1
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Koenig S, Morcos G, Gopinath R, Wang K, Henn F, Leong NL. Is MRI Overutilized for Evaluation of Knee Pain in Veterans? J Knee Surg 2021; 36:305-309. [PMID: 34474493 PMCID: PMC9925228 DOI: 10.1055/s-0041-1733880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
MRI is an essential diagnostic imaging modality for many knee conditions; however, it is not indicated in the setting of advanced knee arthritis. Inappropriate MRI imaging adds to health care costs and may delay definitive management for many patients. The primary purpose of this study was to ascertain the frequency of inappropriate MRI scans performed at one Veterans' Administration Medical Center (VAMC). We performed a retrospective chart review of all knee MRIs ordered over a 6-month period. Inappropriate MRI was defined as MRI performed prior to radiographs (XRs), or in the presence of XRs demonstrating severe osteoarthritis, without leading to a nonarthroplasty procedure of the knee. Of the 304 cases reviewed, 36.8% (112) of the MRIs were deemed inappropriate, 33 were ordered by orthopedists, and 79 were ordered by other health care providers. Of the 33 ordered by orthopedists, 25 were ordered by retired/nonsurgical orthopedists. Obtaining an MRI delayed care by an average of 29.2 days. Of the 252 cases that had XR prior to MRI, none included all four views in the standard knee XR series and only four had weightbearing images. Over a third of knee MRIs performed at this VAMC were inappropriate and delayed care. Additionally, no XRs in our study contained all the necessary views to properly assess knee arthritis. These concerning findings signify a potential opportunity for education in diagnostic strategies, to better patient care and resource utilization in the VAMC.
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Affiliation(s)
- Scott Koenig
- University of Maryland School of Medicine, Orthopaedics, Baltimore, Maryland
| | - George Morcos
- University of Maryland School of Medicine, Orthopaedics, Baltimore, Maryland
| | - Rohan Gopinath
- University of Maryland School of Medicine, Orthopaedics, Baltimore, Maryland
| | - Kenneth Wang
- Department of Radiology, Veterans Affairs Commission, Baltimore, Maryland
| | - Frank Henn
- University of Maryland School of Medicine, Orthopaedics, Baltimore, Maryland
| | - Natalie L. Leong
- University of Maryland School of Medicine, Orthopaedics, Baltimore, Maryland,Address for correspondence Natalie L. Leong, MD 10 N. Greene Street, Baltimore, MD 21201
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2
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Maestas CM, Blankenship JC. Interventional economics provide a roadmap to better patient care. Catheter Cardiovasc Interv 2021; 97:94-96. [PMID: 33460262 DOI: 10.1002/ccd.29442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 12/13/2020] [Indexed: 11/07/2022]
Abstract
Costs of percutaneous coronary intervention including the index procedure and care in the subsequent 30 days are increased by half for patients who are readmitted, and increased up to two-fold for those who have major adverse events during the initial admission. Many factors "predicting" adverse events and readmission are not modifiable. However, some are modifiable. Interventionalists should focus on those. In addition to using strategies to avoid adverse events, interventionalists should lead teams to implement strategies to prevent readmission. This will require a new nonprocedural focus for interventionalists.
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Affiliation(s)
- Camila M Maestas
- Division of Cardiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - James C Blankenship
- Division of Cardiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
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3
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Gilmartin HM, Hess E, Mueller C, Plomondon ME, Waldo SW, Battaglia C. A pilot study to assess the learning environment and use of reliability enhancing work practices in VHA cardiac catheterization laboratories. Learn Health Syst 2021; 5:e10227. [PMID: 33889736 PMCID: PMC8051348 DOI: 10.1002/lrh2.10227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 02/26/2020] [Accepted: 03/15/2020] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION A learning health system (LHS) harnesses data and analytics to learn from clinical encounters to implement the best care with high reliability. The 81 Veterans Health Administration (VHA) cardiac catheterization laboratories (cath lab) are a model LHS. The quality and safety of coronary procedures are monitored and reported by the Clinical Assessment, Reporting and Tracking (CART) Program, which has identified variation in care across cath labs. This variation may be due to underappreciated aspects of LHSs, the learning environment and reliability enhancing work practices (REWPs). Learning environments are the educational approaches, context, and settings in which learning occurs. REWPs are the organizational practices found in high reliability organizations. High learning environments and use of REWPs are associated with improved outcomes. This study assessed the learning environments and use of REWPs in VHA cath labs to examine factors supportive of learning and high reliability. METHODS In 2018, the learning organization survey-27 and the REWP survey were administered to 732 cath lab staff. Factor analysis and linear models were computed. Unit-level analyses and site ranking (high, low) were conducted on cath labs with >40% response rate using Bayesian methods. RESULTS Surveys from 40% of cath lab staff (n = 294) at 84% of cath labs (n = 68) were included. Learning environment and REWP strengths across cath labs include the presence of training programs, openness to new ideas, and respectful interaction. Learning environment and REWP gaps include lack of structured knowledge transfer (eg, checklists) and low use of forums for improvement. Survey dimensions matched established factor structures and demonstrated high reliability (Cronbach's alpha >.76). Unit-level analyses were conducted for 29 cath labs. One ranked as high and four as low learning environments. CONCLUSIONS This work demonstrates an approach to assess local learning environments and use of REWPs, providing insights for systems working to become a LHS.
