-TGA)., Background: Neonatal arterial switch operation is the standard of care for d-TGA. Little is known about the effects of age at operation on clinical outcomes or costs for these neonates., Methods: We conducted a retrospective cohort study of infants at ≥36 weeks' gestation, with d-TGA, with or without ventricular septal defects, admitted to our institution at 5 days of age or younger, between January 1, 2003 and October 1, 2012. Children with other cardiac abnormalities or other major comorbid conditions were excluded. Univariable and multivariable analyses were performed to determine the effects of age at operation on major morbidity and hospital reimbursement., Results: A total of 140 infants met inclusion criteria. Reimbursement data were available for them through January 1, 2012 (n = 128). The mortality rate was 1.4% (n = 2). Twenty percent (n = 28) experienced a major morbidity. The median costs were $60,000, in 2012 dollars (range: $25,000 to $549,000). The median age at operation was 5 days (range: 1 to 12 days). For every day later that surgery was performed, beyond day of life 3, the odds of major morbidity increased by 47% (range: 23% to 66%, p < 0.001) and costs increased by 8% (range: 5% to 11%, p < 0.001), after considering the effects of sex, birth weight, gestational age, year at which surgery was performed, transfer, weekend admission, insurance, surgeon, septostomy, bypass and cross-clamp times, and the presence of ventricular septal defects or abnormal coronary anatomy., Conclusions: Delay of neonatal arterial switch operation beyond 3 days is significantly associated with increased morbidity and healthcare costs., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: We evaluated the combined effect of hospital and surgeon volume on operative outcomes of mitral valve surgery in the United States., Methods: The Nationwide Inpatient Sample was used to identify adult patients undergoing isolated mitral valve surgery for mitral regurgitation from 2003 to 2008. Hospitals and surgeons were separately stratified into equal-size tertiles according to annual overall mitral valve operative volumes. Multivariate logistic regression analysis was conducted, adjusting for multiple patient, hospital, and operative data, to determine the separate and combined effects of hospital and surgeon volume on operative outcomes., Results: A total of 50,152 eligible patients were identified during the study period. Although both hospital and surgeon volume correlated significantly with operative mortality in separate risk-adjusted analyses, only lower surgeon volume persisted as a significant risk factor in the combined risk-adjusted analysis. Moreover, although hospital volume only accounted for 10.7% of the surgeon volume effect on increased mortality for low-volume surgeons, surgeon volume accounted for 74.5% of the hospital volume effect on increased mortality in low-volume hospitals. Surgeon, but not hospital, volume correlated with inpatient costs. Also, significant trends were seen with repair rates, with increasing surgeon volume demonstrating a relatively stronger correlation with the odds of repair (P < .001) than hospital volume (P = .01)., Conclusions: The effect of hospital volume on operative outcomes of mitral valve surgery was largely driven by the individual surgeon volumes within that hospital. Conversely, surgeon volume affected these outcomes independently of hospital volume. Identifying the processes by which higher volume surgeons attain better outcomes in mitral valve surgery would therefore be prudent., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: The scientific understanding of aortic dilation associated with bicuspid aortic valve (BAV) has evolved during the past 2 decades, along with improvements in diagnostic technology and surgical management. We aimed to evaluate secular trends and predictors of thoracic aortic surgery among patients with BAV in the United States., Methods: We used the 1998-2009 Nationwide Inpatient Sample, an administrative dataset representative of US hospital admissions, to identify hospitalizations for adults aged 18 years or more with BAV and aortic valve or thoracic aortic surgery. Covariates included age, gender, year, aortic dissection, endocarditis, thoracic aortic aneurysm, number of comorbidities, hospital teaching status and region, primary insurance, and concomitant coronary artery bypass surgery., Results: Between 1998 and 2009, 48,736 ± 3555 patients with BAV underwent aortic valve repair or replacement and 1679 ± 120 patients with BAV underwent isolated thoracic aortic surgery. The overall number of surgeries increased more than 3-fold, from 4556 ± 571 in 1998/1999 to 14,960 ± 2107 in 2008/2009 (P < .0001). The proportion of aortic valve repair or replacement including concomitant thoracic aortic surgery increased from 12.8% ± 1.4% in 1998/1999 to 28.5% ± 1.6% in 2008/2009, which mirrored an increasing