Variations in surgical spending within hospital systems for complex cancer surgery

Surgeon-Dependent Variability in Cost of Gastrointestinal Operations in a Single Cancer Center

INTRODUCTION

Cancer operations are increasingly utilizing specialized equipment and technology. Related costs are often not known to the responsible surgeon. We seek to evaluate cost aspects of care episodes attributable to the surgeon's management decisions.

METHODS

Financial cost data in a tertiary academic cancer center were queried over 3 y. Consecutive patients undergoing gastrointestinal operations followed by inpatient admission of two or more days were included, excluding patients with 40+ d admissions. Analysis of variance, Kruskal-Wallis, and multiple regression statistics were utilized.

RESULTS

The study population included 1540 patients: 54% men and 46% women, with a median age of 64 y (range 15-95). Eight surgeons conducted major (82%) and minor (18%) operations, with a minimally invasive surgical approach in 60.4%. Procedures included colorectal (37%), pancreatic (19%), esophagogastric (18%), hepatobiliary (18%), and small bowel resections (8%). Total direct costs differed between surgeons with an analysis of variance coefficient range between -$3265 and +$6163 (P < 0.001). Surgeons' cost differences were observed for central medical supply, operating room (OR) supply, total OR, inpatient room, laboratory, pharmacy, supportive care (P < 0.001), and radiology costs (P < 0.02). OR supply cost was the dominant consistent domain with significant differences between surgeons in all case subcategories. When controlled for case category and minimally invasive surgical approach, multiple regression showed the most significant variations between surgeons in ORs, medical supply, and nutrition costs (P < 0.001), followed by laboratory costs (P < 0.01). Top OR supply costs were staplers and energy devices.

CONCLUSIONS

Even in a highly subspecialized surgical environment, surgeons' variable utilization of ORs and medical supplies is strongly linked to variations in care-related costs. Specific queries into supply items should reduce costs and optimize value generated.

Optimizing care delivery in expanding health systems: Views from clinical leaders

INTRODUCTION

In response to intense market pressures, many hospitals have consolidated into systems. However, evidence suggests that consolidation has not led to the improvements in clinical quality promised by proponents of mergers. The challenges to delivering care within expanding health systems and the opportunities posed to surgical leaders remains largely unexplored.

METHODS

Semistructured interviews with 30 surgical leaders at teaching hospitals affiliated with health systems from August-December 2019. Interviews were transcribed verbatim and coded in an iterative process using MaxQDA software. Attitudes and strategies toward redesigning health care delivery across expanding systems were analyzed using thematic analysis.

RESULTS

Leaders reported challenges to redesigning care delivery across the system ranging from resource constraints (e.g. hospital beds and operating rooms) to evolving market demands (e.g., patient preferences to receive care close to home). However, participants also highlighted that system expansion provided multiple opportunities to increase access (e.g. decant low-complexity care to affiliated centers) and improve quality of care (e.g. standardize best practices) for diverse populations including the potential to leverage their health system to expand access and improve quality.

CONCLUSIONS

Though evidence suggests that hospital consolidation has not led to redesigned care delivery or improved clinical quality at a national level, leaders are pursuing varying sets of strategies aimed at leveraging system expansion in order to improve access and quality of care.

Quality indicators for systemic anticancer therapy services: a systematic review of metrics used to compare quality across healthcare facilities

PURPOSE

The number of systemic anticancer therapy (SACT) regimens has expanded rapidly over the last decade. There is a need to ensure quality of SACT delivery across cancer services and systems in different resource settings to reduce morbidity, mortality, and detrimental economic impact at individual and systems level. Existing literature on SACT focuses on treatment efficacy with few studies on quality or how SACT is delivered within routine care in comparison to radiation and surgical oncology.

METHODS

Systematic review was conducted following PRISMA guidelines. EMBASE and MEDLINE were searched and handsearching was undertaken to identify literature on existing quality indicators (QIs) that detect meaningful variations in the quality of SACT delivery across different healthcare facilities, regions, or countries. Data extraction was undertaken by two independent reviewers.

RESULTS

This review identified 63 distinct QIs from 15 papers. The majority were process QIs (n = 55, 87.3%) relating to appropriateness of treatment and guideline adherence (n = 28, 44.4%). There were few outcome QIs (n = 7, 11.1%) and only one structural QI (n = 1, 1.6%). Included studies solely focused on breast, colorectal, lung, and skin cancer. All but one studies were conducted in high-income countries.

