Invited Commentary 

Cardiology

April 2, 2025

What’s Missing From Value-Based Care—Accounting for the Costs and Benefits of Quality Improvement

Donald E. Casey Jr

JAMA Netw Open. 2025;8(4):e252510. doi:10.1001/jamanetworkopen.2025.2510

Current estimated direct and indirect economic cost of cardiovascular diseases from 2019 to 2020 was $422.3 billion with coronary heart disease (CHD) accounting for more than 40% of deaths attributable to diseases of the heart in the US, a rate which has recently been rising again.¹ In 2023, US clinical registries noted a total of 4.3 million catheter-based interventions for CHD,² with a subset of 434 230 estimated for percutaneous coronary interventions performed in the US on an emergency, urgent, and elective basis.¹

Iodinated contrast material (ICM) is administered intravascularly daily to many inpatients and outpatients around the world to increase the diagnostic accuracy of a large variety of imaging evaluations. For procedures such as cardiac catheterization procedures interventions for CHD, this type of contrast is administered intra-arterially. The most important potential major adverse effects from ICM include potentially life-threatening acute kidney injury (AKI) and allergic reactions. Many studies have shown that patients experiencing contrast induced-AKI (CI-AKI) have greater risk for death and prolonged hospitalization and other adverse outcomes, including cardiovascular events.³

In response, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) funded IMPROVE AKI, which was a 2 × 2 factorial cluster-randomized trial across 20 of 70 total cardiac catheterization laboratories within Veterans Affairs medical centers (VAMCs).⁴ The intervention phase of the trial involved patients with preexisting chronic kidney disease, a high risk factor for both reversible and irreversible ICM-induced CI-AKI. Of note, 90% of recruited participants were male. Participating VAMCs were randomized to receive 1 of 3 complex quality improvement (QI) support strategies to assist in ensuring consistent implementation of evidence-based guideline AKI prevention recommendations through: (1) assistance; (2) assistance with either surveillance or collaborative; or (3) collaborative with surveillance. Among 122 803 patients, 13 047 experienced CI-AKI with AKI incidences of 13.3% in assistance, 11.4% in assistance with surveillance, 12.7% in collaborative, and 7.9% in collaborative with surveillance.⁴

In a recently published follow-on study, a subset of IMPROVE AKI investigators performed a well-designed, detailed cost-effectiveness analysis of these 4 implementation interventions deployed in this trial.⁵ Per-patient intervention costs were (1) $12.74 for collaborative with surveillance; (2) $3.97 for collaborative alone; (3) $3.36 for assistance with surveillance; and (4) $2.69 for assistance alone. These overall results were mainly driven by costs of CI-AKI and subsequent development of permanent renal disease. Estimation of incremental cost-effectiveness ratios using willingness-to-pay threshold of $100 000 per quality-adjusted life years (QALY) revealed the collaborative with surveillance strategy as economically dominant. The authors noted overall per-person savings of $742.75 while improving effectiveness by 0.02 QALYs with this strategy.

A common response to impactful findings such as these impressive clinical results and economic evaluation of potential cost savings demonstrated by IMPROVE AKI, often goes something like this: “Why aren’t we doing this in all cardiac catheterization labs everywhere?” While an excellent question, the most meaningful answer is, by no means, a simple one.

First, the US Veterans’ Affairs Health Systems (VAHS) have a well-oiled and funded organization-wide structure and approach to continuous health care QI through its Quality Enhancement Research Initiative, which was first established 25 years ago and supports “evidence to action” research across the VAHS System (such as the IMPROVE AKI initiative).⁶ Second, IMPROVE AKI was also supported by the NIDDK and funding support included reported total funding of $675 270. Third, total funding budget for the Federal Agency for Healthcare Research and Quality (AHRQ) in 2024 was $564 million. The mission of AHRQ is to improve health care for all by producing evidence to make health care of higher quality, safer, patient-centered, timely, effective, accessible, efficiently provided, and equitably distributed. AHRQ works within the US Department of Health and Human Services and collaborates with states, territories, tribal nations, and private partners to ensure that the evidence it generates is understood and used. However, translating such commonly funded QI research into consistent, daily practice often remains an ethereal and elusive tangible outcome. IMPROVE AKI investigators acknowledge concerns regarding sustainability for the participating catheter laboratories and generalizability of their impactful work to other non-VAHS systems.

Recent studies evaluating the association of hospital-wide strategies on both quality and costs with a meaningful return on QI investment that was demonstrated with IMPROVE AKI are scarce. For example, a recent scoping review⁷of how US hospitals have objectively “bent the cost curve” through integrated QI hospital revealed that, of 4198 articles, only 19 case studies from 5 countries were identified. Common themes included recurring barriers for implementation due to a lack of physician engagement, insufficient financial support, and poor data collection, most especially for hospitals in a fiscally constrained environment. Not surprising was a lack of consistent signals that many payers are poised to provide adequate future financial support for QI gains, such as those achieved through IMPROVE AKI. Through a different lens, another study found that only a very few published studies reported on costs or economic evaluations of quality improvement collaboratives (QICs) despite their use across the US health care system. After initially identifying 8505 citations, only 8 articles met inclusion criteria for this evaluation of the quality improvement process.⁸ Of these 8, 5 were considered good quality and favored the establishment of QICs as cost-effective implementation methods. These authors also warned that lack of any studies with negative findings may have been due to publication bias.

Lastly, most health care organizational quality and patient safety department leaders know too well the amount of time, energy, and dedicated full-time professional expertise that is required to design, implement, evaluate, and report on many different QI efforts that face the average health system every single day. Some common examples of the various tangible and intangible costs of real life QI, including more formally structured QICs include:

1. Salary allocations for dedicated QI personnel within quality and patient safety improvement departments, departmental and service line professionals, and unit/microsystem managers
2. Other relevant personnel support from internal service departments (eg, Six Sigma/Lean, biostatistics, healthcare analytics, electronic medical record teams, QI registries)
3. External quality reporting, accreditation and certification fees
4. QI research, dissemination and publication expertise and infrastructure
5. Data management, cybersecurity, report generation, QI dashboard development and maintenance
6. Development, implementation, evaluation and maintenance of guideline-based digital clinical decision support workflow applications
7. Executive leadership management quality performance-based compensation perquisites

A newly published study⁹ reported that the value-based care health care industry in the US is now estimated in 2024 to be $4.01 trillion, with growth forecasted to increase 7.4% annually. The American Medical Association provides a description of value-based care, stating that “Value-based care is really a care-delivery system that rewards for patient outcomes and quality of care, managing a population rather than transactional care.”¹⁰ This assertion is fully in line with what has been said for a very long time by the vast myriad of organizations that actively participate in the expanding multitrillion dollar value-based care industry. Yet, they are way past due to meaningfully answer the question of how best to fully account for the costs and beneficial impacts of quality and patient safety improvements. The time to do this is now.