Pricing of surgeries for colon cancer: patient severity and market factors

Global trends and prospects in health economics of robotic surgery: a bibliometric analysis

BACKGROUND

Over 10 million robotic surgeries have been performed. However, the cost and benefit of robotic surgery need to be evaluated to help hospitals, surgeons, patients, and payers make proper choices, making a health economic analysis necessary. The authors revealed the bibliometric profile in the field of health economics of robotic surgery to prompt research development and guide future studies.

MATERIALS AND METHODS

The Web of Science Core Collection scientific database was searched for documents indexed from 2003 to 31 December 2022. Document types, years, authors, countries, institutions, journal sources, references, and keywords were analyzed and visualized using the Bibliometrix package, WPS Office software, Microsoft PowerPoint 2019, VOSviewer software (version 1.6.18), ggplot2, and Scimago Graphica.

RESULTS

The development of the health economics of robotic surgery can be divided into three phases: slow-growing (2003-2009), developing (2010-2018), and fast-developing (2019-2022). J.C.H. and S.L.C. were the most active and influential authors, respectively. The USA produced the most documents, followed by China, and Italy. Korea had the highest number of citations per document. Surgical Endoscopy and Other Interventional Techniques accepted most documents, whereas Annals of Surgery, European Urology, and Journal of Minimally Invasive Gynecology had the highest number of citations per document. The Journal of Robotic Surgery is promising. The most-cited document in this field is New Technology and Health Care Costs - The Case of Robot-Assisted Surgery in 2010. The proportion of documents on urology is decreasing, while documents in the field of arthrology are emerging and flourishing.

CONCLUSION

Research on the health economics of robotic surgery has been unbalanced. Areas awaiting exploration have been identified. Collaboration between scholars and coverage with provisions for evidence development by the government is needed to learn more comprehensively about the health economics of robotic surgery.

Hospital market concentration and the use of mechanical circulatory support devices in acute myocardial infarction complicated by cardiogenic shock

Background

As health care markets in the United States have become increasingly consolidated, the role of market concentration on physician treatment behavior remains unclear. In cardiology, specifically, there has been evolving treatment of acute myocardial infarction complicated by cardiogenic shock (AMI-CS) with increasing use of mechanical circulatory support (MCS). However, there remains wide variation in it use. The role of market concentration in the utilization of MCS in AMI-CS is unknown. We examined the use of MCS in AMI-CS and its effect on outcomes between competitive and concentrated markets.

Methods and results

We used the National Inpatient Sample to query patients admitted with AMI-CS between 2003 and 2009. The primary study outcome was the use of mechanical circulatory support. The primary study exposure was market concentration, measured using the Herfindahl-Hirschman Index, which was used to classify markets as unconcentrated (competitive), moderately concentrated, and highly concentrated. Baseline characteristics, procedures, and outcomes were compared for patients in differently concentrated markets. Multivariable logistic regression was used to examine the association between HHI and use of MCS.

Results

There were 32,406 hospitalizations for patients admitted with AMI-CS. Patients in unconcentrated markets were more likely to receive MCS than in highly concentrated markets (unconcentrated 46.8% [5087/10,873], moderately concentrated 44.9% [2933/6526], and high concentrated 44.5% [6676/15,007], p < 0.01). Multivariable regression showed that patients in more concentrated markets had decreased use of MCS in patients in later years of the study period (2009, OR 0.64, 95% CI 0.44–0.94, p = 0.02), with no effect in earlier years. There was no significant difference in in-hospital mortality.

Conclusion

Multivariable analysis did not show an association with market concentration and use of MCS in AMI-CS. However, subgroup analysis did show that competitive hospital markets were associated with more frequent use of MCS in AMI-CS as frequency of utilization increased over time. Further studies are needed to evaluate the effect of hospital market consolidation on the use of MCS and outcomes in AMI-CS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07458-1.

Hospital market competition and health technology diffusion: An empirical study of laparoscopic appendectomy in China

The evidence about the role of hospital market competition on health technology diffusion in developing countries is scarce. In this study, we examined the association between hospital market competition and the diffusion of health technologies in China's healthcare system. Laparoscopic appendectomy, a minimally invasive surgery for patients with acute appendicitis, was selected as a representative of cost-effective health technology. The inpatient discharge dataset linked to the annually hospital administrative data and to the demographic and socioeconomic data were used. A total of 261,922 patients who were diagnosed with acute appendicitis and had received either open appendectomy or laparoscopic appendectomy at 820 hospitals in Sichuan, China between 2017 and 2019 were included in our analyses. Our outcome measure was the use of laparoscopic appendectomy during hospitalization. We accounted for the endogeneity of hospital competition measures using the Herfindahl-Hirschman Index calculated by predicted patient flows. Controlling for the observable patient, hospital and region characteristics, multivariate logistic regression was performed to model the association between hospital competition and the diffusion of laparoscopic appendectomy. The rapid diffusion of laparoscopic appendectomy over the study period and the substantial variation in use across regions and hospitals were observed. The regression results showed that laparoscopic appendectomy diffused faster in the markets where hospitals faced more competition. Our findings suggest that the diffusion of laparoscopic appendectomy is not only driven by medical factors but also nonmedical factors like hospital market competition. Our study provides new evidence on the association between market structure and technology diffusion in China's hospital market and offers the implications of appropriate technologies diffusion in health for policymakers.