proportion of patients with a diagnosis of thoracic aortic aneurysm. Mortality was equivalent for patients undergoing aortic valve repair or replacement with thoracic aortic surgery and those undergoing isolated aortic valve repair or replacement (1.8% ± 0.3% vs 1.5% ± 0.2%; multivariable odds ratio, 1.02; 95% confidence interval, 0.67-1.57), with decreasing mortality over the study period (from 2.5% ± 0.6% in 1998/1999 to 1.5% ± 0.2% in 2008/2009; multivariable odds ratio per 2-year increment, 0.89; 95% confidence interval, 0.81-0.99; P = .03). Total charges for BAV surgical hospitalizations increased more than 7.5-fold from approximately $156 million in 1998 to $1.2 billion in 2009 (inflation-adjusted 2009 dollars)., Conclusions: There was a marked increase in the use of thoracic aortic surgery among patients with BAV., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: The feasibility of fast-tracking children undergoing congenital heart disease surgery has not been assessed adequately. Current knowledge is based on limited single-center experiences without contemporaneous control groups., Methods and Results: We compared administrative data for atrial septal defect (ASD) and ventricular septal defect (VSD) surgeries in children 2 months to 19 years of age at the Mount Sinai Medical Center (MSMC) with data from comparable patients at 40 centers contributing to the Pediatric Health Information System. Three-year blocks, early in and after fast tracking had been implemented at the MSMC, were examined. Seventy-seven and 89 children at MSMC undergoing ASD and VSD closure, respectively, were compared with 3103 ASD and 4180 VSD patients nationally. With fast tracking fully implemented, median length of stay at the MSMC decreased by 1 day compared with the earlier era (length of stay, 1 and 3 days for ASD and VSD, respectively). Nationally, median length of stay remained unchanged (3 days for ASD and 4 days for VSD) in the observed time periods. Hospitalization costs fell by 33% and 35% at MSMC (ASD and VSD, respectively), whereas they rose by 16% to 17% nationally. When analyzed in multiple regression models, the decrease in both length of stay and cost remained significantly greater at MSMC compared with nationally (P<0.0001 for all). Hospital mortality and 2-week readmission rates were unchanged at MSMC between the 2 time periods and were not different from the national rates., Conclusion: Shorter length of stay and cost savings compared with national data were observed after implementation of fast tracking.

Background: Within the field of cardiac surgery, several strategies have been adopted in an effort to address contributors to increasing health care costs. Limited data are available on cost analysis within the field of mitral valve surgery. The purpose of our investigation was to analyze cost differences between mitral valve repair and replacement., Methods: The analysis was based on the subset of patients with isolated mitral valve repair or replacement (International Classification of Diseases, ninth revision, clinical codes 35.12, 35.23, and 35.24) using data from the 2005 to 2008 Nationwide Inpatient Sample database, which is the largest all-payer database in the United States. We examined the selective contribution of patient demographics, hospital characteristics, and postoperative complications to cost by using hierarchical linear mixed models. We used mixed effects logistic regression models to identify factors that influence extreme cost expenditures in patients undergoing mitral valve surgery., Results: Independent predictors of increased cost for both repair and replacement on multivariable analysis included increased age, prior myocardial infarction, heart failure, neurologic deficit, renal disease, emergent status, and Medicare or Medicaid insurance type. The presence of postoperative complications also predicted increased costs. However, the model for repair only yielded a reduction in variability of 13%, while the model for replacement produced a reduction of 22%., Conclusions: In this analysis, the most important contributors to cost for mitral valve repair and replacement are preoperative patient comorbidities, most notably history of myocardial infarction and heart failure, emergent admission status, and postoperative complications. The variables in our model failed to account for a large proportion of the variability in cost. This would suggest that future analyses exploring differential procedure costs between hospitals must look for factors beyond patient baseline characteristics and postoperative outcomes., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Medicaid patients bear proportionately greater financial responsibility for the cost of outpatient care and medication than non-Medicaid patients. We hypothesized that this difference in provision of continuing care would be associated with adverse clinical outcomes after cardiac surgery., Materials