Effect of risk factors on the costs of coronary surgery.

F ifteen years ago, the costs of health care accounted for about 2% of the gross national product in the United States and a whopping 14% in 1998, and now is rising faster than ever before, certainly faster than any other expenditure. This triggered not only general budgeting efforts to curb the “health care inflation,” but also moved to reexamine current budgeting policies in different areas of the health care complex. Cardiac surgery, especially coronary interventions, which by their sophistication as well as by their sheer volume take a lion’s share of health care funds, have been and will remain in the center of fiscal scrutiny. One of the key questions of this process is the allocation of the now limited amount of monies available between the ever-growing number of people suffering from different stages of coronary heart disease. Monetary restrictions may be placed on any particular health care sector in several ways: by national or regional limitation of funds, by freezing institutional capacity, or by making individual patient access more difficult. Although the underlying motif is economic, typically these restrictive measures include consideration of clinical data such as making some services less available or unavailable to patients who are albeit in need of but are the least likely to benefit by a particular service. The clinician who is, and hopefully will remain, the patient’s principal “advocate” finds himself in a most frustrating situation. We all know that the surgical care of those with multiple preoperative risk factors costs more, but we are also aware that very little can be done about it. We cannot make our patients any younger, change their gender, or give them better kidneys. We may improve their pulmonary function somewhat, but even that costs money. Thus, because of the undisputed fact that surgical care of patients with high risk factors consume more funds than those without, society now leans toward an economical “solution”: If risk factors cannot be favorably modified, then the access of “high-risk” patients to the health system should be curtailed and our shrinking resources be spent on those who could be treated with better results at a lower cost! This rationing by risk factors already exists in public as well as in private health delivery systems of different countries, where the availability of some specific services, especially dialysis and organ transplantation, are already severely limited by risk factors, especially by age. Other measures, such as mandatory public disclosure of postoperative results of individual surgeons in some states such as New York and Massachusetts, indirectly significantly contribute to the exclusion of “high-risk patients” from the mainstream of surgical care. Most privately owned health care providers fare even worse, by either outright exclusion or financially heavy penalization of patients with risk factors such as advanced age, hypertension, diabetes, renal dysfunction, and so forth. Besides the above cost-related issues, risk factors are also frequently taken into consideration in other areas of health care, such as quality control where presence of a patient population with higher than usual risk factors may be used to explain excess morbidity or mortality. Importantly, the fact that risk factors unfavorably influence both hospital costs and surgical outcome is undeniable. To what degree this occurs, however, is highly debatable. With this basic postulate in mind the relevant literary data were reviewed. As the initial step in this process of evaluation, we tried to identify the “outliers,” sporadic patients with either very low or very high costs. Based on our past clinical experience, we expected to find the costs of coronary surgery to be especially low in patients who were either in exceptionally good shape with no significant preoperative risk factors, or to the contrary, died in the course of their hospitalization. We got our first surprise at that stage. Ten to 15 years ago, patients we have lost in the course of coronary surgery were also the “cheapest” cases—most of them having died in the operating theater, thus incurring no further costs. In the last decade, however, while the answer to the question, “how many patients died?” may not have changed significantly as “when and where did they die?”—did indeed! Today those who in the past would have died in the operating room, despite the most sophisticated (and also most expensive) technology, are now transferred to and kept alive in various intensive care units for extended time periods before they are allowed to meet their maker. Although this practice clinically is certainly justified, in most, if not all, patients, from an economical view it is a most severe drain on health care resources. With the other 2 extremes on the “risk factor scale,” best represented by a vigorous 40-year-old man with 1-vessel disease and no known risk factors on the one hand, and a From the Department of Thoracic and Cardiovascular Surgery, Carolinas Heart Institute, Carolinas Medical Center, Charlotte, North Carolina. Manuscript received and accepted December 7, 1999. Address for reprints: Francis Robicsek, MD, PhD, Department of Thoracic and Cardiovascular Surgery, Carolinas Heart Institute, Carolinas Medical Center, Charlotte, North Carolina.