The Impact of Interhospital Competition on Treatment Strategy and Outcomes for Unruptured Intracranial Aneurysms

BACKGROUND

Interhospital competition has been shown to affect surgical outcomes and expenditures. However, interhospital competition's impact on neurosurgery is poorly characterized.

OBJECTIVE

To assess how interhospital competition is associated with treatment strategy and outcomes for unruptured intracranial aneurysms (UIAs).

METHODS

We identified all elective UIA admissions in the National Inpatient Sample from 2002 to 2011. Competitive intensity of each hospital market was quantified using the validated Herfindahl-Hirschman Index (HHI), with lower values denoting higher competition. We then obtained nationwide HHI values for 2012 to 2016 from the Health Care Cost Project. Outcomes included treatment modality (clipping, coiling, or nonoperative management), inpatient mortality, disposition, complications, length of stay (LOS), and costs. Multivariate regression assessed the association between HHI and outcomes, controlling for patient demographics, severity metrics, hospital characteristics, and treatment.

RESULTS

We studied 157 979 elective UIA admissions at 1435 hospitals from 2002 to 2011, with an increase in coiling admissions (13.4% to 33.7%) and decrease in clipping admissions (30.9% to 17.6%). Mean hospital HHI was 0.11 (range = 0.001-0.97). Competition decreased for 61.8% of hospitals from 2002 to 2011 and 68.1% of metropolitan localities from 2012 to 2016. Admissions in more competitive hospital markets exhibited increased odds of undergoing surgery (odds ratio [OR] = 1.37, P < .001), with preference toward coiling over clipping (OR = 1.27, P < .001). HHI was not associated with mortality, disposition, or LOS. However, increased interhospital competition was associated with more complications (OR = 1.09, P = .001) and greater hospital costs (β-coefficient = 1.06, P < .001).

CONCLUSION

For UIA patients, admission to hospitals in more competitive geographies was associated with increased rates of surgical intervention, coiling utilization, complications, and hospitalization costs.

Use of Flap Salvage for Lower Extremity Chronic Wounds Occurs Most Often in Competitive Hospital Markets

Wounds in the comorbid population require limb salvage to prevent amputation. Extensive health economics literature demonstrates that hospital activities are influenced by level of market concentration. The impact of competition and market concentration on limb salvage remains to be determined.

Methods

Admissions for chronic lower extremity wounds in nonrural hospitals were identified in the 2010-2011 National Inpatient Survey using ICD-9-CM diagnosis codes. The study cohort consisted of admitted patients receiving amputations, salvage without flap techniques (eg, skin grafts), or salvage with flap techniques. The all-service Herfindahl-Hirschman Index (HHI), which is a commonly used tool for market and antitrust analyses, was used to measure hospital competition. Multinomial regression analysis accounting for the complex survey design of the NIS was used to determine the relationship between the HHI and hospital adoption of limb salvage controlling for patient, hospital, and market factors.

Results

The study cohort represents 124,836 admissions nationally: 89,880 amputations, 26,715 salvage without flap techniques, and 8241 salvage flap techniques. Diabetics accounted for 64.1% of all study admissions. Hospitals in highly competitive markets performed more flaps for chronic lower extremity wounds than noncompetitive markets. Controlling for other factors, hospitals in highly competitive markets, relative to those in highly concentrated markets, were 2.48 percentage points more likely to perform limb salvage with flaps (P < 0.01). Other factors were less predictive.

Conclusion

Increased hospital competition is the strongest systems-level predictor of receipt of lower extremity flaps among patients with chronic wounds. Improving access to reconstructive limb services must consider the competitive structure of hospital markets.

Prophylactic Gynecologic Surgery at Time of Colectomy Benefits Women with Lynch Syndrome and Colon Cancer: A Markov Cost-Effectiveness Analysis

BACKGROUND

Women with Lynch syndrome who have completed childbearing should be offered prophylactic hysterectomy and bilateral salpingo-oophorectomy for gynecologic cancer prevention. The benefit of prophylactic gynecologic surgery at the time of colon cancer resection is unclear.

OBJECTIVE

This study aimed to compare the cost, quality of life, and likelihood of being alive and free from colon, endometrial, and ovarian cancer between operative choices for patients with Lynch syndrome undergoing surgery for colon cancer.

DESIGN

A Markov decision tree spanning 40 years was constructed for a hypothetical cohort of 30-year-old women with Lynch syndrome who had been diagnosed with colon cancer. Outcomes of 6 surgical strategies were compared, including segmental or total abdominal colectomy with or without hysterectomy alone or combined with bilateral salpingo-oophorectomy.

SETTINGS

A Markov cost-effectiveness analysis was performed at a single center.

PATIENTS

A literature search was performed identifying studies of patients with genetically diagnosed Lynch syndrome that described cost, risk of mortality, and quality of life after colon cancer resection and prophylactic gynecologic surgery.

MAIN OUTCOME MEASURES

The primary outcomes measured were quality-adjusted life-years and the likelihood of being alive and free from colon, endometrial, and ovarian cancer 40 years after surgery.

RESULTS

Women with Lynch syndrome who underwent a total abdominal colectomy and hysterectomy with bilateral salpingo-oophorectomy had the highest likelihood of being alive and cancer free. Total abdominal colectomy with hysterectomy was a close second, but yielded the largest amount of quality-adjusted life-years and lowest cost.

