# Center-Related Variation in Hospitalization Cost for Patients Undergoing Percutaneous Left Atrial Appendage Occlusion

## TL;DR

This study shows that hospital costs for a heart procedure called Watchman device implantation vary significantly between hospitals, with factors like hospital experience and complications affecting the cost.

## Contribution

The study identifies hospital-specific factors contributing to cost variability in Watchman device implantation, emphasizing the need for standardized practices.

## Key findings

- Hospital costs for the Watchman procedure varied widely, with 13% of cost differences linked to the hospital itself.
- Higher-volume hospitals had lower costs and less cost variation compared to low-volume hospitals.
- Procedural complications, heart failure, and longer hospital stays were linked to higher costs.

## Abstract

The commercial use of percutaneous left atrial appendage occlusion with the Watchman device is increasing in the United States. The purpose of this study was to evaluate center-related variation in total hospital costs for Watchman device implantation and identify factors associated with high hospital costs at a national level.

All adults undergoing elective left atrial appendage occlusion with Watchman were identified in the 2016-2018 National Inpatient Database. Mixed models were used to evaluate the impact of center on total hospital costs, adjusting for patient and center characteristics and length of stay.

A total of 30,175 patients underwent Watchman device implantation at a median cost of $24,500 and demonstrated significant variability across admissions (interdecile range, $13,900-37,000). Nearly 13% of the variability in patient-level costs was related to the center performing the procedure rather than patient factors. Higher-volume centers had lower total costs and demonstrated lesser total cost variation. Centers with low procedural volume, occurrence of procedural complications, congestive heart failure, and length of stay were independent predictors of a high-cost hospitalization. Though complications were associated with increased expenditure, they did not explain the observed cost variation related to the center.

A significant proportion of variation in total hospital cost was attributable to the center performing the procedure. Addressing variability of Watchman-related costs is necessary to achieve high-quality value-based care.

1.What is already known:•Watchman device implantation is a cost-effective alternative for stroke prevention in atrial fibrillation patients unsuitable for long-term oral anticoagulation therapies.2.What this study adds:•There are significant differences in costs between hospitals for the Watchman device procedure, highlighting the need for standardizing hospital practices and optimizing costs.•Variation in hospital costs for the Watchman device procedure is influenced by differences in hospital care pathways and resource utilization, with factors such as low procedural volume, procedural complications, congestive heart failure, and longer hospital stays contributing to increased costs.3.How this study might affect research, practice, or policy:•Our findings demonstrate considerable variability in patient costs for elective left atrial appendage occlusion attributable to the hospital and emphasize the need for further studies analyzing cost variation related to implantation of more contemporary left atrial appendage occlusion devices to develop targeted cost containment strategies.

What is already known:•Watchman device implantation is a cost-effective alternative for stroke prevention in atrial fibrillation patients unsuitable for long-term oral anticoagulation therapies.

Watchman device implantation is a cost-effective alternative for stroke prevention in atrial fibrillation patients unsuitable for long-term oral anticoagulation therapies.

What this study adds:•There are significant differences in costs between hospitals for the Watchman device procedure, highlighting the need for standardizing hospital practices and optimizing costs.•Variation in hospital costs for the Watchman device procedure is influenced by differences in hospital care pathways and resource utilization, with factors such as low procedural volume, procedural complications, congestive heart failure, and longer hospital stays contributing to increased costs.

There are significant differences in costs between hospitals for the Watchman device procedure, highlighting the need for standardizing hospital practices and optimizing costs.

Variation in hospital costs for the Watchman device procedure is influenced by differences in hospital care pathways and resource utilization, with factors such as low procedural volume, procedural complications, congestive heart failure, and longer hospital stays contributing to increased costs.

How this study might affect research, practice, or policy:•Our findings demonstrate considerable variability in patient costs for elective left atrial appendage occlusion attributable to the hospital and emphasize the need for further studies analyzing cost variation related to implantation of more contemporary left atrial appendage occlusion devices to develop targeted cost containment strategies.

Our findings demonstrate considerable variability in patient costs for elective left atrial appendage occlusion attributable to the hospital and emphasize the need for further studies analyzing cost variation related to implantation of more contemporary left atrial appendage occlusion devices to develop targeted cost containment strategies.