PCI could be key to cutting Medicare costs

Early percutaneous coronary intervention (PCI) could be the difference between effective and ineffective spending for both Medicare beneficiaries and their healthcare providers, according to an investigation published in JAMA Cardiology.

While countless studies have centered around the relationship between Medicare costs and health outcomes, fewer have extended that analysis to long-term growth in expenditures and their consequences, first author Donald S. Likosky, PhD, and colleagues wrote. Prior studies have also neglected to break down spending patterns into easily digestible statistics.

“Although it is well-understood that not all spending is cost-effective, nearly all studies have summarized the multidimensional components of patient care by a single dollar measure—total expenditures—rather than considering how the money is spent,” Likosky et al. wrote.

In an effort to evaluate how spending growth has affected mortality rates over the past two decades, the researchers conducted a cross-sectional analysis of nearly 500,000 acute myocardial infarction (AMI) patients across the U.S.

They drew a random 20 percent sample of elderly, fee-for-service Medicare beneficiaries who were diagnosed with AMI between January 1999 and December 2000, resulting in a total population pool of 479,893 patients, according to the study. Though 30-day outcomes and spending in the majority of those cases were similar across the board, Likosky et al. focused on a 180-day post-care window in which results varied among hospitals.

The team’s analysis revealed adjusted expenditures per patient increased 13.9 percent from 1999 through 2000 and Jan. 1, 2013 through June 30, 2014. However, those expenditures declined 0.5 percent between 2008 and 2013-14. In the top 5 percent of hospitals with the most rapid expenditure growth between 1999-2000 and 2013-2014, the authors reported, spending increased by 44.1 percent, while the 5 percent with the slowest expenditure growth during that time saw cost decreases of 18.7 percent.

“Nonetheless, hospitals with more rapid increases in spending did not experience larger case fatality rate declines,” Likosky et al. wrote.

Overall, 180-day case fatality rates per AMI patient dropped from 26.9 percent in 1999 to 21.5 percent in 2014, but most of that reduction could be attributed to the first 3o days of hospitalization. Total expenditures grew from 6.1 percent up to 30 days beyond initial hospital admission and 31 percent from 31 to 365 days beyond initial admission.

One of the most effective money-reducers, Likosky and colleagues wrote, was the increased presence of PCI in American hospitals. Usage of PCI through 180 days of hospitalization increased by nearly 50 percent between 1999 and 2014, and early PCI intervention increased by 102.9 percent. Conversely, CABG rates fell by 35.3 percent. Because PCI is both a noninvasive and cost-effective procedure, the authors said healthcare providers who increase use of PCI while cutting costs elsewhere—perhaps in acute and postacute care—could see the greatest improvement in patient outcomes without increasing Medicare spending.

Jason H. Wasfy, MD, and Robert W. Yeh, MD, MSc, wrote in a JAMA editorial analyses such as Likosky et al.’s are integral to bettering a health system that’s costing American patients tens of thousands of dollars each year.

“More than 1 million Americans experience an AMI each year at a cost of more than $40,000 per patient over the first year,” they wrote. “Furthermore, the cost of AMI treatment has increased by nearly one-fifth over a decade. Understanding which specific components of these cost increases help patients is essential.”