LIMITATIONS

This study is limited by the statistical method and quality of studies used.

CONCLUSIONS

Total abdominal colectomy with prophylactic hysterectomy at 30 years of age was the most cost-effective surgical choice in women with Lynch syndrome and colon cancer. The addition of bilateral salpingo-oophorectomy offered the highest event-free survival and lowest mortality. However, the additional morbidity of premature menopause of prophylactic salpingo-oophorectomy for younger women outweighed the benefit of ovarian cancer prevention. See Video Abstract at http://links.lww.com/DCR/B287. LA CIRUGÍA GINECOLÓGICA PROFILÁCTICA EN EL MOMENTO DE LA COLECTOMÍA BENEFICIA A LAS MUJERES CON SÍNDROME DE LYNCH Y CÁNCER DE COLON: UN ANÁLISIS DE COSTO-EFECTIVIDAD DE MARKOV: Las mujeres con síndrome de Lynch que han completado la maternidad deberían recibir histerectomía profiláctica y salpingooforectomía bilateral para la prevención del cáncer ginecológico. El beneficio de la cirugía ginecológica profiláctica en el momento de la resección del cáncer de colon no está claro.Comparar el costo, la calidad de vida y la probabilidad de estar viva y libre de cáncer de colon, endometrio y ovario entre las opciones quirúrgicas para pacientes con síndrome de Lynch sometidos a cirugía por cáncer de colon.Se construyó un árbol de decisión de Markov que abarca cuarenta años para una cohorte hipotética de mujeres de 30 años con síndrome de Lynch diagnosticadas con cáncer de colon. Se compararon los resultados de seis estrategias quirúrgicas, incluida la colectomía abdominal segmentaria o total con o sin histerectomía sola o combinada con salpingooforectomía bilateral.Se realizó un análisis de costo-efectividad de Markov en un solo centro.se realizó una búsqueda bibliográfica para identificar estudios de pacientes con síndrome de Lynch con diagnóstico genético que describieron el costo, el riesgo de mortalidad y la calidad de vida después de la resección del cáncer de colon y la cirugía ginecológica profiláctica.años de vida ajustados por calidad y probabilidad de estar vivo y libre de cáncer de colon, endometrio y ovario 40 años después de la cirugía.Las mujeres con síndrome de Lynch que se sometieron a una colectomía e histerectomía abdominal total con salpingooforectomía bilateral tuvieron la mayor probabilidad de estar vivas y libres de cáncer. La colectomía abdominal total con histerectomía fue un segundo lugar cercano, pero produjo la mayor cantidad de años de vida ajustados por calidad y el costo más bajo.Este estudio está limitado por el método estadístico y la calidad de los estudios utilizados.La colectomía abdominal total con histerectomía profiláctica a los 30 años fue la opción quirúrgica más rentable en mujeres con síndrome de Lynch y cáncer de colon. La adición de salpingooforectomía bilateral ofreció la mayor supervivencia libre de eventos y la menor mortalidad. Sin embargo, la morbilidad adicional de la menopausia prematura de la salpingooforectomía profiláctica para las mujeres más jóvenes superó el beneficio de la prevención del cáncer de ovario. Consulte Video Resumen en http://links.lww.com/DCR/B287. (Traducción-Dr. Yesenia Rojas-Khalil).

Hospital robotic use for colorectal cancer care

The use of robotic surgery for colorectal cancer continues to increase. However, not all organizations offer patients the option of robotic intervention. This study seeks to understand organizational characteristics associated with the utilization of robotic surgery for colorectal cancer. We conducted a retrospective study of hospitals identified in the United States, State of Florida Inpatient Discharge Dataset, and linked data for those hospitals with the American Hospital Association Survey, Area Health Resource File and the Health Community Health Assessment Resource Tool Set. The study population included all robotic surgeries for colorectal cancer patients in 159 hospitals from 2013 to 2015. Logistic regressions identifying organizational, community, and combined community and organizational variables were utilized to determine associations. Results indicate that neither hospital competition nor disease burden in the community was associated with increased odds of robotic surgery use. However, per capita income (OR 1.07 95% CI 1.02, 1.12), average total margin (OR 1.01, 95% CI 1.001, 1.02) and large-sized hospitals compared to small hospitals (OR: 5.26, 95% CI 1.13, 24.44) were associated with increased odds of robotic use. This study found that market conditions within the U.S. State of Florida are not primary drivers of hospital use of robotic surgery. The ability for the population to pay for such services, and the hospital resources available to absorb the expense of purchasing the required equipment, appear to be more influential.

Costs for Colon Cancer Treatment Comparing Benefit Types and Care Sources in the US Military Health System

INTRODUCTION

Cancer is one of the leading causes of morbidity and mortality in the USA, contributing largely to US healthcare spending. Provision of services (direct or purchased) and insurance benefit type may impact cost for cancer care. As a common cause of cancer in both men and women, we aim to compare colon cancer treatment costs between insurance benefit types and care sources in the US Military Health System (MHS) to better understand whether and to what extent these system factors impact cancer care costs.

