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Ann Thorac Surg 1997;64:49
© 1997 The Society of Thoracic Surgeons
DR CONSTANTINE MAVROUDIS (Chicago, IL): This is an excellent presentation of a landmark paper, which should establish a model for cost and risk analysis for congenital heart operations. My question involves more basic elements than dollars. Instead of tracking costs as 1996 dollars, have you thought of tracking costs in terms of manpower expenditures? For instance, can one assign a comparative value scale for the number of nurse hours, physician hours, equipment needs, and other expenditures that it takes to serve a patient with a given diagnosis? In this manner, dollar costs, which are subject to inflation, can be replaced by actual resource expenditures, which can be compared from one year to the next. Also, have you encountered in your practice patients who have completed their therapeutic course and who, for dietary or other concerns, have their hospital stay extended? Because these situations have an impact on length of hospital stay, are you tracking these data?
DR UNGERLEIDER: Doctor Mavroudis, I appreciate your discussing this paper because you always are able to think of some of the most intriguing questions.
The authorship of this paper represents a diverse group who put considerable time and effort into analyzing these data. Two of them had MBAs and several of them are in our administration and work for the cost accounting system. I do not want to spend inordinate time discussing Transition I, but it is a phenomenally accurate system at tracking exactly what you are discussing or asking about. It calculates the nurse hours, the technician hours in the laboratory, all of the personnel hours-those are indirect costs-and it calculates them in relation to the volume of patients in the hospital as well as to the time required by any individual patient. There are a number of components of cost, including direct costs, variable costs, and fixed direct costs. For example, nurse managers always are going to be hired, and the cost of a nurse manager will be spread among all the patients in the hospital, but that nurse manager is always there. But the number of additional staff nurses will vary in terms of how many are needed depending on the volume of patients being treated by a center.
All of these statistics were taken into account in calculating these costs. The numbers that we do not have, as we look ahead into the year 2010, are what is going to happen to these patients in terms of other outcomes and what kinds of lives they are going to be having, and whether the costs that these patients generate now in 1995 or 1996-these are 1995 data-are going to be warranted against what these patients are going to be able to do for the rest of their lives. I do not have answers for that. But I think, at least as far as anything that I have seen, these data are the most accurate cost data that are available for patients with congenital heart disease.
The second question that you asked about is the variability in discharging patients. Clearly, inpatient hospital days relates greatly to the cost of care. Care maps are coming along that are going to change those things, and total costs might be lowered for individual patients. What we want to emphasize is that there will be certain groups of patients who have high standard deviation in cost, and this variability will relate to unpredictability for cost of care in that group. I suspect that transplant patients, for example, will constitute an unpredictable group, although we do not have those data at this time.
DR DONALD C. WATSON (Memphis, TN): Doctor Ungerleider has presented a high-quality, objective analysis of a complex area. True costs have historically always been difficult to assign. Certified public accountants would have you believe that they understand all of the ramifications of these cost analyses; however, on probing of critical areas, these same certified public accountants will reluctantly admit that this is more of an art form than a science. Doctor Ungerleider has brought us closer to a clearer, objective understanding of some of the variables associated with cardiac operations. In brief summary, sick patients cost more than patients who are not so sick. He has helped us clarify the definition of what sick is in a certain subset of patients.
I have two general questions. Will this information ever-I know you said it does not now-be used to make decisions on what operations can be offered to a specific patient, or a subset of patients? And second, how can we be made better surgeons by using this information in our practice?
DR UNGERLEIDER: Doctor Watson, I appreciate your questions. I know you have a lot of knowledge about this area and have published previously in it. I will answer with two brief comments.
First of all, this information is probably going to be useful to us because it predicts financial risk. We have a lot to learn about that. But we have to emphasize that what we need to focus on is not the actual mean total cost but the patients who have high variability in cost; that may be useful to us in making contracts with payors so that the amount of reimbursement that our institutions receive for those high-risk populations can be based on the financial risk that they bring to us and not some mean total cost that they may not be able to achieve.
Will the information ultimately be refined and made more useful? I do not know. We are just beginning to understand the power of this particular data analysis tool, so we have a lot of work ahead, but I think it at least allows us to look at cost as an outcome parameter for which there are risks. And as we begin to understand those risks, we may be able to talk to the payors about the risks that they are accepting the way we talk to families about the risks that their children have to undergo when they have an operation.
DR WATSON: I would like to just make a brief statement. I think that the cost analysis will highlight areas where patients are truly sicker and force us to look at those areas as clinicians, not financial accountants, and as clinicians we will try to improve the care in those areas.
Related Article
Ann. Thorac. Surg. 1997 64: 44-48.
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