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Affiliation(s)
- Heather M. Gilmartin
- Denver/Seattle Center of Innovation for Veteran‐Centered and Value Driven CareVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
- Health Systems, Management, and PolicyUniversity of Colorado, School of Public HealthAuroraColoradoUSA
| | - Edward Hess
- Denver/Seattle Center of Innovation for Veteran‐Centered and Value Driven CareVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
| | - Candice Mueller
- Denver/Seattle Center of Innovation for Veteran‐Centered and Value Driven CareVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
- Clinical Assessment Reporting and Tracking ProgramVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
| | - Mary E. Plomondon
- Health Systems, Management, and PolicyUniversity of Colorado, School of Public HealthAuroraColoradoUSA
- Clinical Assessment Reporting and Tracking ProgramVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
| | - Stephen W. Waldo
- Denver/Seattle Center of Innovation for Veteran‐Centered and Value Driven CareVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
- Clinical Assessment Reporting and Tracking ProgramVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
| | - Catherine Battaglia
- Denver/Seattle Center of Innovation for Veteran‐Centered and Value Driven CareVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
- Health Systems, Management, and PolicyUniversity of Colorado, School of Public HealthAuroraColoradoUSA
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4
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Sandhu AT, Do R, Lam J, Blankenship J, Van Decker W, Rich J, Gonzalez O, Wu X, Pershing S, Lin E, MaCurdy TE, Bhattacharya J, Nagavarapu S. Development of the Elective Outpatient Percutaneous Coronary Intervention Episode-Based Cost Measure. Circ Cardiovasc Qual Outcomes 2021; 14:e006461. [PMID: 33653117 DOI: 10.1161/circoutcomes.119.006461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Merit-Based Incentive Payment System adjusts clinician payments based on a performance score that includes cost measures. With the Centers for Medicare & Medicaid Services, we developed a novel cost measure that compared interventional cardiologists on a targeted set of costs related to elective percutaneous coronary intervention (PCI). We describe the measure and compare it to a hypothetical version including all expenditures post-PCI. METHODS Measure development was guided by 39 clinician experts. They identified services within 30 days of PCI that could be potentially affected by the interventional cardiologist. Expenditures for these PCI-related services were included as measure costs in a process termed service assignment. We used 1 year of Medicare claims to calculate clinician scores using the final measure that included only PCI-related costs (with service assignment) and a hypothetical version that included all costs post-PCI (without service assignment). We calculated reliability for both measures. This marker of precision breaks measure variance into signal (difference between clinicians) versus noise (difference between PCI episodes for a clinician). We also determined the change in clinician performance quintile between measures. RESULTS We identified 100 992 elective outpatient PCI episodes from May 2, 2016, to May 1, 2017. Total Medicare expenditures within 30 days of PCI averaged $13 234. After excluding costs unrelated to PCI, average cost was $10 966. For individual clinicians, mean reliability for the hypothetical measure without service assignment was 0.36. After service assignment, final measure reliability increased to 0.53. When evaluated as clinician groups, reliability increased from 0.43 to 0.73 following service assignment. Approximately 66% (2340 of 3527) of clinicians were reclassified into a different performance quintile after excluding unrelated costs. CONCLUSIONS The elective outpatient PCI cost measure had increased precision and reclassified clinician performance relative to a hypothetical version that included total expenditures.
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Affiliation(s)
- Alexander T Sandhu
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.).,Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA (A.T.S.)
| | - Rose Do
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.).,Division of Cardiology, Department of Medicine, University of California Irvine, Irvine, CA (R.D.).,Veterans Affairs Long Beach Health Care System, Long Beach, CA (R.D.)
| | - Joyce Lam
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.)
| | - James Blankenship
- Division of Cardiology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM (J. Blankenship)
| | - William Van Decker
- Division of Cardiology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (W.V.D.)
| | - Jeffrey Rich
- Heart and Vascular Institute, Cleveland Clinic, OH (J.R.)
| | - Oscar Gonzalez
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.)
| | - Xiaolu Wu
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.)
| | - Suzann Pershing
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.).,Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Stanford, CA (S.P.).,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA (S.P.)
| | - Eugene Lin
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.).,Division of Nephrology, Department of Medicine, Keck School of Medicine of USC and the USC Price School of Public Policy, Los Angeles, CA (E.L.)
| | - Thomas E MaCurdy
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.).,Department of Economics (T.E.M.), Stanford University, Stanford, CA.,Hoover Institution (T.E.M.), Stanford University, Stanford, CA
| | - Jay Bhattacharya
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.).,Center for Health Policy/Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA. (J. Bhattacharya)
| | - Sriniketh Nagavarapu
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.)
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Grunwald GK, Arnett JA, Liu W, Ho PM. Bayesian profiling for cost with zeros to decompose total cost into probability of cost and mean nonzero cost. Biom J 2020; 62:1631-1649. [PMID: 32542678 DOI: 10.1002/bimj.201900148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 04/09/2020] [Accepted: 04/16/2020] [Indexed: 11/09/2022]
Abstract
Cost of health care can vary substantially across hospitals, centers, or providers. Data from electronic health records provide information for studying patterns of cost variation and identifying high or low cost centers. Cost data often include zero values when patients receive no care, and joint two-part models have been developed for clustered cost data with zeros. Standard methods for center comparisons, sometimes called profiling, can use these methods to incorporate zero values into total cost. However, zero costs also provide opportunities to further examine sources of cost variation and outliers. For example, a hospital may have high (or low) cost due to frequency of nonzero cost, amount of nonzero cost, or a combination of those. We give methods for decomposing hospital differences in total cost with zeros into components for probability of use (i.e., of nonzero cost) and for cost of use (mean of nonzero cost). The components multiply to total cost and quantify components on the same easily interpreted multiplicative scales. The methods are based on Bayesian hierarchical models and counterfactual arguments, with Markov chain Monte Carlo estimation. We used simulated data to illustrate use, interpretation, and visualization of the methods in diverse situations, and applied the methods to 30,024 patients at 57 US Veterans Administration hospitals to characterize outlier hospitals in one year cost of inpatient care following a cardiac procedure. Twenty eight percent of patients had zero cost. These methods are useful in providing insight into cost variation and outliers for planning future studies or interventions.
