Author + information
- Sandra Lauck1,
- David Cohen2,
- Suzanne Baron3,
- Matthew Reynolds4,
- Seth Clancy5,
- Philippe Genereux6,
- Vinod Thourani7,
- Susheel Kodali8,
- John Webb1 and
- David Wood1
- 1Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospital, Vancouver, British Columbia, Canada
- 2Saint Luke's Mid America Heart Institute, Kansas City, Missouri, United States
- 3St. Luke's Mid America Heart Institute, Kansas City, Missouri, United States
- 4Lahey Clinic Medical Center, Boston, Massachusetts, United States
- 5Edwards Lifesciences, Irvine, California, United States
- 6Columbia, new york, New York, United States
- 7Emory University Hospital Midtown, Atlanta, Georgia, United States
- 8New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York, United States
In 2014, the inpatient hospitalization cost of transcatheter aortic valve replacement (TAVR) procedures in the U.S. was $978 million. There is increasing interest in clinical pathways that risk stratify patients and facilitate early discharge as a strategy to streamline modern TAVR and reduce health resource utilization. The potential cost savings associated with next-day discharge are unknown.
We performed a retrospective analysis using U.S. Medicare Provider Analysis and Review (MedPAR) and Medicare Standard Analytical File data for TAVR. Index hospitalization cost was estimated by multiplying the total charges by the appropriate cost-to-charge ratio. We compared clinical characteristics, in-hospital outcomes, and hospital costs, exclusive of physician remuneration, stratified by next-day discharge and longer length of stay (LOS) in 16,716 patients undergoing transfemoral TAVR in 2015. Regression analysis was used to determine risk-adjusted costs.
We identified a cohort of 545 (3.4%) patients successfully discharged the day after their procedure. Compared with longer LOS patients (median LOS 4 days, IQR 4), next-day discharge patients were younger, mostly male, and had lower Charlson comorbidity scores. They experienced lower 30-day mortality (0.7% vs. 2.1%, p<0.01) and fewer complications. Most were discharged home (79% vs. 41%, p<0.01) and were less likely to be rehospitalized within 30 days (11% vs. 21%, p<0.01) (Table 1). The mean index unadjusted hospitalization cost was 25.7% lower for next-day discharge ($45,727 vs. $61,579). In the risk-adjusted model, next-day discharge was associated with lower index hospitalization cost ($10,159) and reduced risk of rehospitalization (OR 0.61, CI 0.45-0.84).
|Next-Day Discharge N=545||All Others N=16,171|
|30-Day mortality (all-cause)||0.7%**||2.1%**|
|Acute Kidney Injury||1.8%**||10.2%**|
*p-value <0.05; **p-value <0.01
Next-day discharge after TAVR is associated with significant cost savings. Prospective multicenter studies of clinical pathways that can reliably identify patients suitable for next-day discharge home are needed before early discharge can be advocated as a strategy to reduce the cost of TAVR.
OTHER: Cost-Effectiveness and Reimbursement Issues