Center Related Variation in Hospitalization Cost for Patients undergoing Percutaneous Left Atrial Appendage Occlusion

Background The commercial use of percutaneous LAAO 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. Methods All adults undergoing elective LAAO with Watchman were identified in the 2016 to 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. Results A total of 30,175 patients underwent Watchman device implantation at a median cost of $24,500 and demonstrated significant variability across admissions (inter-decile 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. Conclusion 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. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement no external funding was received ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was exempt from an Institutional Review Board approval because HCUP-NIS is a publicly available database containing only de-identified patient information. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Not Applicable I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Not Applicable I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Not Applicable The data described in this article are available at https://hcup-us.ahrq.gov