News & Commentary

First-Day Use of Coronary Angioplasty Improves Heart Attack Outcomes

Frank Diamond

Sometimes you get what you pay for. But when it comes to heart attacks, additional health care spending was only weakly associated with lower case-fatality rates, according to a study of Medicare patients by a team of researchers led by Donald Likosky of the University of Michigan.

What did make a difference, according to these researchers, was coronary angioplasty on the first day of heart attack patients’ hospitalizations. The association between early coronary angioplasty and the 180-day case fatality rate “is large, statistically significant, and robust,” especially among patients with serious (STEMI) heart attacks, they reported in an article published online in JAMA Cardiology on Dec. 20, 2017.

Moreover, the researchers noted, the cost of heart attack care at hospitals that increased the use of early angioplasty did not increase by a large amount, although the authors didn’t provide much in the way of detail about that relationship.

The study states that increases in 180-day case fatality were associated positively with cardiac procedure spending and negatively with post-acute care, the latter of which translates to a cost-effectiveness ratio of $455,000 per life saved.

The goal of this study was to tease out which components, if any, of the expenditures on heart attack patients are associated with better outcomes for those patients. Presumably, the health care system should be investing in those that give the biggest outcome bang for the health care buck. For the purposes of this study, a better outcome was defined as a better 180-day risk-adjusted case fatality rate. Likosky and his colleagues set out to find the answer to the expenditure–outcome question by crunching numbers culled from data on nearly half a million (479,893) fee-for-service Medicare beneficiaries who had been hospitalized for a heart attack.

Not surprisingly, they found that heart attack care has gotten more expensive. Between 1999–2000 and 2013–2014, the per-patient expenditure, adjusted for inflation and risk, increased from $32,182 to $36,668, a $4,486 difference that works out to a 13.9% increase. Interestingly, though, all of that increase had occurred by 2008; spending leveled off after that.

TABLE. Average expenditure for Medicare heart attack patients
1999–2000 2013–2014 Change, %
Total spending, 180 days $32,182 $36,668 13.9%
Inpatient services $23,734 $24,151 1.8%
Skilled nursing facility $1,545 $3,127 102.4%
Physician payment $5,304 $5,041 –5.0%
Outpatient services $673 $2,491 270.1%
Home health, hospice, or DME $998 $2,002 100.6%
Source: Likosky, DS et al., JAMA Cardiology, Dec. 20, 2017

Another finding jumped off the page: The spending growth was highest between the 31st day and the 180th day of the 180-day period the researchers studied. A doubling of nursing home and home health care expenditures is one of the reasons for the jump in post-acute care costs. One takeaway, the researchers noted, is that if you want to use bundled payments to curb spending on heart attack patients, those bundles should include services provided after the first 30 days of care because that is where spending is variable and climbing.

Their other big takeaway was that spending early on angioplasty was one of the few areas that was associated with lower 180-day case-fatality rates, so hospitals should be encouraged to treat heart attack patients early on with angioplasty.

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