Objective To determine if permanent pacemaker implants (PPM) interventions and change of generator are more efficient in small hospitals. Design A cost-effective analysis and retrospective, cross-sectional and observational study of diagnostic related groups (DRG). Setting The data was obtained from the national Minimum Basic Data Set (MBDS) for the year 2007 provided by the Health Ministry. Patients This includes the total number of patients who required treatment in all national hospitals for 5 DRG: 115 - bradyarrhythmic complication during the acute coronary syndrome, heart failure or shock; 116 - symptomatic isolated conduction defects; 117 - revisions, but without changing the battery, 118 - application of a new one, 549 - implementation or revision but with serious complications. Principal variables of interest Demographic, clinical (number of secondary diagnoses (NSD) and procedures (NP), mortality) and management (total and preoperative length of stay (LOS), access, discharge, hospital size), defining inefficient stays as those exceeding 2 days on the average. Results 23,154 episodes, 5.3% small hospitals. The comparative bivariate study between small hospitals and the rest, not discriminated by DRG, showed a mean LOS of 7.87±8.78 days vs 11.01±12.95 (p=0.005, 95% CI for mean difference [0.17, 1.65]) and also lower than preoperatively (3.62±6.14 vs. 4.22±6.68 days [p=0.015]) without greater comorbidity, as measured by proxy through the NSD (5.23±2.88 vs 5.42±3.28 [p=0.055]) and NP as proxy of diagnostic and therapeutic effort (3.79±2.50 vs 3.55±2.69 [p=0.002]). A total of 24.1% were inefficient, there being an association with preoperative stay, NDS, NP and emergency access. Conclusion Pacemaker implantation and generator change in small hospitals is more efficient, with internal consistency by subgroups.