and Methods: In a retrospective cohort analysis, 5056 consecutive adult patients undergoing cardiac surgery at a single institution between 2005 and 2010 were divided according to payer status. Propensity scores were calculated using 16 preoperative and demographic variables for each patient, and 461 1:1 propensity score-matched pairs were analyzed. Patient socioeconomic position was determined using aggregate data derived from zip codes. The main outcome measures were early mortality, postoperative complications, and patient survival., Results: In multivariate analysis, Medicaid was found to be an independent predictor of worse survival after cardiac surgery (hazard ratio [HR], 2.1; 95% confidence interval [CI], 1.2-3.7; P = .01). No significant difference was observed in operative mortality in the 2 groups. After propensity score matching and controlling for socioeconomic position, the only independent predictors of worse midterm survival were an ejection fraction = 30% (HR, 1.7; 95% CI, 1.1-2.7; P = .02) and a higher logistic EuroSCORE (HR, 1.03; 95% CI, 1.0-1.1; P = .02)., Conclusions: Comorbidity and lower socioeconomic status appear to be more important predictors of late mortality after cardiac surgery than payer status, which does not have a significant impact on survival.

Objective: The goal of this study was to quantify the net increase in resource use associated with complications after isolated mitral valve surgery., Methods: Deidentified patient-level claims data on a random sample of mitral valve operations performed in the United States from January 1, 2006, to December 31, 2007, were obtained from the National Inpatient Sample (n = 16,788). Patients with major concomitant cardiac procedures were excluded from the analysis for a net sample size of 6297 patients. Risk-adjusted median total hospital costs and length of stay were analyzed by major complications, including pneumonia, sepsis, stroke, renal failure requiring hemodialysis, cardiac tamponade, myocardial infarction, gastrointestinal bleed, and venous thromboembolism., Results: There were a total of 1323 complication events that occurred in 1089 patients. The most common complication was pneumonia (n = 346, 5.5%), which was associated with a $29,692 increase in hospital costs and a 10.2-day increase in median length of stay (P < .001). The most costly complication was cardiac tamponade, which resulted in an increase in hospital cost of $56,547 and an increase in length of stay of 19.3 days (P < .001). There was a stepwise association between the hospital costs and length of stay and the number of complications per patient (P < .001). There was also a significant association between the discharge location and the occurrence of a complication, with 25% more patients who underwent routine home discharge when there were no complications (P < .001)., Conclusions: In patients undergoing isolated mitral valve surgery, postoperative complications were associated with significant increases in mortality, hospital costs, and length of stay, as well as with discharge location. With growing national attention to improving quality and containing costs, it is important to understand the nature and impact of complications on outcomes and costs., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Hypoplastic left heart syndrome (HLHS) is one of the most serious congenital cardiac anomalies. Typically, it is managed with a series of 3 palliative operations or cardiac transplantation. Our goal was to quantify the inpatient resource burden of HLHS across multiple academic medical centers., Methods: The University HealthSystem Consortium is an alliance of 101 academic medical centers and 178 affiliated hospitals that share diagnostic, procedural, and financial data on all discharges. We examined inpatient resource use by patients with HLHS who underwent a staged palliative procedure or cardiac transplantation between 1998 and 2007., Results: Among 1941 neonates, stage 1 palliation (Norwood or Sano procedure) had a median length of stay (LOS) of 25 days and charges of $214,680. Stage 2 and stage 3 palliation (Glenn and Fontan procedures, respectively) had median LOS and charges of 8 days and $82,174 and 11 days and $79,549, respectively. Primary neonatal transplantation had an LOS of 87 days and charges of $582,920, and rescue transplantation required 36 days and $411,121. The median inpatient wait time for primary and rescue transplants was 42 and 6 days, respectively. Between 1998 and 2007, the LOS for stage 1 palliation increased from 16 to 28 days and inflation-adjusted charges increased from $122,309 to $280,909, largely because of increasing survival rates (57% in 1998 and 83% in 2007)., Conclusions: Patients with HLHS demand considerable inpatient resources, whether treated with the Norwood-Glenn-Fontan procedure pathway or cardiac transplantation. Improved survival rates have led to increased hospital stays and costs.

