Abstract 2: Facility-level Variation in 30-day PCI Mortality, Readmission, and Costs in the VA Health Care System: Insights About Short-term Healthcare Value From The VA CART Program

Background: Value in health care, defined as the health outcomes achieved per dollar spent, is emerging as a framework for improvement in health care delivery. We sought to describe facility-level variation in 30-day PCI mortality, readmission and costs. Methods: Using national data from the VA CART Program, we evaluated all patients who had PCI from 2008 to 2010. 30-day total patient costs, readmission, and mortality were attributed to the hospital where the PCI was performed. Risk standardized costs and outcomes were calculated using standardized covariates, adjusting for cardiac and non-cardiac comorbidities. Results: There were 60 hospitals (21,173 patients) that performed more than 20 PCIs during the study period with a mean of 353 PCIs. The unadjusted mean mortality rate was 2.5%, with no significant variation in facility-level risk standardized mortality. The unadjusted mean readmission rate was 10.6%. The risk standardized readmission rate ranged from 0.8 to 1.58 times the average, with 2 hospitals significantly below and 8 hospitals significantly above the risk standardized average. The facility-level median per patient total costs was $26,491 (IQR $20,943 to $31,866). The index hospitalization accounted for 42.4% of 30-day total costs, and readmission accounted for 5.6% of the 30-day total costs at the facility-level. Comparison of risk standardized costs identified 17 hospitals with lower than expected costs and 15 hospitals with higher than expected costs. Facilities with low readmission rates were not overrepresented among low cost facilities, suggesting readmissions are not a major contributor to facility-level 30-day cost (Figure). Conclusion: We observed no variation in facility-level 30-day PCI mortality despite large variation in cost. Although readmission rates varied, readmission accounted for less than 6% of 30-day cost and was not related to facility-level costs. Further studies are needed to determine factors associated with high-value PCI care, defined by low morbidity and mortality despite similar or lower costs.

Abstract 2162: Mechano-energetic Superiority Of Left Ventricular Apex And Left Ventricular Septal Pacing

Objective: Previous studies showed hemodynamic benefits over right ventricular (RV) apex pacing by left ventricular (LV) septal or LV apex pacing. We investigated whether this benefit is also reflected in mechanical efficiency. Methods: After AV-nodal ablation, dogs received 16 weeks of VDD pacing at the RV apex (RVa; n = 8), LV apex (LVa; n = 7) or LV septum (LVs; n = 8; transventricular-septal approach). After chronic pacing, LV stroke work (SW; conductance catheter) was measured, as well as relative myocardial oxygen consumption (MVO 2 , coronary flow velocity and arterial-coronary sinus O 2 difference). Baseline efficiency (SW/MVO 2 ) was assessed during implant site (IS), RVa, LVa, and RVa + LV lateral (BiV) pacing. In order to investigate the effect of pacing site udner different conditions, measurements were performed during baseline and dobutamine infusion +/− partial aortic occlusion. The O 2 cost of generating SW, corrected for end-systolic elastance and effective arterial elastance, was calculated using the Suga model of mechano-energetics. Results: RVa pacing after chronic LV pacing reduced SW/MVO 2 (Figure a ; mean ± SD, *p<0.05 vs. 1) and increased O 2 cost (Figure b ) in combination with a 12% fall in LV dP/dt-max. However, LVa or BiV pacing after chronic RVa pacing did not significantly alter efficiency, despite a 12% increase in LV dP/dt-max. LVa pacing improved efficiency over LVs and collectively over BiV pacing (p<0.05). Conclusions: Acutely, LVa pacing results in the greatest mechanical efficiency. The lack of improvement in efficiency despite increasing contractility when switching from chronic RVa pacing to LV based pacing may indicate contractile remodeling.

The CyberKnife Stereotactic Radiosurgery System: Description, Installation, and an Initial Evaluation of Use and Functionality

The CyberKnife Stereotactic Radiosurgery System is manufactured by Accuray, Inc. (570 Del Rey Avenue, Sunnyvale, CA 94085; telephone 1-888/522-3740 or 1-408/522-3740; http://www.accuray.com). It is currently available for purchase (capital cost of US $3.2 million plus US $0.5 to 0.75 million for site setup), or in a revenue-sharing plan (US $0.5 to 0.75 million setup cost). FIGURE

Looking Backwards: How Do You Get Paid?1

ABSTRACT While a number of factors play a significant role in an oil spill response, of critical interest to every participant is money: how much and who pays! A responsible party clearly cares about the ultimate cost figure for a response; its insurer is very interested in that figure but may have quite a different view on its obligations. Contractors and subcontractors want to be paid fully and promptly, as do third parties who may suffer damages. The Federal On-Scene Coordinator (FOSC), the Oil Spill Liability Trust Fund (OSLTF or the Fund), and insurers become key players after the event in cost recovery and payment for damages. Despite these sometimes conflicting interests, every response participant can benefit from understanding the standards applied by payors. Based on the standards and procedures for making claims, the participant can create a system that helps in collecting costs or damages. This paper briefly describes the sources of funding, and the standards and process for submitting claims for response costs and damages related to spills in U.S. waters. It then offers suggestions and tools for documenting decisions and costs in a way that enhances the ability to get paid.

Cost-effectiveness analysis of telemedicine

There are a number of different costs associated with the development and operation of telemedicine services. A model is proposed in order to assist in strengthening the evidence base for telemedicine. It includes the following components: project establishment costs; equipment costs; maintenance costs; communication costs; staffing costs. All need to be considered in arriving at an annual cost figure for operating a telemedicine service. The inclusion of all these costs, prepared in the standard manner outlined in the model, will ensure that a realistic cost figure is available when evaluating the cost-effectiveness of a telemedicine service.

An Overview of Total Medical Information Systems

This paper is addressed to the practising physician, hospital administrator, and allied health professional. The function of a computerized information system in health care today is defined as a traffic controller, Factors justifying the implementation of a hospital information system will be discussed and the crucial considerations of competent management and long-range education explained. The paper describes various philosophies undertaken and reviews the approaches of a sampling of vendors and organizations endeavoring to implement computerized hospital information systems. Included in each system discussion is: 1.) a brief description of the functions undertaken, 2.) hardware and software used, type of terminal used for input at designated stations, 3.) a listing, where possible, of planned and/or present instillations, 4.) an approximate cost figure, where available, and 5.) a brief statement containing additional information.The Appendix composes a list of locations of operational total systems should the reader desire either to arrange a site visit or obtain additional information.

A decision procedure for selecting among proposed automatic analog computer patching systems

In the recent literature, a paper1 and a contract report2 indicate that automatic analog computer patching sys tems have become economically and technologically feasible. In anticipation of the development of a variety of proposed patching systems, a specific decision pro cedure is developed for the rational evaluation of com peting automatic analog patching systems. The design procedure described in this paper facilitates selection of the patching system best suited for a partic ular computer and a particular problem class. Sufficient information is abstracted from a typical problem set to determine the number of relays required for (and thus to assign a cost figure to) each possible patching system without requiring the actual design of each system. Nom inally, the best system is that with the lowest cost figure. It is recognized, however, that there are many subjective decisions (e.g., captive vs. free pots) involved in the de sign process that are not quantified in this overall cost figure. This problem is met in part by providing inter mediate information relating to the optimal module size, combinations of proposed systems, etc. to help estab lish some of the sensitivity properties of the optimal system. The procedure is illustrated by applying it to a particu lar case and evaluating a number of alternative switching systems.