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Improved Quality and Cost Effectiveness of Coronary Artery Bypass Grafting in the United States from 1988-2005
H. K. Song*, B. S. Diggs, R. M. Ungerleider*, K. F. Welke*. Oregon Health and Science University, Portland, OR,
BACKGROUND:
Coronary artery bypass grafting (CABG) has been routinely performed for the treatment of obstructive coronary artery disease for the past several decades. During this period, changes have occurred both in the patient population undergoing surgery and the cost of healthcare delivery that have the potential to impact the clinical and economic outcomes of CABG surgery. This study was undertaken to assess the impact of increasing patient complexity and healthcare cost on cardiovascular surgery quality and cost effectiveness in the United States over an 18 year period.
METHODS:
A retrospective study was carried out utilizing the Nationwide Inpatient Sample (NIS), a project of the Agency for Healthcare Research and Quality, to track the characteristics and outcomes of 5,549,700 patients undergoing isolated CABG in the United States from 1988-2005. A risk adjusted analysis was performed using patient data available through the NIS to track hospital mortality during this period. Hospital charges associated with CABG were adjusted for all item inflation and medical care services inflation.
RESULTS:
The complexity of patients undergoing CABG increased substantially over the study period. The incidence of congestive heart failure, chronic pulmonary disease, diabetes, obesity, and acute myocardial infarction all increased significantly (p<0.0001). Expected mortality increased from 2.79% to 3.71%, reflecting the increasing prevalence of patient comorbidities over time (p<0.0001). Despite this, CABG surgery outcomes improved, leading to a decrease in risk adjusted mortality from 5.72% to 2.09% (p<0.0001, see Figure 1). While the all item inflation-adjusted hospital charges of CABG increased over this period, when hospital charges were corrected for the accelerated rise in the cost of medical care services, hospital charges associated with CABG declined significantly, from $26,210 per surgery in 1988 to $19,196 in 2005 (expressed in 1988 dollars, p<0.0001, see Figure 2).
CONCLUSIONS:
CABG surgery is being performed on an increasingly complex and high-risk patient population in the United States. Despite this challenge, observed and adjusted operative mortality has progressively declined. Moreover, the hospital charges associated with CABG in relation to other medical care services has been reduced. These findings reflect substantially improved quality and cost effectiveness of CABG surgery in the United States over the past two decades. Given the current economic challenges faced by the health care system, studies of treatment strategies that measure quality as well as cost effectiveness will be important to assess the efficiency of different components of the health care system.  
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