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Affiliation(s)
- Gary K Grunwald
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,VA Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Health Care System, Aurora, CO, USA
| | - James A Arnett
- Medical Economics, Contessa Health Inc., Nashville, TN, USA
| | - Wenhui Liu
- VA Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Health Care System, Aurora, CO, USA
| | - P Michael Ho
- VA Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Health Care System, Aurora, CO, USA.,Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
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6
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Burke RE, Canamucio A, Glorioso TJ, Barón AE, Ryskina KL. Variability in Transitional Care Outcomes Across Hospitals Discharging Veterans to Skilled Nursing Facilities. Med Care 2020; 58:301-306. [PMID: 31895308 PMCID: PMC11078064 DOI: 10.1097/mlr.0000000000001282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The period after transition from hospital to skilled nursing facility (SNF) is high-risk, but variability in outcomes related to transitions across hospitals is not well-known. OBJECTIVES Evaluate variability in transitional care outcomes across Veterans Health Administration (VHA) and non-VHA hospitals for Veterans, and identify characteristics of high-performing and low-performing hospitals. RESEARCH DESIGN Retrospective observational study using the 2012-2014 Residential History File, which concatenates VHA, Medicare, and Medicaid data into longitudinal episodes of care for Veterans. SUBJECTS Veterans aged 65 or older who were acutely hospitalized in a VHA or non-VHA hospital and discharged to SNF; 1 transition was randomly selected per patient. MEASURES Adverse "transitional care" outcomes were a composite of hospital readmission, emergency department visit, or mortality within 7 days of hospital discharge. RESULTS Among the 365,942 Veteran transitions from hospital to SNF across 1310 hospitals, the composite outcome rate ranged from 3.3% to 23.2%. In multivariable analysis adjusting for patient characteristics, hospital discharge diagnosis and SNF category, no single hospital characteristic was significantly associated with the 7-day adverse outcomes in either VHA or non-VHA hospitals. Very few high or low-performing hospitals remained in this category across all 3 years. The increased odds of having a 7-day event due to being treated in a low versus high-performing hospital was similar to the odds carried by having an intensive care unit stay during the index admission. CONCLUSIONS While variability in hospital outcomes is significant, unmeasured care processes may play a larger role than currently measured hospital characteristics in explaining outcomes.
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Affiliation(s)
- Robert E. Burke
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VHA Medical Center
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Anne Canamucio
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VHA Medical Center
| | - Thomas J. Glorioso
- Center of Innovation for Veteran-Centered and Value-Driven Care, Denver VHA Medical Center, Denver
| | - Anna E. Barón
- Center of Innovation for Veteran-Centered and Value-Driven Care, Denver VHA Medical Center, Denver
- Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Kira L. Ryskina
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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7
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Same-day discharge among patients undergoing elective PCI: Insights from the VA CART Program. Am Heart J 2019; 218:75-83. [PMID: 31707331 DOI: 10.1016/j.ahj.2019.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 09/04/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Available data suggest that same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is safe in select patients. Yet, little is known about contemporary adoption rates, safety, and costs in a universal health care system like the Veterans Affairs Health System. METHODS Using data from the Veterans Affairs Clinical Assessment Reporting and Tracking Program linked with Health Economics Resource Center data, patients undergoing elective PCI for stable angina between October 1, 2007 and Sepetember 30, 2016, were stratified by SDD versus overnight stay. We examined trends of SDD, and using 2:1 propensity matching, we assessed 30-day rates of readmission, mortality, and total costs at 30 days. RESULTS Of 21,261 PCIs from 67 sites, 728 were SDDs (3.9% of overall cohort). The rate of SDD increased from 1.6% in 2008 to 9.7% in 2016 (P < .001). SDD patients had lower rates of atrial fibrillation, peripheral arterial disease, and prior coronary artery bypass grafting and were treated at higher-volume centers. Thirty-day readmission and mortality did not differ significantly between the groups (readmission: 6.7% SDD vs 5.6% for overnight stay, P = .24; mortality: 0% vs. 0.07%, P = .99). The mean (SD) 30-day cost accrued by patients undergoing SDD was $23,656 ($15,480) versus $25,878 ($17,480) for an overnight stay. The accumulated median cost savings for SDD was $1503 (95% CI $738-$2,250). CONCLUSIONS Veterans Affairs Health System has increasingly adopted SDD for elective PCI procedures, and this is associated with cost savings without an increase in readmission or mortality. Greater adoption has the potential to reduce costs without increasing adverse outcomes.
