Medicare and heart transplants: will lightning strike twice?

The financial burden of destination left ventricular assist device therapy: who and when?

Heart failure continues to be an economic health care burden of profound proportion. The disease in its end stage has limited therapeutic options. Transplantation is limited by the number of available organs. Mechanical assist therapy has continued to be an increasingly feasible strategy for bridging patients to heart transplantation but is also now used in place of transplantation. The REMATCH trial was the first trial to document the failure of medical therapy in end-stage heart failure when compared with mechanical support. However, one of the primary concerns is the marked expense involved with this invasive therapy. As the cost of ventricular assist devices (VADs) for destination therapy has been appraised in the medical literature, and through examination of patients who have been implanted in the "post-REMATCH era," a subset of patients has emerged in whom VAD implantation is futile, as well as another subset that clearly benefits both in quality of life as well as in mortality. We review the current literature on VAD feasibility for destination therapy as well as ongoing trends in careful patient selection to improve outcomes and, implicitly, cost benefit of VAD therapy.

Volume and outcome of organ transplantation

In general, technically demanding medical procedures are associated with better outcomes when they are carried out in institutions and by physicians with higher volumes of practice. This paper examines the evidence for a volume-outcome relationship in the case of organ transplantation. Although few studies have been done on this subject, existing evidence is consistent with improved outcomes at higher volumes. Therefore, evidence supports policies that regionalize transplantation services.

Institutes of Quality: Prudential's approach to outcomes management for specialty procedures

The Prudential Institutes of Quality program was developed to respond to the growing interest in the quality of care available to patients through both indemnity and managed medical plans and clients' concern about the continued escalation of health care costs. The program is based on the premise that high-quality care is the most efficient care that utilizes resources appropriately because of the experience of both the hospital and the physicians. Hospitals and physicians are selected through a questionnaire and site-visit process based on criteria developed from a literature review and outside expert counsel. Networks of facilities meeting the criteria serve the Prudential patient population. The history and results through the third quarter of 1989 and the implications of selective contracting for health care policy are presented.