Decreased patient charges following implementation of point-of-care cardiac troponin monitoring in acute coronary syndrome patients in a community hospital cardiology unit

BACKGROUND

The need to rapidly evaluate patients presenting to emergency departments and cardiology services for ruling in and ruling out acute myocardial infarction (AMI) is widely recognized as a clinical challenge. We determined the impact of incorporating point-of-care (POC) cardiac troponin I (cTnI) testing into a cardiology service regarding assay turn around time (TAT), patient length of stay (LOS), financial matrixes and patient outcomes compared to central laboratory cTnI testing.

METHODS

Patients presenting with symptoms suggestive of acute coronary syndrome (ACS) were enrolled pre-POC (PreCS, n=271) and post-POC (PostCS, n=274). POC cTnI determinations were performed at the bedside on the Dade Behring Stratus CS by nursing staff. Routine cTnI determinations were performed in the central laboratory (Dade Behring Dimension) by laboratory staff. Data were collected and analyzed on each patient per hospital stay by review of electronic medical and financial records. In addition, risk stratification outcomes for all cause death were determined at 30 days and 1 y following baseline sampling based on the 99th percentile cutoff concentrations of <0.1 microg/l for both assays.

RESULTS

There was a decrease in time from blood draw to result to healthcare provider (PreCS mean 76 min; PostCS mean 19.5 min; p<0.001) as well as a decrease trend in charge per patient admission (4281 dollars savings) following implementation of POC testing. Total charges per patient admission decreased by 25% PostCS vs. PreCS (17,163 dollars vs. 12,882 dollars); a composite of lower charges for: boarding (-21%), other departments (-58%), pharmacy (-28%), labs (-22%), non-cardiac procedures (-28%), cardiac procedures (-14%). The mean LOS also decreased 8% (p=0.05) from PreCS (2.36 days) to PostCS (2.19 days). cTnI reagents charges to the laboratory were higher for the POC assay, 10.54 dollars, vs. the central lab assay, 3.83 dollars. One year survival was greater in the <0.1 microg/l patients (PreCS 96.2%, PostCS 97.2%) compared to the >0.1 microg/l patients (PreCS 77.7%, PostCS 75.5%); both p<0.001. Kaplan-Meier survival curves showed early separation by 30 days in each group.

CONCLUSIONS

Our study demonstrates the cost effectiveness and clinical effectiveness of implementation of POC whole blood, cTnI testing for assisting clinicians with diagnostic and risk assessment of ACS patients.

Cost-effectiveness of hospital pay-for-performance incentives

One increasingly popular mechanism for stimulating quality improvements is pay-for-performance, or incentive, programs. This article examines the cost-effectiveness of a hospital incentive system for heart-related care, using a principal-agent model, where the insurer is the principal and hospitals are the agents. Four-year incentive system costsfor the payer were dollar 22,059,383, composed primarily of payments to the participating hospitals, with approximately 5 percent in administrative costs. Effectiveness is measured in stages, beginning with improvements in the processes of heart care. Care process improvements are converted into quality-adjusted life years (QALYs) gained, with reference to literatures on clinical effectiveness and survival. An estimated 24,418 patients received improved care, resulting in a range of QALYs from 733 to 1,701, depending on assumptions about clinical effectiveness. Cost per QALY was found to be between dollar 12,967 and dollar 30,081, a level well under consensus measures of the value of a QALY.

Cost of diagnosis and treatment of syncope in patients admitted to a cardiology unit

AIMS

Despite the large number of hospital admissions due to syncope, information on the in-hospital cost of management of these patients remains incomplete.

METHODS AND RESULTS

In order to assess such cost, we analysed the clinical histories of the patients suffering from syncope who were admitted to our Unit of Cardiology in 2003. We determined the length of stay (in days) for each inpatient, the number of diagnostic tests performed, and the various therapeutic procedures undertaken. Two hundred and three patients (mean age 68 +/- 14, 49% female) were admitted because of syncope. Final diagnoses on discharge were drug-induced syncope in 10 patients, vasovagal syncope in 11, syncope secondary to cardiac ischaemia in 18, valvular disease in 4, rapid supraventricular arrhythmia in 20, ventricular arrhythmia in 19, atrioventricular block in 90, and unexplained syncope in 31 patients. Of these 203 patients, 70 (34.5%) had a previous history of cardiac disease. The global cost for all 203 patients was 2,264,979 Euros. The overall cost per patient was 11,158 Euros (range: 1651-31,762) including stay, diagnosis, and treatment. The overall cost of hospital stay per patient was 3718 Euros (range: 1436-5679). The overall cost per diagnosis of the 203 patients was 1141 Euros (range: 155-3577), and the cost of the therapeutic procedures required was 6299 Euros (range: 0-23 115). The most expensive were those cases of syncope secondary to ventricular arrhythmia, the cost of which is 20 times that of drug-induced syncope.

CONCLUSION

The cost per diagnosis and treatment of a patient admitted because of syncope varies widely with important differences depending on the specific cause.

Randomized clinical trial of a postdischarge pharmaceutical care program vs. regular follow-up in patients with heart failure

OBJECTIVE

To assess the efficacy of a multifactorial educational intervention carried out by a pharmacist in patients with heart failure (HF).