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8
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Barnett PG, Hong JS, Carey E, Grunwald GK, Joynt Maddox K, Maddox TM. Comparison of Accessibility, Cost, and Quality of Elective Coronary Revascularization Between Veterans Affairs and Community Care Hospitals. JAMA Cardiol 2019; 3:133-141. [PMID: 29299607 PMCID: PMC5838592 DOI: 10.1001/jamacardio.2017.4843] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Question Does the Veterans Affairs Community Care Program, which allows veterans to receive care at non–Veterans Affairs sites, increase the accessibility and value of their elective coronary revascularization procedures? Findings Among 13 237 elective percutaneous coronary interventions and 5818 elective coronary artery bypass graft procedures in this veteran cohort study, use of the Community Care Program reduced aggregate veteran travel distance for revascularization. Community Care Program hospitals had higher mortality and costs for percutaneous coronary intervention and had equivalent mortality and lower costs for coronary artery bypass graft surgery. Meaning In our veteran cohort, use of Community Care Program hospitals improved overall access for revascularization; Community Care Program hospitals provided lower-value percutaneous coronary intervention procedures but higher-value coronary artery bypass graft procedures. Importance The Veterans Affairs (VA) Community Care (CC) Program supplements VA care with community-based medical services. However, access gains and value provided by CC have not been well described. Objectives To compare the access, cost, and quality of elective coronary revascularization procedures between VA and CC hospitals and to evaluate if procedural volume or publicly reported quality data can be used to identify high-value care. Design, Setting, and Participants Observational cohort study of veterans younger than 65 years undergoing an elective coronary revascularization, controlling for differences in risk factors using propensity adjustment. The setting was VA and CC hospitals. Participants were veterans undergoing elective percutaneous coronary intervention (PCI) and veterans undergoing coronary artery bypass graft (CABG) procedures between October 1, 2008, and September 30, 2011. The analysis was conducted between July 2014 and July 2017. Exposures Receipt of an elective coronary revascularization at a VA vs CC facility. Main Outcomes and Measures Access to care as measured by travel distance, 30-day mortality, and costs. Results In the 3 years ending on September 30, 2011, a total of 13 237 elective PCIs (79.1% at the VA) and 5818 elective CABG procedures (83.6% at the VA) were performed in VA or CC hospitals among veterans meeting study inclusion criteria. On average, use of CC was associated with reduced net travel by 53.6 miles for PCI and by 73.3 miles for CABG surgery compared with VA-only care. Adjusted 30-day mortality after PCI was higher in CC compared with VA (1.54% for CC vs 0.65% for VA, P < .001) but was similar after CABG surgery (1.33% for CC vs 1.51% for VA, P = .74). There were no differences in adjusted 30-day readmission rates for PCI (7.04% for CC vs 7.73% for VA, P = .66) or CABG surgery (8.13% for CC vs 7.00% for VA, P = .28). The mean adjusted PCI cost was higher in CC ($22 025 for CC vs $15 683 for VA, P < .001). The mean adjusted CABG cost was lower in CC ($55 526 for CC vs $63 144 for VA, P < .01). Neither procedural volume nor publicly reported mortality data identified hospitals that provided higher-value care with the exception that CABG mortality was lower in small-volume CC hospitals. Conclusions and Relevance In this veteran cohort, PCIs performed in CC hospitals were associated with shorter travel distance but with higher mortality, higher costs, and minimal travel savings compared with VA hospitals. The CABG procedures performed in CC hospitals were associated with shorter travel distance, similar mortality, and lower costs. As the VA considers expansion of the CC program, ongoing assessments of value and access gains are essential to optimize veteran outcomes and VA spending.
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Affiliation(s)
- Paul G Barnett
- Veterans Affairs Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California.,Veterans Affairs Center for Innovation to Implementation, Menlo Park, California.,Center for Primary Care and Outcomes Research, Stanford University, Stanford, California
| | - Juliette S Hong
- Veterans Affairs Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Evan Carey
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora.,Veterans Affairs Eastern Colorado Health Care System, Denver
| | - Gary K Grunwald
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora.,Veterans Affairs Eastern Colorado Health Care System, Denver
| | - Karen Joynt Maddox
- Cardiology Division, John T. Milliken Department of Internal Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Thomas M Maddox
- Cardiology Division, John T. Milliken Department of Internal Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
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9
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Alyesh DM, Seth M, Miller DC, Dupree JM, Syrjamaki J, Sukul D, Dixon S, Kerr EA, Gurm HS, Nallamothu BK. Exploring the Healthcare Value of Percutaneous Coronary Intervention: Appropriateness, Outcomes, and Costs in Michigan Hospitals. Circ Cardiovasc Qual Outcomes 2019; 11:e004328. [PMID: 29853465 DOI: 10.1161/circoutcomes.117.004328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 04/26/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Assessments of healthcare value have largely focused on measuring outcomes of care at a given level of cost with less attention paid to appropriateness. However, understanding how appropriateness relates to outcomes and costs is essential to determining healthcare value. METHODS AND RESULTS In a retrospective cohort study design, administrative data from fee-for-service Medicare patients undergoing percutaneous coronary intervention (PCI) in Michigan hospitals between June 30, 2010, and December 31, 2014, were linked with clinical data from a statewide PCI registry to calculate hospital-level measures of (1) appropriate use criteria scores, (2) 90-day risk-standardized readmission and mortality rates, and (3) 90-day risk-standardized episode costs. We then used Spearman correlation coefficients to assess the relationship between these measures. A total of 29 839 PCIs were performed at 33 PCI hospitals during the study period. A total of 13.3% were for ST-segment-elevation myocardial infarction, 25.0% for non-ST-segment-elevation myocardial infarction, 47.1% for unstable angina, 9.8% for stable angina, and 4.7% for other. The overall hospital-level mean appropriate use criteria score was 8.4±0.2. Ninety-day risk-standardized readmission occurred in 23.7%±3.7% of cases, 90-day risk-standardized mortality in 4.3%±0.6%, and mean risk-standardized episode costs were $26 159±$1074. Hospital-level appropriate use criteria scores did not correlate with 90-day readmission, mortality, or episode costs. CONCLUSIONS Among Medicare patients undergoing PCI in Michigan, we found hospital-level appropriate use criteria scores did not correlate with 90-day readmission, mortality, or episode costs. This finding suggests that a comprehensive understanding of healthcare value requires multidimensional consideration of appropriateness, outcomes, and costs.