MATERIALS AND METHODS

Department of Defense Central Cancer Registry records and MHS Data Repository administrative claims were used to identify MHS beneficiaries aged 18-64 who were diagnosed with primary colon adenocarcinoma and received treatment between 2003 and 2008. The data linkage was approved by the Institutional Review Boards of the Walter Reed National Military Medical Center, the Defense Health Agency, and the National Institutes of Health. Costs to the MHS for each claim related to cancer treatment were extracted from the linked data and adjusted to 2008 USD. We used quantile regression models to compare median cancer treatment costs between benefit types and care sources (direct, purchased, or both), adjusted for demographic, tumor, and treatment characteristics.

RESULTS

The median per capita (n = 801) costs for colon cancer care were $60,321 (interquartile range $24,625, $159,729) over a median follow-up of 1.7 years. The model-estimated treatment costs were similar between benefit types. Patients using direct care had significantly lower estimated median costs [$34,145 (standard error $4,326)] than patients using purchased care [$106,395 ($10,559)] or both care sources [$82,439 ($13,330)], controlled for patient demographic, tumor, and treatment characteristics. Differences in cost by care source were noted for patients with later stage tumors and by treatment type. Relative costs were 2-3 times higher for purchased care compared to direct care for patients with late-stage tumors and for patients receiving chemotherapy or radiation treatment.

CONCLUSIONS

In the MHS, median cost for colon cancer treatment was lower in direct care compared to purchased care or patients using a combination of direct and purchased care. The variation in cancer treatment costs between care sources may be due to differences in treatment incentives or capabilities. Additional studies on cost differences between direct and purchased services are needed to understand how provision of care affects cancer treatment costs and to identify possible targets for cost reduction.

Provider Practice Competition and Adoption of Medicare's Oncology Care Model

BACKGROUND

There is a concern that the Oncology Care Model (OCM), a voluntary bundled payment program, may incentivize mergers and acquisitions among physician practices leading to reduced competition and price increases. These concerns are heightened if OCM is preferentially adopted in competitive health care markets because it could result in reduced competition, but little is known about the characteristics of markets where OCM is adopted.

OBJECTIVE

To measure the association between regional market competition among medical oncologists with the initial adoption of OCM.

RESEARCH DESIGN

The Herfindahl-Hirschman Index (HHI), a measure of competition, was calculated for hospital referral regions (HRRs) using secondary data from the Centers for Medicare and Medicaid Services. The relationship between HHI and OCM adoption was assessed using a 2-part regression model adjusting for the market-level number of practices, physician density, average practice size, sociodemographic characteristics, and medical resources. A count model on all HRRs was also estimated to assess an overall effect.

SUBJECTS

A total of 10,788 physicians in 3,537 practices who billed Medicare for oncology services in 2015.

RESULTS

OCM was adopted in 114 (37%) of the 306 HRRs. We found that practices in competitive health care markets were more likely to adopt OCM than in noncompetitive markets. Two-part regression analysis indicated a nonlinear relationship between HHI and OCM adoption. Average practice size, number of practices in an HRR, and the hospital bed rate were positively associated with adoption, whereas the rate of full-time equivalent hospital employees to 1000 residents was negatively associated with adoption.

CONCLUSIONS

OCM adoption was higher in HRRs with greater competition. Careful monitoring of market-level changes among OCM adopters should be undertaken to ensure that the benefits of the OCM outweigh the negative consequences of possible changes in competition.

Factors Associated With Hospital Decisions to Purchase Robotic Surgical Systems

Background. Robotic surgical systems are expensive to own and operate, and the purchase of such technology is an important decision for hospital administrators. Most prior literature focuses on the comparison of clinical outcomes between robotic surgery and other laparoscopic or open surgery. There is a knowledge gap about what drives hospitals’ decisions to purchase robotic systems. Objective. To identify factors associated with a hospital’s acquisition of advanced surgical systems. Method. We used 2002 to 2011 data from the State of California Office of Statewide Health Planning and Development to examine robotic surgical system purchase decisions of 476 hospitals. We used a probit estimation allowing heteroscedasticity in the error term including a set of two equations: one binary response equation and one heteroscedasticity equation. Results. During the study timeframe, there were 78 robotic surgical systems purchased by hospitals in the sample. Controlling for hospital characteristics such as number of available beds, teaching status, nonprofit status, and patient mix, the probit estimation showed that market-level directly relevant surgery volume in the previous year (excluding the hospital’s own volume) had the largest impact. More specifically, hospitals in high volume (>50,000 surgeries v. 0) markets were 12 percentage points more likely to purchase robotic systems. We also found that hospitals in less competitive markets (i.e., Herfindahl index above 2500) were 2 percentage points more likely to purchase robotic systems. Limitations. This study has limitations common to observational database studies. Certain characteristics such as cultural factors cannot be accurately quantified. Conclusions. Our findings imply that potential market demand is a strong driver for hospital purchase of robotic surgical systems. Market competition does not significantly increase the adoption of new expensive surgical technologies.

Total abdominal colectomy is cost-effective in treating colorectal cancer in patients with genetically diagnosed Lynch Syndrome

BACKGROUND

Lynch syndrome (LS) has a 80% lifetime risk of developing colorectal cancer and metachronous cancer. No studies have examined the quality adjusted life expectancy after SEG or TAC for LS patients, which this study was aiming for. If TAC offers a higher quality adjusted life year (QALY) to SEG in LS patients, preoperative diagnosis of LS is critical as it alters the recommended surgical procedure.