METHOD

A randomized, prospective, open clinical trial in patients admitted for HF. The patients assigned to the intervention group received information about the disease, drug therapy, diet education, and active telephone follow-up. Visits were completed at 2, 6, and 12 months. Hospital re-admissions, days of hospital stay, treatment compliance, satisfaction with the care received, and quality of life (EuroQol) were evaluated; a financial study was conducted in order to assess the possible impact of the program. The intervention was performed by the pharmacy department in coordination with the cardiology unit.

RESULTS

134 patients were included, with a mean age of 75 years and a low educational level. The patients of the intervention group had a higher level of treatment compliance than the patients in the control group. At 12 months of follow-up, 32.9% fewer patients in the intervention group were admitted again vs. the control group. The mean days of hospital stay per patient in the control group were 9.6 (SD=18.5) vs. 5.9 (SD=14.1) in the intervention group. No differences were recorded in quality of life, but the intervention group had a higher score in the satisfaction scale at two months [9.0 (SD=1.3) versus 8.2 (SD=1.8) p=0.026]. Upon adjusting a Cox survival model with the ejection fraction, the patients in the intervention group had a lower risk of re-admission (Hazard ratio 0.56; 95% CI: 0.32-0.97). The financial analysis evidenced savings in hospital costs of euro 578 per patient that were favorable to the intervention group.

CONCLUSIONS

Postdischarge pharmaceutical care allows for reducing the number of new admissions in patients with heart failure, the total days of hospital stay, and improves treatment compliance without increasing the costs of care.

Smart strategic planning for cardiovascular services

Strategic planning for cardiovascular services should include formation of a cardiovascular advisory committee composed of key stakeholders. The strategic plan should include an internal assessment, external market analysis, review of operations, development of strategies and initiatives, and a financial analysis. The organization's mission and vision, as well as its financial situation, need to be considered in formulating strategies.

Surgeons' economic profiles: can we get the "right" answers?

Hospitals and payers use economic profiling to evaluate physician and surgeon performance. However, there is significant variation in the data sources and analytic methods that are used. We used information from a hospital's cardiac surgery and cost accounting information systems to create surgeon economic profiles. Three scenarios were examined: (1) surgeon modeled as fixed effect with no patient-mix adjustment; (2) surgeon modeled as fixed effect with patient-mix adjustment; (3) and surgeon modeled as random effect with patient-mix adjustment. We included 574 patients undergoing coronary artery bypass surgery at Baptist Medical Center, Oklahoma City, OK between July 1, 1995 and April 30, 1996. We found that profiles reporting unadjusted average surgeon costs may incorrectly identify high- and low-cost outliers. Adjusting for patient-mix differences and treating surgeons as random effects was the preferred approach. These results demonstrate the need for hospitals to reexamine their economic profiling methods.

Leaders with heart

Although cardiovascular care is typically a lucrative service line, competition from other providers is often fierce. To gain market advantage, providers should follow best practices of top-performing organizations and use benchmarking data to identify areas in need of process improvement.

Advance-practice nursing in heart-failure management: an integrative review

The number of patients with heart failure (HF) is predicted to escalate into the next decade, whereas the number of cardiac specialists who are skilled in evidence-based recommendations in HF practice will struggle to provide available, quality care. The advance-practice nurse, whose focus is HF management, may be an important key to improving access to this growing aggregate. This integrative review indicates the positive cost-to-benefit ratio for the advance-practice nurse's collaboration in HF management. Other measurable nursing outcomes have yet to scratch the surface, thereby inviting studies into areas that will promote the patient's quality of life.

The rise and uncertain future of cath labs

Few places have the potential to dramatically change the clinical and financial landscape."Cath labs are turning hospitals and health care upside down right now" says Skip Meador, director of cardiology for Centra Health, Lynchburg, Va."It's sure a different animal now than it was even seven or eight years ago" Cardiovascular programs--which increasingly rely on procedures performed in the cath lab--have long been the linchpin of hospital profitability, and have tended to prop up other money-losing areas. But critical issues threaten that profitability, such as the cost of technology, operating expenses and payer reimbursement. Likewise, such other technology as implantable cardiac defibrillators, biventricular pacemakers and ventricular assist devices bring more potential to change the landscape of cardiac care delivery. A case in point: the advent of primary angioplasty.

A six sigma approach to maximizing productivity in the cardiac cath lab

Cardiac catheterization laboratories represent one of the most significant capital investments for hospitals. Historically, hospitals could achieve an economic return fairly rapidly on this capital investment because of the relatively high contribution margin on many of the procedures performed in the department. However, recent changes in DRG assignments, declines in Medicare reimbursement, and the advent of new technologies, such as drug-coated stents, pose a threat to achieving planned economic return. In response, many hospitals are pursuing strategies to improve throughput in the cardiac cath lab and maximize the number of procedures performed. The case example in this article describes how a busy cardiac catheterization lab in the southeastern United States successfully applied the Six Sigma methodology to improving productivity and increasing available capacity.

Could your financial health be heading for heart break?

A new type of stent may alter demand and affect the financial performance of cardiovascular programs. Patients electing angioplasty instead of CABG as the preferred initial treatment for coronary stenosis may increase. The need for CABG procedures to correct restenosis following angioplasty may decline.