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Affiliation(s)
- Daniel M Alyesh
- Division of Cardiovascular Medicine, Department of Internal Medicine (D.M.A., D.S., H.S.G., B.K.N.)
| | - Milan Seth
- University of Michigan Medical School, Ann Arbor. Blue Cross Blue Shield of Michigan Cardiovascular Collaborative, Ann Arbor, MI (M.S., H.S.G.)
| | - David C Miller
- Department of Urology (D.C.M., J.M.D., J.S.).,Blue Cross Blue Shield Michigan Value Collaborative, Ann Arbor, MI (D.C.M., J.M.D., J.S.)
| | - James M Dupree
- Department of Urology (D.C.M., J.M.D., J.S.).,Blue Cross Blue Shield Michigan Value Collaborative, Ann Arbor, MI (D.C.M., J.M.D., J.S.).,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., E.A.K., B.K.N. J.M.D.)
| | - John Syrjamaki
- Department of Urology (D.C.M., J.M.D., J.S.).,Blue Cross Blue Shield Michigan Value Collaborative, Ann Arbor, MI (D.C.M., J.M.D., J.S.)
| | - Devraj Sukul
- Division of Cardiovascular Medicine, Department of Internal Medicine (D.M.A., D.S., H.S.G., B.K.N.).,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., E.A.K., B.K.N. J.M.D.)
| | - Simon Dixon
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, MI (S.D.)
| | - Eve A Kerr
- Ann Arbor Veterans Affairs Center for Clinical Management Research, MI (E.A.K., H.S.G., B.K.N.).,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., E.A.K., B.K.N. J.M.D.)
| | - Hitinder S Gurm
- Division of Cardiovascular Medicine, Department of Internal Medicine (D.M.A., D.S., H.S.G., B.K.N.).,University of Michigan Medical School, Ann Arbor. Blue Cross Blue Shield of Michigan Cardiovascular Collaborative, Ann Arbor, MI (M.S., H.S.G.).,Ann Arbor Veterans Affairs Center for Clinical Management Research, MI (E.A.K., H.S.G., B.K.N.)
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Medicine, Department of Internal Medicine (D.M.A., D.S., H.S.G., B.K.N.).,Ann Arbor Veterans Affairs Center for Clinical Management Research, MI (E.A.K., H.S.G., B.K.N.).,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., E.A.K., B.K.N. J.M.D.)
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10
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Tripathi B, Yeh RW, Bavishi CP, Sardar P, Atti V, Mukherjee D, Bashir R, Abbott JD, Giri J, Chatterjee S. Etiologies, trends, and predictors of readmission in ST‐elevation myocardial infarction patients undergoing multivessel percutaneous coronary intervention. Catheter Cardiovasc Interv 2019; 94:905-914. [DOI: 10.1002/ccd.28344] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 05/16/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Byomesh Tripathi
- Division of Cardiology, Banner University Medical CenterUniversity of Arizona Phoenix Arizona
| | - Robert W. Yeh
- Division of Cardiovascular Medicine, Smith Center for Outcomes Research in CardiologyBeth Israel Deaconess Medical Center Boston Massachusetts
| | - Chirag P. Bavishi
- Division of Cardiology, Cardiovascular InstituteWarren Alpert Medical School at Brown University Providence Rhode Island
| | - Partha Sardar
- Division of Cardiology, Cardiovascular InstituteWarren Alpert Medical School at Brown University Providence Rhode Island
| | - Varunsiri Atti
- Department of MedicineMichigan State University East Lansing Michigan
| | - Debabrata Mukherjee
- Division of Cardiology, Texas Tech University Health Sciences Center El Paso Texas
| | - Riyaz Bashir
- Division of CardiologyTemple University Hospital Philadelphia Pennsylvania
| | - Jinnette Dawn Abbott
- Division of Cardiology, Cardiovascular InstituteWarren Alpert Medical School at Brown University Providence Rhode Island
| | - Jay Giri
- Cardiovascular Medicine DivisionHospital of the University of Pennsylvania Philadelphia Pennsylvania
| | - Saurav Chatterjee
- Division of Cardiovascular Medicine, Hoffman Heart Institute, Saint Francis HospitalTeaching Affiliate of the University of Connecticut School of Medicine Hartford Connecticut
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11
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Kwok CS, Narain A, Pacha HM, Lo TS, Holroyd EW, Alraies MC, Nolan J, Mamas MA. Readmissions to Hospital After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Factors Associated with Readmissions. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:375-391. [PMID: 31196797 DOI: 10.1016/j.carrev.2019.05.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/05/2019] [Accepted: 05/17/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Readmissions after PCI are a burden to patients and health services that are not well understood. METHODS A systematic review was performed to identify studies of readmission after PCI. Readmission rates and causes of readmission were examined and factors associated with 30-day readmissions were combined using meta-analyses. RESULTS A total of 39 studies evaluated readmissions after PCI (6,569,690 patients, 31 studies). The 30-day readmission rate varied from 3.3%-15.8%. Beyond 30-days, the readmission rate was 6% at 2 months, 31.5% at 6 months, 18.6-50.4% at 12 months and 26.3-71% beyond 48 months. The pooled proportion of patients with cardiac cause for readmissions ranged from 4.6%-75.3%. The range of rates of 30-day readmissions for reinfarction/stent