Pay-for-performance measures, as part of the Affordable Care Act, aim to reduce healthcare costs by linking value to Medicare payments. In order to define value in coronary artery bypass grafting (CABG) and provide a framework to identify high-value centers, a group of researchers matched clinical patient-level data from multi-institutional statewide databases of 42,839 patients undergoing CABG with cost data. Hierarchical models with adjustments for relevant preoperative patient characteristics and comorbidities were used to estimate center-specific risk-adjusted costs and risk-adjusted postoperative length of stay. Variation in value across centers was assessed by the correlation between risk-adjusted measures of quality (mortality, morbidity/mortality) and resource use (costs and length of stay).
The researchers found that there were no significant correlations between risk-adjusted costs and risk-adjusted mortality or morbidity/mortality across centers. Risk-adjusted costs and length of stay were not significantly associated. The differences in cost accounting across centers may explain this lack of correlation between risk-adjusted quality and risk-adjusted cost measures. When risk-adjusted length of stay and morbidity/mortality were used for the framework, there was a strong positive correlation, indicating that higher risk-adjusted quality is associated with shorter risk-adjusted length of stay.
Risk-adjusted length of stay and risk-adjusted combined morbidity/mortality are important outcome measures for assessing value in cardiac surgery. The proposed framework can be used to define value in CABG and identify high-value centers. This provides information for quality improvement and pay-for-performance initiatives associated with adverse events that are more suitable for prioritizing quality improvement efforts.
References: Osnabrugge RL, Speir AM, Head SJ, Jones PG, Ailawadi G, Fonner CE, Fonner E Jr, Kappetein AP, Rich JB. “Cost, quality, and value in coronary artery bypass grafting,” J Thorac Cardiovasc Surg. 2014; 148(6): 2729-35. (Transonic Reference # 10602AHR)