Heart Disease

Normalizing clinical practice for coronary bypass surgery could save money without worsening patient outcomes

More than 500,000 coronary artery bypass graft (CABG) surgeries are performed annually in the United States, at a cost of over $10 billion. New York hospitals vary considerably in their cost for CABG surgery, and these cost differences are due more to hospital factors than to patient differences, according to a study supported by the Agency for Healthcare Research and Quality (HS06503).

Normalizing the way hospitals manage CABG surgery cases (i.e., streamlining care delivery and shortening postoperative stays) could reduce CABG costs without worsening patient outcomes, according to Elizabeth R. DeLong, Ph.D., of the Duke Clinical Research Institute. Dr. DeLong and her colleagues analyzed 1992 clinical and medical claims data on CABG surgeries performed on patients in 21 New York hospitals to examine the relationship between in-hospital mortality and cost. Most of the patients in this study were white (86 percent) and male (73 percent), with an average age of 65 years.

The mean cost for CABG surgery—exclusive of professional fees (e.g., surgeon's fee) and noncomparable costs (e.g., salaried physician compensation, indirect teaching costs, and malpractice insurance) and adjusted for variation in input costs—was $15,713, with a mean length of stay (LOS) of 14 days. One-fifth of the variation in medical resource use was explained by baseline patient risk factors. However, after adjustment for differences in patient risk, the hospital explained an additional 40 percent of variation in cost and 8 percent of variation in LOS. In fact, the hospital effect explained almost twice as much variation in cost as did patient characteristics. Yet, hospital costs were not associated with mortality rates (adjusted for patient risk factors).

Cost differences associated with the bypass care process itself, such as the anesthesia protocol and early discharge protocols, may affect postoperative LOS and attendant costs. Variation in staffing patterns and efficiency of scheduling surgeries also may play a role in cost differences. The research suggests that hospitals with less resource-intensive practice styles can maintain their quality of care. The researchers caution, however, that they were unable to determine the extent to which resource-saving practices might be offset by increased use of home health care or readmissions for postdischarge complications.

See "Variability in cost of coronary bypass surgery in New York State: Potential for cost savings," by Patricia A. Cowper, Ph.D., Dr. DeLong, Eric D. Peterson, M.D., M.P.H., and others, in the American Heart Journal 143(1), pp. 130-139, 2002.

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