thrombosis, heart failure, chest pain and bleeding were 2.5%-9.5%, 5.9%-12%, 6.7-38.1% and 0.7-7.5%, respectively. Meta-analysis suggests that female gender (RR 1.25(1.20-1.30), I2 = 65.2%), diabetes (RR 1.22(1.20-1.25), I2 = 0%), heart failure (RR 1.43(CI 1.28-1.60), I2 = 92.8%), renal failure (RR 1.50(1.45-1.55), I2 = 0%), chronic lung disease (RR 1.34(1.26-1.44), I2 = 87.5%), peripheral artery disease (RR 1.20(1.15-1.25), I2 = 46.5%) and cancer (RR 1.35(1.15-1.58), I2 = 72.8%) were associated with 30-day readmissions. The average cost of unplanned and all 30-day readmissions has been reported to be $12,636 and $17,576, respectively. CONCLUSIONS We estimate that 1 in 7 patients who undergo PCI are readmitted within 30-days and the rate can rise to up to 3 in 4 patients beyond 3 years. Interventions should be considered to reduce readmissions such as discharge checklists, evaluation of medication compliance at follow-up and prompt management when patients re-present to emergency department.
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Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Primary Care & Health Sciences, Keele University, Stoke-on-Trent, UK; Royal Stoke University Hospital, Stoke-on-Trent, UK.
| | - Aditya Narain
- Keele Cardiovascular Research Group, Primary Care & Health Sciences, Keele University, Stoke-on-Trent, UK; Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | - Ted S Lo
- Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | - M Chadi Alraies
- Wayne State University, Detroit Medical Center, Detroit, MI, USA
| | - Jim Nolan
- Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Primary Care & Health Sciences, Keele University, Stoke-on-Trent, UK; Royal Stoke University Hospital, Stoke-on-Trent, UK
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12
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Gibbons RJ, Weintraub WS, Brindis RG. Moving from volume to value for revascularization in stable ischemic heart disease: A review. Am Heart J 2018; 204:178-185. [PMID: 30077336 DOI: 10.1016/j.ahj.2018.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/02/2018] [Indexed: 01/09/2023]
Abstract
IMPORTANCE Although percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are both commonly employed in the treatment of stable ischemic heart disease (SIHD), their ability to reduce subsequent heart attacks and death is currently in question. These procedures will come under increasing scrutiny as the healthcare reimbursement system moves away from the traditional fee for service model in favor of "pay for value". OBSERVATION Both international and domestic data show wide variability in the use of PCI and CABG in patients with SIHD. There is evidence of ongoing quality improvement over the last 5 years in reducing the use of inappropriate procedures, but there is still room for improvement. We present ideas regarding health policy interventions that might help manage the transition to value-based payments in this area, including improvements in national registries, more rapid revision of appropriate use criteria, shared decision making, and evidence-based management of PCI in SIHD. CONCLUSIONS AND RELEVANCE The use of revascularization procedures in patients with SIHD is potentially a model for how care might be improved with health care policy intervention. We suggest that the status quo, although apparently improved over the last 5 years, is still unacceptable when 25% of hospitals have a rate of unnecessary PCI in patients with SIHD that approaches 25%.
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13
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Markovitz AA, Ellimoottil C, Sukul D, Mullangi S, Chen LM, Nallamothu BK, Ryan AM. Risk Adjustment May Lessen Penalties On Hospitals Treating Complex Cardiac Patients Under Medicare's Bundled Payments. Health Aff (Millwood) 2018; 36:2165-2174. [PMID: 29200351 DOI: 10.1377/hlthaff.2017.0940] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To reduce variation in spending, Medicare has considered implementing a cardiac bundled payment program for acute myocardial infarction and coronary artery bypass graft. Because the proposed program does not account for patient risk factors when calculating hospital penalties or rewards ("reconciliation payments"), it might unfairly penalize certain hospitals. We estimated the impact of adjusting for patients' medical complexity and social risk on reconciliation payments for Medicare beneficiaries hospitalized for the two conditions in the period 2011-13. Average spending per episode was $29,394. Accounting for medical complexity substantially narrowed the gap in reconciliation payments between hospitals with high medical severity (from a penalty of $1,809 to one of $820, or a net reduction of $989), safety-net hospitals (from a penalty of $217 to one of $87, a reduction of $130), and minority-serving hospitals (from a penalty of $70 to a reward of $56, an improvement of $126) and their counterparts. Accounting for social risk alone narrowed these gaps but had minimal incremental effects after medical complexity was accounted for. Risk adjustment may preserve incentives to care for patients with complex conditions under Medicare bundled payment programs.
