Cost Analysis of Isolated Mitral Valve Surgery in the United States
ABSTRACT Within the field of cardiac surgery, several strategies have been adopted in an effort to address contributors to increasing health care costs. Limited data are available on cost analysis within the field of mitral valve surgery. The purpose of our investigation was to analyze cost differences between mitral valve repair and replacement.
The analysis was based on the subset of patients with isolated mitral valve repair or replacement (International Classification of Diseases, ninth revision, clinical codes 35.12, 35.23, and 35.24) using data from the 2005 to 2008 Nationwide Inpatient Sample database, which is the largest all-payer database in the United States. We examined the selective contribution of patient demographics, hospital characteristics, and postoperative complications to cost by using hierarchical linear mixed models. We used mixed effects logistic regression models to identify factors that influence extreme cost expenditures in patients undergoing mitral valve surgery.
Independent predictors of increased cost for both repair and replacement on multivariable analysis included increased age, prior myocardial infarction, heart failure, neurologic deficit, renal disease, emergent status, and Medicare or Medicaid insurance type. The presence of postoperative complications also predicted increased costs. However, the model for repair only yielded a reduction in variability of 13%, while the model for replacement produced a reduction of 22%.
In this analysis, the most important contributors to cost for mitral valve repair and replacement are preoperative patient comorbidities, most notably history of myocardial infarction and heart failure, emergent admission status, and postoperative complications. The variables in our model failed to account for a large proportion of the variability in cost. This would suggest that future analyses exploring differential procedure costs between hospitals must look for factors beyond patient baseline characteristics and postoperative outcomes.
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ABSTRACT: Given recent economic implications in caring for an aging population, we sought to determine if postoperative complications and costs for octogenarians differed based on the type of cardiac operation. From 2003 to 2008, patients who underwent cardiac operations at 16 different centers were identified from the Virginia Cardiac Surgery Quality Initiative and selected into two cohorts (<80 years and ≥80 years). Octogenarians (≥80 years) were stratified into isolated primary coronary bypass graft, aortic valve, mitral valve, or combined operation. Preoperative risks, outcomes, and costs were analyzed. Case-mix adjusted models for mortality and major complication rate were developed. We examined 45,731 patients, of which 3,079 were octogenarians (82.7 ± 2.5 years). Compared with younger patients, octogenarians incurred higher mortality (6.5% vs 3.1%, p < 0.001) and major complication rates (13.2% vs 8.4%, p < 0.001) with only incrementally higher total costs (p < 0.001). Among octogenarians mortality was similar despite the operation. Cross-clamp and cardiopulmonary bypass time (p < 0.001), hospital length of stay (p = 0.001), and major complication rate (p = 0.002) were highest for combined operation. Despite the fewest complications, mitral valve operation had the highest total costs (p < 0.001). Type of operation was not predictive of mortality or major complication rate. However, age, female gender, emergent status, and prolonged cardiopulmonary bypass time were independently associated with death despite risk-adjustment. Advanced age confers increased risks and incrementally higher costs in patients undergoing cardiac operations. Isolated mitral and combined procedures have the highest complications and costs. Any proposed cardiac operation in octogenarians mandates careful consideration of resource utilization.The Annals of thoracic surgery 02/2011; 91(2):499-505. DOI:10.1016/j.athoracsur.2010.10.059 · 3.65 Impact Factor
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ABSTRACT: Mitral valve repair is acknowledged as desirable and superior to replacement for virtually all mitral pathology. Utilizing The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD), a multivariable model was created that included patient clinical characteristics and surgeon-specific mitral volume to predict the likelihood of mitral valve repair. Between January 2005 and December 2007, 28,507 patients undergoing isolated mitral valve surgery (with or without tricuspid valve surgery, with or without atrial fibrillation surgery) by 1,088 surgeons at 639 hospitals in the STS ACSD were identified. Patient characteristics independently associated with mitral valve repair were identified using a generalized estimating equations logistic regression model. Observed mitral valve repair rates were plotted against surgeon-specific annual mitral volume, and predicted probabilities of mitral repair by surgeon volume were calculated after adjusting for patient baseline covariates. On average, patients undergoing mitral valve surgery were 62 years old, with 51% female and 82% Caucasian. Among surgeons performing mitral procedures, the mean rate of mitral valve repair was 41% (range, 0% to 100%) and the median number of mitral valve operations per year was 5 (range, 1 to 166). Several patient characteristics were independently associated with a decreased odds of mitral repair (versus replacement), including mitral stenosis (odds ratio 0.09; 95% confidence interval: 0.08 to 0.11) and active endocarditis (odds ratio 0.21; 95% confidence interval: 0.17 to 0.25). While substantial variability in repair rates was observed among low-volume surgeons, increased surgeon-level mitral volume was independently associated with an increased probability of mitral repair. This analysis demonstrates marked variability in the frequency of mitral valve repair, and the influence of both patient- and surgeon-level factors on the likelihood of mitral valve repair. Increasing surgeon-specific annual mitral valve volume is associated with a higher probability of mitral repair. Identification of these predictors of mitral valve repair creates substantial opportunity for quality improvement in patient outcomes in mitral valve surgery, potentially through education, adoption of best practices, and improved mitral repair enabling technology.The Annals of thoracic surgery 12/2010; 90(6):1904-11; discussion 1912. DOI:10.1016/j.athoracsur.2010.07.062 · 3.65 Impact Factor
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ABSTRACT: sites and then analyzed the patient and hospital characteristics that had an impact on clinical outcomes. RESULTS: The mortality rates for the high- and low-volume OPCAB facilities both averaged 2.9% (p = NS). Patients at the high-volume OPCAB facilities had significantly lower rates of major complications (shock/hemorrhage, neurologic, renal, and cardiac) than those at the low-volume OPCAB facilities. Of the seven minor complications, rates for six were lower in the high-volume OPCAB facilities, but none of the differences reached statistical significance. High-volume OPCAB sites were significantly more likely to discharge their patients directly home than were low-volume OPCAB sites (80% versus 66%; p = 0.001). CONCLUSIONS: The results suggested that surgical team experience and choice of approaches to performing CABG had an impact on patient outcomes.The Annals of Thoracic Surgery 10/2001; 72(3):S1009-15. DOI:10.1016/S0003-4975(01)02937-X · 3.63 Impact Factor