METHODS

A Markov decision tree was constructed using Treeage software to compare QALY of LS patients following SEG or TAC. Probabilities, cost, and utility were obtained from literature. Cost-effectiveness analyses were performed.

RESULTS

TAC dominates SEG as both the life-saving and cost-saving strategy. TAC dominated SEG on QALY (17.80 vs 17.13 QALY) for a cohort of LS patients diagnosed at an average of 30 year old and followed every 2 years after initial surgery.

CONCLUSIONS

We conclude that TAC as the primary surgical option for LS patients diagnosed with Stage I-III colon cancer is cost-effective. Further cost-effectiveness study is recommended to include extra-colonic malignancies in LS patients.

Do All Hospital Systems Have Market Power? Association Between Hospital System Types and Cardiac Surgery Prices

OBJECTIVE

This study explores the price implications of hospital systems by analyzing the association of system characteristics with selected cardiac surgery pricing.

DATA SOURCE

Using a large private insurance claim database, the authors identified 11 282 coronary artery bypass graft (CABG) cases and 49 866 percutaneous coronary intervention (PCI) cases from 2002 to 2007.

STUDY DESIGN

We conducted a retrospective observational study using generalized linear models.

PRINCIPAL FINDINGS

We found that the CABG and PCI prices in centralized health and physician insurance systems were significantly lower than the prices in stand-alone hospitals by 4.4% and 6.4%, respectively. In addition, the CABG and PCI prices in independent health systems were significantly lower than in stand-alone hospitals, by 15.4% and 14.5%, respectively.

CONCLUSION

The current antitrust guidelines tend to focus on the market share of merging parties and pay less attention to the characteristics of merging parties. The results of this study suggest that antitrust analysis could be more effective by considering characteristics of hospital systems.

Association of Early Physical Therapy With Long-term Opioid Use Among Opioid-Naive Patients With Musculoskeletal Pain

IMPORTANCE

Nonpharmacologic methods of reducing the risk of new chronic opioid use among patients with musculoskeletal pain are important given the burden of the opioid epidemic in the United States.

OBJECTIVE

To determine the association between early physical therapy and subsequent opioid use in patients with new musculoskeletal pain diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis of health care insurance claims data between January 1, 2007, and December 31, 2015, included privately insured patients who presented with musculoskeletal pain to an outpatient physician office or an emergency department at various US facilities from January 1, 2008, to December 31, 2014. The sample comprised 88 985 opioid-naive patients aged 18 to 64 years with a new diagnosis of musculoskeletal shoulder, neck, knee, or low back pain. The data set (obtained from the IBM MarketScan Commercial database) included person-level International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis codes, Current Procedural Terminology codes, and date of service as well as pharmaceutical information (National Drug Code, generic name, dose, and number of days supplied). Early physical therapy was defined as at least 1 session received within 90 days of the index date, the earliest date a relevant diagnosis was provided. Data analysis was conducted from March 1, 2018, to May 18, 2018.

MAIN OUTCOMES AND MEASURES

Opioid use between 91 and 365 days after the index date.

RESULTS

Of the 88 985 patients included, 51 351 (57.7%) were male and 37 634 (42.3%) were female with a mean (SD) age of 46 (11.0) years. Among these patients, 26 096 (29.3%) received early physical therapy. After adjusting for potential confounders, early physical therapy was associated with a statistically significant reduction in the incidence of any opioid use between 91 and 365 days after the index date for patients with shoulder pain (odds ratio [OR], 0.85; 95% CI, 0.77-0.95; P = .003), neck pain (OR, 0.92; 95% CI, 0.85-0.99; P = .03), knee pain (OR, 0.84; 95% CI, 0.77-0.91; P < .001), and low back pain (OR, 0.93; 95% CI, 0.88-0.98; P = .004). For patients who did use opioids, early physical therapy was associated with an approximately 10% statistically significant reduction in the amount of opioid use, measured in oral morphine milligram equivalents, for shoulder pain (-9.7%; 95% CI, -18.5% to -0.8%; P = .03), knee pain (-10.3%; 95% CI, -17.8% to -2.7%; P = .007), and low back pain (-5.1%; 95% CI, -10.2% to 0.0%; P = .046), but not for neck pain (-3.8%; 95% CI, -10.8% to 3.3%; P = .30).

CONCLUSIONS AND RELEVANCE

Early physical therapy appears to be associated with subsequent reductions in longer-term opioid use and lower-intensity opioid use for all of the musculoskeletal pain regions examined.

Regional Market Competition and the Use of Immediate Breast Reconstruction After Mastectomy

BACKGROUND

Prior work has shown that the competitiveness of the market in which hospitals operate is associated with use of surgical procedures. This study examined the association between regional market competition and use of breast reconstruction for women with breast cancer and ductal carcinoma in situ undergoing mastectomy.

METHODS

Women who underwent mastectomy from 2010 to 2011 recorded in the National Inpatient Sample were selected. The competitive market environment for each hospital in which patients were treated was estimated using the Herfindahl-Hirschman Index. Multivariable models were developed to examine the association between regional market competition and breast reconstruction, with adjustment for other clinical, demographic, and structural variables.

