BACKGROUND: Care fragmentation is associated with higher rates of infection after durable left ventricular assist device (LVAD) implant. Less is known about the relationship between care fragmentation and total spending, and whether this relationship is mediated by infections. METHODS: Total payments were captured from admission to 180 days post-discharge. Drawing on network theory, a measure of care fragmentation was developed based on the number of shared patients among providers (ie, anesthesiologists, cardiac surgeons, cardiologists, critical care specialists, nurse practitioners, physician assistants) caring for 4,987 Medicare beneficiaries undergoing LVAD implantation between July 2009 - April 2017. Care fragmentation was measured using average path length, which describes how efficiently information flows among network members; longer path length indicates greater fragmentation. Terciles based on the level of care fragmentation and multivariable regression were used to analyze the relationship between care fragmentation and LVAD payments and mediation analysis was used to evaluate the role of post-implant infections. RESULTS: The patient cohort was 81% male, 73% white, 11% Intermacs Profile 1 with mean (SD) age of 63.1 years (11.1). The mean (SD) level of care fragmentation in provider networks was 1.7 (0.2) and mean (SD) payment from admission to 180 days post-discharge was $246,905 ($109,872). Mean (SD) total payments at the lower, middle, and upper terciles of care fragmentation were $250,135 ($111,924), $243,288 ($109,376), and $247,290 ($108,241), respectively. In mediation analysis, the indirect effect of care fragmentation on total payments, through infections, was positive and statistically significant (β=16032.5, p=0.008). CONCLUSIONS: Greater care fragmentation in the delivery of care surrounding durable LVAD implantation is associated with a higher incidence of infections, and consequently, higher payments for Medicare beneficiaries. Interventions to reduce care fragmentation may reduce the incidence of infections and in turn enhance the value of care for patients undergoing durable LVAD implantation.
Bibliographical noteFunding Information:
This study involved the secondary analysis of (1) Medicare claims (through data use agreement 2019-54083 between the University of Michigan and the Research Data Assistance Center) and (2) STS Intermacs data (provided by its Data Coordinating Center at the University of Alabama to the University of Michigan through permission from the National Heart, Lung Blood Institute under Contract No. HHSN268201100025C for the purposes of dataset linkage). Data was received before the date of STS administration of the registry (January 1, 2018). Informed consent for registrant participation in STS Intermacs was required until the implementation of Protocol v4.0 (February 27, 2014). Details regarding the linkage of these 2 distinct datasets have been reported.
This project was supported by grant number R01HS026003 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Support for Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative is provided by Blue Cross and Blue Shield of Michigan and Blue Care Network as part of the Blue Cross and Blue Shield of Michigan Value Partnerships program. Although Blue Cross Blue Shield of Michigan and Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative work collaboratively, the opinions, beliefs, and viewpoints expressed by the author do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees.
Dr Likosky receives: (1) extramural support from the Agency for Healthcare Research and Quality and National Institutes of Health; (2) partial salary support from Blue Cross Blue Shield of Michigan; and (3) support as a consultant to the American Society of ExtraCorporeal Technology. Dr Pagani is a member of the scientific advisory board of FineHeart, Inc, member of the Data Safety Monitoring Board for Carmat, Inc., member of the Data Safety Monitoring Board for the National Heart, Blood, and Lung Institute PumpKIN clinical trial, and Chair of The Society of Thoracic Surgeons, INTERMACS Task Force. Keith Aaronson serves on a Medtronic Independent Physician Quality Panel. The other authors have no relevant disclosures.
© 2022 American Heart Association, Inc.
- Delivery of health care
- Health expenditures
- Heart-assist devices
- Mediation analysis
- Social network analysis
PubMed: MeSH publication types
- Journal Article
- Research Support, Non-U.S. Gov't
- Research Support, U.S. Gov't, P.H.S.