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Affiliation(s)
- Adam A Markovitz
- Adam A. Markovitz ( ) is an MD/PhD candidate in health management and policy and a graduate student research assistant in the Center for Evaluating Health Reform at the University of Michigan, in Ann Arbor, and the Center for Clinical Management Research at the Veterans Affairs (VA) Ann Arbor Healthcare System
| | - Chandy Ellimoottil
- Chandy Ellimoottil is an assistant professor in the Department of Urology and the Institute for Healthcare Policy and Innovation, both at the University of Michigan. He is also director of analytics for the Michigan Value Collaborative, in Ann Arbor
| | - Devraj Sukul
- Devraj Sukul is a fellow in cardiovascular medicine at the University of Michigan Medical School
| | - Samyukta Mullangi
- Samyukta Mullangi is a healthcare administration scholar in internal medicine at the University of Michigan
| | - Lena M Chen
- Lena M. Chen is an assistant professor in the Department of Internal Medicine and the Institute for Healthcare Policy and Innovation, both at the University of Michigan, and a physician in the VA Ann Arbor Healthcare System
| | - Brahmajee K Nallamothu
- Brahmajee K. Nallamothu is a professor in the Department of Internal Medicine, Division of Cardiovascular Medicine, and the Institute for Healthcare Policy and Innovation and director of the Michigan Integrated Center for Health Analytics and Medical Prediction, all at the University of Michigan. He is also an investigator in the Center for Clinical Management Research at the VA Ann Arbor Healthcare System
| | - Andrew M Ryan
- Andrew M. Ryan is an associate professor in the Department of Health Management and Policy and the Institute for Healthcare Policy and Innovation, and director of the Center for Evaluating Health Reform, all at the University of Michigan
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14
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Within-Hospital Variation in 30-Day Adverse Events: Implications for Measuring Quality. J Healthc Qual 2018; 40:147-154. [DOI: 10.1097/jhq.0000000000000086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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15
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Tripathi A, Abbott JD, Fonarow GC, Khan AR, Barry NG, Ikram S, Coram R, Mathew V, Kirtane AJ, Nallamothu BK, Hirsch GA, Bhatt DL. Thirty-Day Readmission Rate and Costs After Percutaneous Coronary Intervention in the United States. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.117.005925. [DOI: 10.1161/circinterventions.117.005925] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 10/23/2017] [Indexed: 11/16/2022]
Abstract
Background—
The association of short-term readmissions after percutaneous coronary intervention (PCI) on healthcare costs has not been well studied.
Methods and Results—
The Healthcare Cost and Utilization Project National Readmission Database encompassing 722 US hospitals was used to identify index PCI cases in patients ≥18 years old. Hierarchical regression analyses were used to examine the factors associated with risk of 30-day readmission and higher cumulative costs. We evaluated 206 869 hospitalized patients who survived to discharge after PCI from January through November 2013 and analyzed readmissions over 30 days after discharge. A total of 24 889 patients (12%) were readmitted within 30 days, with rates ranging from 6% to 17% across hospitals. Among the readmitted patients, 13% had PCI, 2% had coronary artery bypass surgery, and 3% died during the readmission. The most common reasons for readmission included nonspecific chest pain/angina (24%) and heart failure (11%). Mean cumulative costs were higher for those with readmissions ($39 634 versus $22 058;
P
<0.001). The multivariable analyses showed that readmission increased the log
10
cumulative costs by 45% (β: 0.445;
P
<0.001). There was no significant difference in cumulative costs by the type of insurance.
Conclusions—
In a national sample of inpatient PCI cases, 30-day readmissions were associated with a significant increase in cumulative costs. The majority of readmissions were because of low-risk chest pain that did not require any intervention. Ongoing effort is warranted to recognize and mitigate potentially preventable post-PCI readmissions.
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Affiliation(s)
- Avnish Tripathi
- From the Division of Cardiology, University of Louisville Medical School, KY (A.T., A.R.K., N.G.B., S.I., R.C., G.A.H.); Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI (J.D.A.); Division of Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, CA (G.C.F.); Division of Cardiology, Stritch School of Medicine, Loyola University, Chicago, IL (V.M.); Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital (A.J.K.)
| | - J. Dawn Abbott
- From the Division of Cardiology, University of Louisville Medical School, KY (A.T., A.R.K., N.G.B., S.I., R.C., G.A.H.); Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI (J.D.A.); Division of Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, CA (G.C.F.); Division of Cardiology, Stritch School of Medicine, Loyola University, Chicago, IL (V.M.); Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital (A.J.K.)
| | - Gregg C. Fonarow
- From the Division of Cardiology, University of Louisville Medical School, KY (A.T., A.R.K., N.G.B., S.I., R.C., G.A.H.); Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI (J.D.A.); Division of Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, CA (G.C.F.); Division of Cardiology, Stritch School of Medicine, Loyola University, Chicago, IL (V.M.); Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital (A.J.K.)
| | - Abdur R. Khan
- From the Division of Cardiology, University of Louisville Medical School, KY (A.T., A.R.K., N.G.B., S.I., R.C., G.A.H.); Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI (J.D.A.); Division of Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, CA (G.C.F.); Division of Cardiology, Stritch School of Medicine, Loyola University, Chicago, IL (V.M.); Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital (A.J.K.)
| | - Neil G. Barry
- From the Division of Cardiology, University of Louisville Medical School, KY (A.T., A.R.K., N.G.B., S.I., R.C., G.A.H.); Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI (J.D.A.); Division of Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, CA (G.C.F.); Division of Cardiology, Stritch School of Medicine, Loyola University, Chicago, IL (V.M.); Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital (A.J.K.)
