Invited Commentary

Abstract

As scrutiny of the allocation of health care dollars has increased, the need for hospitals to provide not only high-quality care but also cost-effective care has increased. As capitated care becomes more prevalent, the need to be attentive to cost increases further. Congenital cardiac surgery is additionally influenced by the relatively small number of patients treated each year and the increased competition for those patients driven in part by the economics of these trends. The authors conducted an investigation of the hospital-level relationship between cost and quality in congenital cardiac surgery [1Pasquali S.K. Jacobs J.P. Bove E.L. et al.Quality-cost relationship in congenital heart surgery.Ann Thorac Surg. 2015; 100: 1416-1422Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. They found that in general, lower-cost hospitals delivered higher-quality care as measured by in-hospital mortality. There were trends toward similar associations with adverse events and length of stay. The strength of the correlation between cost and mortality was moderate because of variability in the relationship at individual hospitals. This, combined with conflicting findings from studies performed in other populations, may indicate that overall cost is too coarse a measure to be used to define the cost–quality relationship for actionable use. Instead, it may be the distribution of cost that matters. Strategic spending in areas such as dedicated congenital cardiac intensive care units, high nurse-to-patient ratios, and specialized technology may improve outcomes whereas spending in less critical areas may not. All hospitals that achieve superior outcomes may be investing in these vital areas, whereas the low-cost hospitals have learned to be more efficient in nonvital areas where the high-cost hospitals have not. Rather than institute a blanket effort to reduce cost in all areas of care, we should strive to understand in which areas cost can be reduced without undesirable effects on patients. The authors’ study design harnessed the combined strength of administrative data from the Pediatric Health Information Systems database and clinical data from The Society of Thoracic Surgeons Congenital Heart Surgery Database. This allowed the use of both superior risk adjustment and case categorization from clinical data and cost data available in administrative data. However, despite the benefits of this strategy, when analyzing large databases one is confined to the important but limited metrics of quality collected. A favorable result as measured by a patient or family may be only partially captured in the available data. The associations between cost and long-term morbidity and mortality and also functional and neurologic outcomes could not be assessed. Money spent in the short term may be associated with better outcomes in the long term. Multicenter initiatives to improve quality may be better suited to studying the patient perspective and, given the association between high quality and low cost, may prove to be economical as well. As we aim to reduce cost we must insure that our efforts preserve or improve the experience of the patients and their families by tracking outcomes that compromise the full scope of what they deem to be success. Quality-Cost Relationship in Congenital Heart SurgeryThe Annals of Thoracic SurgeryVol. 100Issue 4PreviewThere is an increasing focus on optimizing health care quality and reducing costs. The care of children undergoing heart surgery requires significant investment of resources, and it remains unclear how costs of care relate to quality. We evaluated this relationship across a multicenter cohort. Full-Text PDF