RESULTS

Immediate breast reconstruction was performed for 9902 (45%) of 22,011 women. The rate of immediate breast reconstruction was 34.5% at hospitals in non-competitive markets, 49% at hospitals in moderately competitive markets, and 56.4% at hospitals in highly competitive markets (P < 0.0001). In a multivariable model, women in moderately competitive markets were 24% (risk ratio [RR] 1.24; 95% confidence interval [CI] 1.10-1.41) more likely to undergo immediate breast reconstruction than women in noncompetitive markets, whereas those in competitive markets were 25% (RR 1.25; 95% CI 1.11-1.41) more likely to have reconstruction. Later year of treatment, higher census tract income level, and residence in an urban area were associated with an increased likelihood of reconstruction (P < 0.05 for all). In contrast, older age, non-white race, and non-commercial insurance were associated with a lower likelihood of reconstruction (P < 0.05 for all).

CONCLUSION

Patients who undergo mastectomy at hospitals in competitive markets are more likely to undergo immediate breast reconstruction.

Assessing the economic advantage of laparoscopic vs. open approaches for colorectal cancer by a propensity score matching analysis

PURPOSES

This study investigated the surgical outcomes and potential economic advantage of open vs. laparoscopic surgery for colorectal cancer using a propensity score matching analysis.

METHODS

We examined the surgical and economic outcomes of patients undergoing laparoscopic (N = 127) and open surgery (N = 253) for colorectal cancer and then compared these outcomes in two groups (N = 103 each) using a propensity score matching analysis.

RESULTS

Compared to open surgery, the laparoscopic approach was associated with a significantly lower overall morbidity rate (14 vs. 40%; P < 0.001) and shorter mean (± standard deviation) postoperative hospital stay (12.6 ± 8.3 vs. 16.8 ± 9.9 days, respectively; P = 0.001). Despite generating higher mean surgical costs (Japanese yen) (985,000 ± 215,000 vs. 812,000 ± 222,000 yen; P < 0.001), utilizing a laparoscopic approach significantly reduced the non-surgical costs (773,000 ± 440,000 vs. 1075,000 ± 508,000 yen; P < 0.001). The mean total cost of laparoscopic-assisted surgery (1758,000 ± 576,000 yen) was decreased by approximately 130,000 yen compared with open surgery (1886,000 ± 619,000 yen), although the difference was not statistically significant (P = 0.125).

CONCLUSIONS

Laparoscopic surgery for colorectal cancer is advantageous in reducing morbidity and facilitating an early discharge and does not increase hospital costs. These findings are consistent with the general consensus supporting the benefits of laparoscopic surgery as a minimally invasive approach.

Effect of patient choice and hospital competition on service configuration and technology adoption within cancer surgery: a national, population-based study

Background

There is a scarcity of evidence about the role of patient choice and hospital competition policies on surgical cancer services. Previous evidence has shown that patients are prepared to bypass their nearest cancer centre to receive surgery at more distant centres that better meet their needs. In this national, population-based study we investigated the effect of patient mobility and hospital competition on service configuration and technology adoption in the National Health Service (NHS) in England, using prostate cancer surgery as a model.

Methods

We mapped all patients in England who underwent radical prostatectomy between Jan 1, 2010, and Dec 31, 2014, according to place of residence and treatment location. For each radical prostatectomy centre we analysed the effect of hospital competition (measured by use of a spatial competition index [SCI], with a score of 0 indicating weakest competition and 1 indicating strongest competition) and the effect of being an established robotic radical prostatectomy centre at the start of 2010 on net gains or losses of patients (difference between number of patients treated in a centre and number expected based on their residence), and the likelihood of closing their radical prostatectomy service.

Findings

Between Jan 1, 2010, and Dec 31, 2014, 19 256 patients underwent radical prostatectomy at an NHS provider in England. Of the 65 radical prostatectomy centres open at the start of the study period, 23 (35%) had a statistically significant net gain of patients during 2010–14. Ten (40%) of these 23 were established robotic centres. 37 (57%) of the 65 centres had a significant net loss of patients, of which two (5%) were established robotic centres and ten (27%) closed their radical prostatectomy service during the study period. Radical prostatectomy centres that closed were more likely to be located in areas with stronger competition (highest SCI quartile [0·87–0·92]; p=0·0081) than in areas with weaker competition. No robotic surgery centre closed irrespective of the size of net losses of patients. The number of centres performing robotic surgery increased from 12 (18%) of the 65 centres at the beginning of 2010 to 39 (71%) of 55 centres open at the end of 2014.

Interpretation

Competitive factors, in addition to policies advocating centralisation and the requirement to do minimum numbers of surgical procedures, have contributed to large-scale investment in equipment for robotic surgery without evidence of superior outcomes and contributed to the closure of cancer surgery units. If quality performance and outcome indicators are not available to guide patient choice, these policies could threaten health services' ability to deliver equitable and affordable cancer care.

Funding

National Institute for Health Research.

Patient, Hospital, and Geographic Disparities in Laparoscopic Surgery Use Among Surveillance, Epidemiology, and End Results-Medicare Patients With Colon Cancer

BACKGROUND

Surgical resection is the primary treatment for colon cancer, but use of laparoscopic approaches varies widely despite demonstrated short- and long-term benefits.

OBJECTIVE

The purpose of this study was to identify characteristics associated with laparoscopic colon cancer resection and to quantify variation based on patient, hospital, and geographic characteristics.

DESIGN

Bayesian cross-classified, multilevel logistic models calculated adjusted ORs and CIs for patient, surgeon, hospital, and geographic characteristics and unexplained variability (predicted vs. observed values) using adjusted median odds ratios for hospitals and counties.

