IN-HOSPITAL COST OF PERCUTANEOUS CORONARY REVASCULARIZATION - CRITICAL DETERMINANTS AND IMPLICATIONS

Background Hospital charges associated with percutaneous transluminal coronary revascularization (PTCR) in the United States exceeded $6 bil lion in 1994 and are likely to be constrained in some manner in the ne ar future. Despite this high cost to the public, little is known about the major determinants and sources of variability of PTCR. Methods an d Results From a consecutive series of 1258 procedures with attempted PTCR at a single tertiary referral center, we analyzed 65 clinical, an giographic, physician, and outcome variables as potential correlates o f total (hospital and physician) cost. Direct and indirect costs, both hospital and physician, were determined on the basis of resource util ization using ''top-down'' methodology and were available for 1237 pro cedures (1086 patients) (98.3%). Mean (+/-SD) patient age was 62+/-11 years, 76% were male, 3% had acute myocardial infarction, 71% had unst able angina, 58% had multivessel disease, left ventricular ejection fr action was 54+/-12%, 26% had use of at least one nonballoon revascular ization device, and median length of stay was 4.4 days. procedural suc cess was obtained in 89%, and major complications (death, bypass surge ry, or Q-wave myocardial infarction) occurred in 3.8%. The median cost was $9176, but it was asymmetrically distributed, and the interquarti le and total ranges were wide ($7333 to $13845 and $3422 to $193474, r espectively). Analyses of independent correlates of cost and log(e)(co st) were performed using multivariate linear regression in training an d test populations. Modeling found 15 independent preprocedural correl ates of log(e)(cost) (R(2)=.37) and 23 overall correlates (R(2)=.65), excluding length of stay per se. Addition of length of stay to the mod el increased the explanatory power of the model to R(2)=.82. Preproced ural variables most predictive of log(e)(cost) included presentation w ith acute myocardial infarction, decision delay (>48 hours between adm ission and diagnostic angiography and/or >24 hours between angiography and intervention), weekend delay, use of intra-aortic balloon counter pulsation, intention to stent, creatinine greater than or equal to 2.0 mg%, and lesion complexity (modified American College of Cardiology/A merican Heart Association score) (all P<.001). In the model that inclu ded postprocedural variables as well, length of stay, noncardiac death , urgent bypass surgery, use of the Rotablator, Q-wave myocardial infa rction, rise in creatinine greater than or equal to 1.0%, and blood pr oduct transfusion were all strong independent correlates of log(e)(cos t) (P<.001).Conclusions The range of total hospital costs associated w ith percutaneous intervention is extraordinarily wide. Baseline patien t characteristics account for nearly half of the explained variance, b ut procedural complications and system delays account for much of the remainder. Quantification of the determinants of cost may promote more economically efficient care in the future.