Differential Cost Analysis of Peripheral Arterial Atherectomies performed as Inpatient versus Outpatient across the United States.
Satinderjit Locham, MD, Besma Nejim, MBChB, MPH, Hanaa Dakour Aridi, MD, Husain Alshaikh, Mahmoud B. Malas, MD, MHS.
Johns Hopkins Medical Institutions, Baltimore, MD, USA.
Objective:
Atherectomy has been established as a minimally invasive approach to treat symptomatic atherosclerotic occlusive lesions in patients with multiple comorbidities. Due to its lesser invasive nature, it can easily be performed at an outpatient center. There aren't proper studies to differentiate the cost of atherectomies performed at an inpatient versus outpatient facilities. The aim of our study was to evaluate the cost of atherectomy in inpatient and outpatient centers across the US and to evaluate the regional variability in procedure setting.
Methods:
Using the Premier database (2011-2015), we identified all patients with PAD, who underwent atherectomy in the inpatient or outpatient settings. Chi-square, Student's t-tests, medians test, univariate and multivariable linear regression analyses were implemented to examine in-hospital and outpatient cost adjusting for patients' characteristics.
Results:
A total of 16,914 patients underwent atherectomy [Inpatient: 3,848 (23%) vs. Outpatient: 13,066 (77%)]. An increasing trend from 2011 to 2015 in the number of outpatient procedures for atherectomy was noted in the West, while inpatient procedures were increasing in the North-East (Figure 1A and 1B). However, no temporal trend was observed in the Midwest or in the South (Figure 1C and 1D). Overall, the median cost of atherectomy was $5,781 higher for inpatients as compared to outpatients ($14,893 vs $9,112, p<0.001). Moreover, the median cost was significantly higher for inpatient across all the regions. After adjusting for patients' characteristics and comorbidities, the multivariable regression analysis showed that inpatient cost was on average $4,284 higher compared to outpatient (95% CI: $4,072-$4,496, P<.001). Additionally, the adjusted average cost of atherectomy, regardless of the setting, was significantly higher in the West by $1,926 ($1,683 - $2,168; P<.001) and in the Northeast by $1,544 ($1,279 - $1,808; P<.001) but similar in the Midwest [$118 (-$76 - $311; P=0.23)] as compared to the South.
Conclusion:
In this large cohort of PAD patients undergoing atherectomies, we showed that the cost of inpatient is significantly higher than outpatient. Marked regional variability exists in the trend and cost of atherectomies procedures. The factors underpinning this variability and the differential perioperative outcomes between the inpatient and outpatient settings, deserve further elucidation. 
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