SETTINGS

The Surveillance, Epidemiology, and End Results-Medicare claims database (2008-2011) supplemented with county-level American Community Survey (2008-2012) demographic data was used.

PATIENTS

A total of 10,618 patients ≥66 years old who underwent colon cancer resection were included.

MAIN OUTCOME MEASURES

Nonurgent/nonemergent resections for colon cancer patients ≥66 years old were classified as laparoscopic or open procedures.

RESULTS

Patients resided in 579 counties and used 950 hospitals; 47% of patients underwent laparoscopic surgery. Medicare/Medicaid dual enrollment, age ≥85 years, and higher tumor stage and grade were negatively associated with laparoscopic surgery receipt; proximal tumors and increasing hospital size and surgeon caseload were positively associated. Significant unexplained variability at the hospital (adjusted median OR = 3.31; p < 0.001) and county levels (adjusted median OR = 1.28; p < 0.05) remained after adjustment.

LIMITATIONS

This was an observational study lacking generalizability to younger patients without Medicare or those with Health Maintenance Organization coverage and data set did not reflect national hospital studies or hospital volume. In addition, we were unable to account for specific types of comorbidities, such as obesity, and had broad categories for surgeon caseload.

CONCLUSIONS

Determining sources of hospital-level variation among poor insured patients may help increase laparoscopic resection to maximize health outcomes and reduce cost. See Video Abstract at http://links.lww.com/DCR/A363.

Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis

Objectives To identify trends in concurrent use of a benzodiazepine and an opioid and to identify the impact of these trends on admissions to hospital and emergency room visits for opioid overdose.Design Retrospective analysis of claims data, 2001-13.Setting Administrative health claims database.Participants 315 428 privately insured people aged 18-64 who were continuously enrolled in a health plan with medical and pharmacy benefits during the study period and who also filled at least one prescription for an opioid.Interventions Concurrent benzodiazepine/opioid use, defined as an overlap of at least one day in the time periods covered by prescriptions for each drug. Main outcome measures Annual percentage of opioid users with concurrent benzodiazepine use; annual incidence of visits to emergency room and inpatient admissions for opioid overdose.Results 9% of opioid users also used a benzodiazepine in 2001, increasing to 17% in 2013 (80% relative increase). This increase was driven mainly by increases among intermittent, as opposed to chronic, opioid users. Compared with opioid users who did not use benzodiazepines, concurrent use of both drugs was associated with an increased risk of an emergency room visit or inpatient admission for opioid overdose (adjusted odds ratio 2.14, 95% confidence interval 2.05 to 2.24; P<0.001) among all opioid users. The adjusted odds ratio for an emergency room visit or inpatient admission for opioid overdose was 1.42 (1.33 to 1.51; P<0.001) for intermittent opioid users and 1.81 (1.67 to 1.96; P<0.001) chronic opioid users. If this association is causal, elimination of concurrent benzodiazepine/opioid use could reduce the risk of emergency room visits related to opioid use and inpatient admissions for opioid overdose by an estimated 15% (95% confidence interval 14 to 16).Conclusions From 2001 to 2013, concurrent benzodiazepine/opioid use sharply increased in a large sample of privately insured patients in the US and significantly contributed to the overall population risk of opioid overdose.

Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period

IMPORTANCE

Chronic opioid use imposes a substantial burden in terms of morbidity and economic costs. Whether opioid-naive patients undergoing surgery are at increased risk for chronic opioid use is unknown, as are the potential risk factors for chronic opioid use following surgery.

OBJECTIVE

To characterize the risk of chronic opioid use among opioid-naive patients following 1 of 11 surgical procedures compared with nonsurgical patients.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of administrative health claims to determine the association between chronic opioid use and surgery among privately insured patients between January 1, 2001, and December 31, 2013. The data concluded 11 surgical procedures (total knee arthroplasty [TKA], total hip arthroplasty, laparoscopic cholecystectomy, open cholecystectomy, laparoscopic appendectomy, open appendectomy, cesarean delivery, functional endoscopic sinus surgery [FESS], cataract surgery, transurethral prostate resection [TURP], and simple mastectomy). Multivariable logistic regression analysis was performed to control for possible confounders, including sex, age, preoperative history of depression, psychosis, drug or alcohol abuse, and preoperatice use of benzodiazepines, antipsychotics, and antidepressants.

EXPOSURES

One of the 11 study surgical procedures.

MAIN OUTCOMES AND MEASURES

Chronic opioid use, defined as having filled 10 or more prescriptions or more than 120 days' supply of an opioid in the first year after surgery, excluding the first 90 postoperative days. For nonsurgical patients, chronic opioid use was defined as having filled 10 or more prescriptions or more than 120 days' supply following a randomly assigned "surgery date."

