The rapid approach of capitated reimbursement mandates that providers examine their practice patterns associated with all surgical procedures. Documentation of (1) the complications associated with these procedures and (2) the additional hospital costs associated with the management of these complications is critical for comprehensive fiscal accountability. This study analyzed (1) the feasibility of obtaining accurate hospital cost data specific for complications and (2) the outcome in terms of fully loaded hospital costs generated in the management of the most common surgical complications associated with pacemaker and nonthoracotomy implantable defibrillator therapies. Between July 1989 and September 1994, a total of 1031 pacemaker and 105 implantable defibrillator procedures were performed by a cardiac surgeon in a tertiary-level teaching hospital setting. The additional fully loaded hospital costs were determined by (1) correlating clinical data from the complete medical record with complete hospital charge data for the admission(s) related to the complication, (2) carving out complication-related charges based on the clinical data, (3) converting complication-related charges to fully loaded costs based on conversion factors in effect at the time of service, and (4) correlating cost with hospital net reimbursement and payor source. The feasibility study determined that accurate and reliable cost data specific to complications can be obtained, although the process was cumbersome and difficult. The outcomes study determined that mean fully loaded complication costs were $4345 +/- $1540 for pacemaker lead revision and $4879 +/- $3167 for implantable defibrillator lead dislodgement, $24,459 +/- $14,585 for pacemaker infection, and $13,736 +/- $12,505 for defibrillator generator system malfunction. The one infected defibrillator cost $57,213 to treat. Costs exceeded reimbursement for almost all Medicare patients with complications in this study, suggesting that similar shortfalls would occur under a capitation scheme. This information is critical to a complete understanding of the financial impact of interventional procedures in a capitated reimbursement environment.

BackgroundSame‐day discharge (SDD) after elective percutaneous coronary intervention is safe, less costly, and preferred by patients, but it is usually performed in low‐risk patients, if at all. To increase the appropriate use of SDD in more complex patients, we implemented a “patient‐centered” protocol based on risk of complications at Barnes‐Jewish Hospital.Methods and ResultsOur objectives were as follows: (1) to evaluate time trends in SDD; (2) to compare (a) mortality, bleeding, and acute kidney injury, (b) patient satisfaction, and (c) hospital costs by SDD versus no SDD (NSDD); and (3) to compare SDD eligibility by our patient‐centered approach versus Society for Cardiovascular Angiography and Interventions guidelines. Our patient‐centered approach was based on prospectively identifying personalized bleeding, mortality, and acute kidney injury risks, with a personalized safe contrast limit and mitigating those risks. We analyzed Barnes‐Jewish Hospital's National Cardiovascular Data Registry CathPCI Registry data from July 1, 2009 to September 30, 2015 (N=1752). SDD increased rapidly from 0% to 77% (P<0.001), independent of radial access. Although SDD patients were comparable to NSDD patients, SDD was not associated with adverse outcomes (0% mortality, 0% bleeds, and 0.4% acute kidney injury). Patient satisfaction was high with SDD. Propensity score–adjusted costs were $7331 lower/SDD patient (P<0.001), saving an estimated $1.8 million annually. Only 16 patients (6.95%) met the eligibility for SDD by Society for Cardiovascular Angiography and Interventions guidelines, implying our patient‐centered approach markedly increased SDD eligibility.ConclusionsWith a patient‐centered approach, SDD rapidly increased and was safe in 75% of patients undergoing elective percutaneous coronary intervention, despite patient complexity. Patient satisfaction was high, and hospital costs were lower. Patient‐centered decision making to facilitate SDD is an important opportunity to improve the value of percutaneous coronary intervention.

Background Bleeding is a common, morbid, and costly complication of percutaneous coronary intervention. While bleeding avoidance strategies ( BAS ) are effective, they are used paradoxically less in patients at high risk of bleeding. Whether a patient‐centered approach to specifically increase the risk‐concordant use of BAS and, thus, reverse the risk‐treatment paradox is associated with reduced bleeding and costs is unknown. Methods and Results We implemented an intervention to reverse the bleeding risk‐treatment paradox at Barnes‐Jewish Hospital, St. Louis, MO, and examined: (1) the temporal trends in BAS use and (2) the association of risk‐concordant BAS use with bleeding and hospital costs of percutaneous coronary intervention. Among 3519 percutaneous coronary interventions, there was a significantly increasing trend ( P =0.002) in risk‐concordant use of BAS . The bleeding incidence was 2% in the risk‐concordant group versus 9% in the risk‐discordant group (absolute risk difference, 7%; number needed to treat, 14). Risk‐concordant BAS use was associated with a 67% (95% confidence interval, 52–78%; P <0.001) reduction in the risk of bleeding and a $4738 (95% confidence interval, 3353–6122; P <0.001) reduction in per‐patient percutaneous coronary intervention hospitalization costs (21.6% cost‐savings). Conclusions In this study, patient‐centered care directly aimed to make treatment‐related decisions based on predicted risk of bleeding, led to more risk‐concordant use of BAS and reversal of the risk‐treatment paradox. This, in turn, was associated with a reduction in bleeding and hospitalization costs. Larger multicentered studies are needed to corroborate these results. As clinical medicine moves toward personalization, both patients and hospitals can benefit from a simple practice change that encourages objectivity and mitigates variability in care.