| | - Sohail Ikram
- From the Division of Cardiology, University of Louisville Medical School, KY (A.T., A.R.K., N.G.B., S.I., R.C., G.A.H.); Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI (J.D.A.); Division of Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, CA (G.C.F.); Division of Cardiology, Stritch School of Medicine, Loyola University, Chicago, IL (V.M.); Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital (A.J.K.)
| | - Rita Coram
- From the Division of Cardiology, University of Louisville Medical School, KY (A.T., A.R.K., N.G.B., S.I., R.C., G.A.H.); Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI (J.D.A.); Division of Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, CA (G.C.F.); Division of Cardiology, Stritch School of Medicine, Loyola University, Chicago, IL (V.M.); Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital (A.J.K.)
| | - Verghese Mathew
- From the Division of Cardiology, University of Louisville Medical School, KY (A.T., A.R.K., N.G.B., S.I., R.C., G.A.H.); Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI (J.D.A.); Division of Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, CA (G.C.F.); Division of Cardiology, Stritch School of Medicine, Loyola University, Chicago, IL (V.M.); Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital (A.J.K.)
| | - Ajay J. Kirtane
- From the Division of Cardiology, University of Louisville Medical School, KY (A.T., A.R.K., N.G.B., S.I., R.C., G.A.H.); Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI (J.D.A.); Division of Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, CA (G.C.F.); Division of Cardiology, Stritch School of Medicine, Loyola University, Chicago, IL (V.M.); Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital (A.J.K.)
| | - Brahmajee K. Nallamothu
- From the Division of Cardiology, University of Louisville Medical School, KY (A.T., A.R.K., N.G.B., S.I., R.C., G.A.H.); Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI (J.D.A.); Division of Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, CA (G.C.F.); Division of Cardiology, Stritch School of Medicine, Loyola University, Chicago, IL (V.M.); Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital (A.J.K.)
| | - Glenn A. Hirsch
- From the Division of Cardiology, University of Louisville Medical School, KY (A.T., A.R.K., N.G.B., S.I., R.C., G.A.H.); Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI (J.D.A.); Division of Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, CA (G.C.F.); Division of Cardiology, Stritch School of Medicine, Loyola University, Chicago, IL (V.M.); Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital (A.J.K.)
| | - Deepak L. Bhatt
- From the Division of Cardiology, University of Louisville Medical School, KY (A.T., A.R.K., N.G.B., S.I., R.C., G.A.H.); Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI (J.D.A.); Division of Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, CA (G.C.F.); Division of Cardiology, Stritch School of Medicine, Loyola University, Chicago, IL (V.M.); Division of Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital (A.J.K.)
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16
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Affiliation(s)
- Jordan B Strom
- From the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Robert W Yeh
- From the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
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17
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Bradley SM, Strauss CE, Ho PM. Value in cardiovascular care. Heart 2017; 103:1238-1243. [DOI: 10.1136/heartjnl-2016-309753] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 03/31/2017] [Accepted: 04/03/2017] [Indexed: 11/04/2022] Open
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18
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Affiliation(s)
- Jason H. Wasfy
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (J.H.W.) and The Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.)
| | - Robert W. Yeh
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (J.H.W.) and The Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.)
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19
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Bradley SM, O'Donnell CI, Grunwald GK, Liu CF, Hebert PL, Maddox TM, Jesse RL, Fihn SD, Rumsfeld JS, Ho PM. Response to Letter Regarding Article, "Facility Level Variation in Hospitalization, Mortality, and Costs in the 30 Days After Percutaneous Coronary Intervention: Insights on Short-Term Healthcare Value From the Veterans Affairs Clinical Assessment, Reporting, and Tracking System (VA CART) Program". Circulation 2016; 133:e377. [PMID: 26831442 DOI: 10.1161/circulationaha.115.019552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Steven M Bradley
- VA Eastern Colorado Health Care System, Denver, COUniversity of Colorado School of Medicine, Aurora, CO
| | - Colin I O'Donnell
- VA Eastern Colorado Health Care System, Denver, COUniversity of Colorado School of Public Health, Aurora, CO
| | - Gary K Grunwald
- VA Eastern Colorado Health Care System, Denver, COUniversity of Colorado School of Public Health, Aurora, CO
| | | | | | - Thomas M Maddox
- VA Eastern Colorado Health Care System, Denver, COUniversity of Colorado School of Medicine, Aurora, CO
| | - Robert L Jesse
- Veterans Health Administration, US Department of Veteran Affairs, Washington, DC
| | - Stephan D Fihn
- Veterans Health Administration, US Department of Veteran Affairs, Washington, DC
| | - John S Rumsfeld
- VA Eastern Colorado Health Care System, Denver, COUniversity of Colorado School of Medicine, Aurora, CO
| | - P Michael Ho
- VA Eastern Colorado Health Care System, Denver, COUniversity of Colorado School of Medicine, Aurora, CO
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20
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Wasfy JH, Dominici F, Yeh RW. Letter by Wasfy et al Regarding Article, "Facility Level Variation in Hospitalization, Mortality, and Costs in the 30 Days After Percutaneous Coronary Intervention: Insights on Short-Term Healthcare Value From the Veterans Affairs Clinical Assessment, Reporting, and Tracking System (VA CART) Program". Circulation 2016; 133:e376. [PMID: 26831441 DOI: 10.1161/circulationaha.115.017851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Robert W Yeh
- The Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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