RESULTS

The study included 641 941 opioid-naive surgical patients (169 666 men; mean [SD] age, 44.0 [12.8] years), and 18 011 137 opioid-naive nonsurgical patients (8 849 107 men; mean [SD] age, 42.4 [12.6] years). Among the surgical patients, the incidence of chronic opioid in the first preoperative year ranged from 0.119% for Cesarean delivery (95% CI, 0.104%-0.134%) to 1.41% for TKA (95% CI, 1.29%-1.53%) The baseline incidence of chronic opioid use among the nonsurgical patients was 0.136% (95% CI, 0.134%-0.137%). Except for cataract surgery, laparoscopic appendectomy, FESS, and TURP, all of the surgical procedures were associated with an increased risk of chronic opioid use, with odds ratios ranging from 1.28 (95% CI, 1.12-1.46) for cesarean delivery to 5.10 (95% CI, 4.67-5.58) for TKA. Male sex, age older than 50 years, and preoperative history of drug abuse, alcohol abuse, depression, benzodiazepine use, or antidepressant use were associated with chronic opioid use among surgical patients.

CONCLUSIONS AND RELEVANCE

In opioid-naive patients, many surgical procedures are associated with an increased risk of chronic opioid use in the postoperative period. A certain subset of patients (eg, men, elderly patients) may be particularly vulnerable.

No Significant Association between Anesthesia Group Concentration and Private Insurer Payments in the United States

Background:

Markets for physician services are becoming increasingly concentrated, with many areas being dominated by a few groups. Antitrust authorities are concerned that increasing concentration will lead to inappropriately high payments for physician services from private insurers. The authors examined the association between market concentration and private insurer payments for anesthesia services.

Methods:

The authors obtained data on average payments from private insurers for five commonly used anesthesia Current Procedure Terminology codes for physicians located in 229 counties in the United States between 2002 and 2010. The authors calculated a measure of market concentration (the Herfindahl–Hirschman Index [HHI]) for anesthesiologists in each county using Medicare claims data. The authors then estimated the association between market concentration and private insurer payments using a difference-in-differences approach to minimize confounding.

Results:

Private insurer payments to anesthesiologists in more concentrated markets were not significantly different from payments in less concentrated markets. Compared with the 25% of counties with the least concentration (counties with an HHI in the 0th to 25th percentile), payments in counties in the 25th to 50th percentile of HHI were approximately 0.51% less (95% CI, −2.3 to 1.3%, P = 0.95), whereas payments in counties in the 50th to 75th percentile of HHI were approximately 2.8% less (95% CI, −6.7 to 1.4%, P = 0.41) and payments in counties in the 75th to 100th percentile were approximately 3.1% less (95% CI, −8.1 to 1.2%, P = 0.32).

Conclusion:

Increasing market concentration of anesthesia groups is not associated with significantly greater payments from private insurers.

Costs of hepato-pancreato-biliary surgery and readmissions in privately insured US patients

BACKGROUND

Surgical costs are influenced by perioperative care, readmissions, and further therapies. We aimed to characterize costs in hepato-pancreato-biliary surgery in the United States.

METHODS

The MarketScan database (2008-2010) was used to identify privately insured patients undergoing pancreatectomy (n = 2254) or hepatectomy (n = 1702). Costs associated with the index surgery, readmissions, and total short-term costs were assessed from a third party payer perspective using generalized linear regression models.

RESULTS

Mean total costs of pancreatectomy and hepatectomy were $107,600 (95% confidence interval [CI], 101,200-114,000) and $81,300 (95% CI, 77,600-85,000), respectively, with corresponding surgical costs of 69.2% and 60.9%. Ninety-day readmission costs were $36,200 (95% CI, 32,000-40,400) and $34,100 (95% CI, 28,100-40,100), respectively. In multivariate analysis, readmissions were associated with an almost two-fold increase in total costs in both pancreatectomy (cost ratio = 1.98; P < 0.001) and hepatectomy (cost ratio = 1.92; P < 0.001).

CONCLUSIONS

Hepato-pancreato-biliary surgery is associated with significant economic burden in the privately insured population. Substantial costs are incurred beyond the index surgical admission, with readmissions representing a major source of potentially preventable health care spending. Sustained efforts in defining high-risk populations and decreasing the burden of postoperative complications through a combination of prevention and improved outpatient management offer promising strategies to reduce readmissions and control costs.

The burden of gastrointestinal anastomotic leaks: an evaluation of clinical and economic outcomes

OBJECTIVE

To evaluate the clinical and economic burden associated with anastomotic leaks following colorectal surgery.

METHODS

Retrospective data (January 2008 to December 2010) were analyzed from patients who had colorectal surgery with and without postoperative leaks, using the Premier Perspective™ database. Data on in-hospital mortality, length of stay (LOS), re-admissions, postoperative infection, and costs were analyzed using univariate and multivariate analyses, and the propensity score matching (PSM) and generalized linear models (GLM).

RESULTS

Of the patients, 6,174 (6.18 %) had anastomotic leaks within 30 days after colorectal surgery. Patients with leaks had 1.3 times higher 30-day re-admission rates and 0.8-1.9 times higher postoperative infection rates as compared with patients without leaks (P < 0.001 for both). Anastomotic leaks incurred additional LOS and hospital costs of 7.3 days and $24,129, respectively, only within the first hospitalization. Per 1,000 patients undergoing colorectal surgery, the economic burden associated with anastomotic leaks--including hospitalization and re-admission--was established as 9,500 days in prolonged LOS and $28.6 million in additional costs. Similar results were obtained from both the PSM and GLM for assessing total costs for hospitalization and re-admission.

CONCLUSIONS

Anastomotic leaks in colorectal surgery increase the total clinical and economic burden by a factor of 0.6-1.9 for a 30-day re-admission, postoperative infection, LOS, and hospital costs.