Defining value in cardiac surgery: A contemporary analysis of cost variation across the United States

Clinical Outcomes and Costs of Robotic-assisted vs Conventional Mitral Valve Repair: A National Analysis

BACKGROUND

Robotic approaches have been increasingly utilized for cardiothoracic operations, though concerns regarding costs remain. We evaluated short-term outcomes and costs of robotic-assisted and conventional mitral valve repair (MV-repair), hypothesizing that cost differences would be mitigated at high-volume programs.

METHODS

Adults undergoing elective MV-repair from 2016 to 2020 were identified in the Nationwide Readmissions Database. Patients with rheumatic heart disease, mitral stenosis, and those undergoing concomitant operations were excluded. Generalized linear models were utilized to evaluate the association between approach and in-hospital mortality, complications, length of stay, costs, and 90-day readmissions. Annual institutional MV-repair volume was modeled using restricted cubic splines, and cost differences subsequently evaluated by volume tertile.

RESULTS

Of 40,738 patients, 9.8% underwent robotic-assisted MV-repair. Risk-adjusted outcomes including mortality, stroke, reoperation, respiratory complications, postoperative infection, and readmission were comparable between the 2 groups, while those undergoing robotic-assisted MV-repair had lower rates of nonhome discharge. The median cost of robotic-assisted MV-repair was greater than conventional surgery ($46,800 vs $38,500, P < .001). Despite a 1.3-day decrement (95% CI, 1.1-1.6) in length of stay, robotic-assisted MV-repair was associated with greater risk-adjusted costs by $10,500 (95% CI, $5800-$15,200). Programs in the highest volume tertile exhibited comparable costs for robotic-assisted and conventional MV-repair (cost difference, $5900; 95% CI, -$1200 to $12,200; P > .05).

CONCLUSIONS

Robotic-assisted MV-repair had comparable short-term outcomes relative to conventional surgery. Despite increased costs of robotic-assisted MV-repair overall, high-volume programs had similar risk-adjusted costs by approach. These findings support the designation and performance of robotic MV-repair at centers of excellence in the United States.

Assessment of Price Variation in Coronary Artery Bypass Surgery at US Hospitals

BACKGROUND

Little is known about hospital pricing for coronary artery bypass grafting (CABG). Using new price transparency data, we assessed variation in CABG prices across US hospitals and the association between higher prices and hospital characteristics, including quality of care.

METHODS AND RESULTS

Prices for diagnosis related group code 236 were obtained from the Turquoise database and linked by Medicare Facility ID to publicly available hospital characteristics. Univariate and multivariable analyses were performed to assess factors predictive of higher prices. Across 544 hospitals, median commercial and self-pay rates were 2.01 and 2.64 times the Medicare rate ($57 240 and $75 047, respectively, versus $28 398). Within hospitals, the 90th percentile insurer-negotiated price was 1.83 times the 10th percentile price. Across hospitals, the 90th percentile commercial rate was 2.91 times the 10th percentile hospital rate. Regional median hospital prices ranged from $35 624 in the East South Central to $84 080 in the Pacific. In univariate analysis, higher inpatient revenue, greater annual discharges, and major teaching status were significantly associated with higher prices. In multivariable analysis, major teaching and investor-owned status were associated with significantly higher prices (+$8653 and +$12 200, respectively). CABG prices were not related to death, readmissions, patient ratings, or overall Centers for Medicare and Medicaid Services hospital rating.

CONCLUSIONS

There is significant variation in CABG pricing, with certain characteristics associated with higher rates, including major teaching status and investor ownership. Notably, higher CABG prices were not associated with better-quality care, suggesting a need for further investigation into drivers of pricing variation and the implications for health care spending and access.

Socioeconomic disparities in risk of financial toxicity following elective cardiac operations in the United States

BACKGROUND

While insurance reimbursements allay a portion of costs associated with cardiac operations, uncovered and additional fees are absorbed by patients. An examination of financial toxicity (FT), defined as the burden of patient medical expenses on quality of life, is warranted. Therefore, the present study used a nationally representative database to demonstrate the association between insurance status and risk of financial toxicity (FT) among patients undergoing major cardiac operations.