Background: Given recent economic implications in caring for an aging population, we sought to determine if postoperative complications and costs for octogenarians differed based on the type of cardiac operation., Methods: From 2003 to 2008, patients who underwent cardiac operations at 16 different centers were identified from the Virginia Cardiac Surgery Quality Initiative and selected into two cohorts (<80 years and ≥80 years). Octogenarians (≥80 years) were stratified into isolated primary coronary bypass graft, aortic valve, mitral valve, or combined operation. Preoperative risks, outcomes, and costs were analyzed. Case-mix adjusted models for mortality and major complication rate were developed., Results: We examined 45,731 patients, of which 3,079 were octogenarians (82.7 ± 2.5 years). Compared with younger patients, octogenarians incurred higher mortality (6.5% vs 3.1%, p < 0.001) and major complication rates (13.2% vs 8.4%, p < 0.001) with only incrementally higher total costs (p < 0.001). Among octogenarians mortality was similar despite the operation. Cross-clamp and cardiopulmonary bypass time (p < 0.001), hospital length of stay (p = 0.001), and major complication rate (p = 0.002) were highest for combined operation. Despite the fewest complications, mitral valve operation had the highest total costs (p < 0.001). Type of operation was not predictive of mortality or major complication rate. However, age, female gender, emergent status, and prolonged cardiopulmonary bypass time were independently associated with death despite risk-adjustment., Conclusions: Advanced age confers increased risks and incrementally higher costs in patients undergoing cardiac operations. Isolated mitral and combined procedures have the highest complications and costs. Any proposed cardiac operation in octogenarians mandates careful consideration of resource utilization., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Quality control and performance improvement in the US health care system are based on several pillars: external review is performed by either government agencies, insurance companies, or public media. In cardiac surgery the STS database forms the backbone of most of these reviews. Internal review is based on providing outcome data, establishing benchmarks for performance, and root-cause analysis of adverse events. Peer review is used to analyze major issues in providing care. Transparency of the process and of outcome numbers generated is key for the success of measurements to improve performance. Finally, education of all health care providers in the hospital is needed to provide quality care and good outcomes. Maintaining proficiency of physicians and hospital personal in pathways and procedures requires constant educational efforts and clear pathways and guidelines. Growing resources have to be dedicated to quality management. As outcome data become essential in obtaining insurance contracts and government certification the investing into a comprehensive quality assurance program will pay off., (Georg Thieme Verlag KG Stuttgart, New York.)

In 2002, several hospitals in the Tenet system were accused of overbilling Medicare for cardiac surgery. This led to increased scrutiny of so-called outlier payments, which are used to compensate hospitals when actual costs far exceed those anticipated under prospective payment. Since then, the overall proportion of coronary artery bypass graft (CABG) procedures associated with outlier payments has fallen from 13 percent in 2000-02 to 8 percent in 2003-06. Still, there is variation across U.S. hospitals, with some hospitals experiencing much higher rates. These findings imply that there is potential for quality improvement to reduce costs while improving morbidity and mortality.