Higher Costs for Hospitals without Onsite Cardiac Surgery

Los Angeles—Nine months after undergoing an angioplasty procedure, patients who received percutaneous coronary intervention (PCI) at sites with onsite cardiac surgery had greater resource use, more hospital admissions, longer lengths of hospital stays, and lower medical costs compared with patients who were at sites without cardiac surgery, according to a prospective economic study.

Eric L. Eisenstein, DBA, the study’s lead author and assistant professor at Duke University School of Medicine, presented the results in a late-breaking abstract session at the AHA meeting. He attributed the higher costs in the group without access to onsite cardiac surgery to the use of the intensive care unit for post-PCI care and a higher rate of subsequent revascularization after treatment.

The CPORT-E (Cardiovascular Patient Outcomes Research Team Non-Primary Percutaneous Coronary Intervention) trial randomly assigned patients to undergo nonprimary PCI at a hospital without onsite cardiac surgery (n=14,149) or to be transferred to a hospital with onsite PCI capabilities (n=4718). The authors tested the noninferiority of the 2 groups. They found the mortality rate at 6 weeks was 0.9% in the non-onsite group and 1.0% in the onsite group (P=.004), while the rate of adverse major cardiac events at 9 months was 12.1% in the non-onsite group and 11.2% in the onsite group (P=.05).

Dr. Eisenstein noted that at 9 months, patients in the onsite group had more staged PCI procedures because they were transferred, but had fewer subsequent revascularizations compared with the non-onsite group during the follow-up period.

In this trial, Dr. Eisenstein said he and his colleagues wanted to compare the medical resource use and costs for the groups. Of the 18,867 patients in CPORT-E, 18,273 were analyzed for this study: 4569 in the onsite group and 13,704 in the non-onsite group. The study period began with index diagnostic catheterization at the nonsurgical site and lasted 9 months.

To determine the costs, the coordinators at the 60 CPORT-E sites collected inpatient bills. The authors estimated hospital costs using patient bills and correcting for Medicare patients, and estimated physician costs and ambulance transportation using information from case report forms and Medicare reimbursement. They reported the results in 2011 US dollars.

The groups were well balanced. Mean age was 64 years, approximately 80% of patients were white, and approximately 64% were males. In addition, 39% of patients had diabetes, 73% underwent elective PCI surgery, and the remaining 27% had urgent or emergency surgery.

At the end of 9 months, the mean number of admissions was 2.80 in the onsite group compared with 1.99 for the non-onsite group (P<.0001). There was also a statistically significant difference in length of stay in the hospital: 3.73 days for the onsite group and 3.14 days for the non-onsite group (P<.0001). However, there was no significant difference during the follow-up period (P=.17). After 9 months, the mean length of stay was 6.20 days in the onsite group compared with 5.76 days for the non-onsite group (P=.002).

There was a significant difference in the index procedure cost: $18,975 for the onsite group versus $19,840 for the non-onsite group (P=.12). The total cost during the 9 months was $23,991 in the onsite group and $25,450 in the non-onsite group (P=.02).

Dr. Eisenstein said that although patients at the sites without surgical backup had shorter length-of-stay at the hospital, the need to use the intensive care unit after surgery led to higher room costs.