METHODS

Adults admitted for elective coronary artery bypass grafting (CABG) and isolated or concomitant valve operations were assessed using the 2016-2019 National Inpatient Sample. FT risk was defined as out-of-pocket expenditure >40% of post-subsistence income. Regression models were developed to determine factors associated with FT risk in insured and uninsured populations. To demonstrate the association between insurance status and risk of FT among patients undergoing major cardiac operations.

RESULTS

Of an estimated 567,865 patients, 15.6% were at risk of FT. A greater proportion of uninsured patients were at risk of FT (81.3 vs. 14.8%, p<0.001), compared to insured. After adjustment, FT risk among insured patients was not affected by non-income factors. However, Hispanic race (Adjusted Odds Ratio [AOR] 1.60), length of stay (AOR 1.17/day), and combined CABG-valve operations (AOR 2.31, all p<0.05) were associated with increased risk of FT in the uninsured.

CONCLUSION

Uninsured patients demonstrated higher FT risk after undergoing major cardiac operation. Hispanic race, longer lengths of stay, and combined CABG-valve operations were independently associated with increased risk of FT amongst the uninsured. Conversely, non-income factors did not impact FT risk in the insured cohort. Culturally-informed reimbursement strategies are necessary to reduce disparities in already financially disadvantaged populations.

Patient-, Clinician-, and Institution-level Variation in Inotrope Use for Cardiac Surgery: A Multicenter Observational Analysis

BACKGROUND

Conflicting evidence exists regarding the risks and benefits of inotropic therapies during cardiac surgery, and the extent of variation in clinical practice remains understudied. Therefore, the authors sought to quantify patient-, anesthesiologist-, and hospital-related contributions to variation in inotrope use.

METHODS

In this observational study, nonemergent adult cardiac surgeries using cardiopulmonary bypass were reviewed across a multicenter cohort of academic and community hospitals from 2014 to 2019. Patients who were moribund, receiving mechanical circulatory support, or receiving preoperative or home inotropes were excluded. The primary outcome was an inotrope infusion (epinephrine, dobutamine, milrinone, dopamine) administered for greater than 60 consecutive min intraoperatively or ongoing upon transport from the operating room. Institution-, clinician-, and patient-level variance components were studied.

RESULTS

Among 51,085 cases across 611 attending anesthesiologists and 29 hospitals, 27,033 (52.9%) cases received at least one intraoperative inotrope, including 21,796 (42.7%) epinephrine, 6,360 (12.4%) milrinone, 2,000 (3.9%) dobutamine, and 602 (1.2%) dopamine (non-mutually exclusive). Variation in inotrope use was 22.6% attributable to the institution, 6.8% attributable to the primary attending anesthesiologist, and 70.6% attributable to the patient. The adjusted median odds ratio for the same patient receiving inotropes was 1.73 between 2 randomly selected clinicians and 3.55 between 2 randomly selected institutions. Factors most strongly associated with increased likelihood of inotrope use were institutional medical school affiliation (adjusted odds ratio, 6.2; 95% CI, 1.39 to 27.8), heart failure (adjusted odds ratio, 2.60; 95% CI, 2.46 to 2.76), pulmonary circulation disorder (adjusted odds ratio, 1.72; 95% CI, 1.58 to 1.87), loop diuretic home medication (adjusted odds ratio, 1.55; 95% CI, 1.42 to 1.69), Black race (adjusted odds ratio, 1.49; 95% CI, 1.32 to 1.68), and digoxin home medication (adjusted odds ratio, 1.48; 95% CI, 1.18 to 1.86).

CONCLUSIONS

Variation in inotrope use during cardiac surgery is attributable to the institution and to the clinician, in addition to the patient. Variation across institutions and clinicians suggests a need for future quantitative and qualitative research to understand variation in inotrope use affecting outcomes and develop evidence-based, patient-centered inotrope therapies.

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