CONCLUSIONS

The results of this review highlight a significant lack of research on SACT QIs particularly those appropriate for resource-constrained settings in low- and middle-income countries. This review should form the basis for future work in transforming performance measurement of SACT provision, through context-specific QI SACT development, validation, and implementation.

Variation in the Price of Head and Neck Surgical Oncology Procedures

Health care costs can present a significant strain on patients with head and neck cancer. It remains unclear how much prices may vary among hospitals providing care and what factors lead to differences in prices of surgical procedures. A cross-sectional analysis of private payer-negotiated prices was performed for 10 commonly performed head and neck surgical oncology procedures. In total, 896 hospitals disclosed prices for at least 1 common head and neck surgical oncology procedure. Wide variation in negotiated surgical prices was identified. Across-center ratios ranged from 6.2 (partial glossectomy without primary closure) to 22.8 (excision of tongue lesion without closure). For-profit hospital ownership structure and geographic region outside of the northeast United States were associated with increased prices. For example, private payer-negotiated prices for direct laryngoscopy with biopsy were on average $2083 greater at for-profit hospitals when compared with nonprofit hospitals ($5215 vs $3132, P < .001). Further research comparing prices and outcomes is needed.

Association Between Cancer Center Accreditation and Compliance With Price Disclosure of Common Oncologic Surgical Procedures

BACKGROUND

Cancer center accreditation status is predicated on several factors that measure high-value healthcare. However, price transparency, which is critical in healthcare decisions, is not a quality measure included for accreditation. We reported the rates of price disclosure of surgical procedures for 5 cancers (breast, lung, cutaneous melanoma, colon, and prostate) among hospitals ranked by the American College of Surgeon's Commission on Cancer (ACS-CoC).

METHODS

We identified nonfederal, adult, and noncritical access ACS-CoC accredited hospitals and used the commercial Turquoise Health database to perform a cross-sectional analysis of hospital price disclosures for 5 common oncologic procedures (mastectomy, lobectomy, wide local excision for cutaneous melanoma, partial colectomy, prostatectomy). Publicly available financial reporting data were used to compile facility-specific features, including bed size, teaching status, Centers for Medicare & Medicaid wage index, and patient revenues. Modified Poisson regression evaluated the association between price disclosure and ACS-CoC accreditation after adjusting for hospital financial performance.

RESULTS

Of 1,075 total ACS-CoC accredited hospitals, 544 (50.6%) did not disclose prices for any of the surgical procedures and only 313 (29.1%) hospitals reported prices for all 5 procedures. Of the 5 oncologic procedures, prostatectomy and lobectomy had the lowest price disclosure rates. Disclosing and nondisclosing hospitals significantly differed in ACS-CoC accreditation, ownership type, and teaching status. Hospitals that disclosed prices were more likely to receive Medicaid disproportionate share hospital payments, have lower average charge to cost ratios (4.53 vs 5.15; P<.001), and have lower net hospital margins (-2.03 vs 0.44; P=.005). After adjustment, a 1-point increase in markup was associated with a 4.8% (95% CI, 2.2%-7.4%; P<.001) higher likelihood of nondisclosure.

CONCLUSIONS

More than half of the hospitals did not disclose prices for any of the 5 most common oncologic procedures despite ACS-CoC accreditation. It remains difficult to obtain price transparency for common oncologic procedures even at centers of excellence, signaling a discordance between quality measures visible to patients.

Do all Patients Get the Same Care Across Hospitals?

There is extensive research demonstrating significant variation in the utilization of surgery and outcomes from surgery, including differences in mortality, complications, readmission, and failure to rescue. Literature suggests that these variations exist across as well as within small area geographies in the United States. There is also significant evidence of variation in access and outcomes from surgery that is attributable to race. Emerging research is demonstrating that there may be some variation attributable to a patient's social determinants of health and their lived averment. Those affected must work together to determine rate of utilization and how much variation is acceptable.

Variation in Hospital Cost and 1-Year Episodes of Care after Diaphragmatic Hernia Repair

BACKGROUND

Diaphragmatic hernia repair is a common operation performed at all types of hospitals. The variation in costs and repeat episodes of care after this operation is not known.

STUDY DESIGN

The Healthcare Cost and Utilization Project State Inpatient and State Ambulatory Surgery and Services Databases for Florida were queried to identify patients undergoing diaphragmatic hernia repair between 2011 and 2018 and the associated inpatient and outpatient encounters within 12 months postoperatively. Hospitals were ranked by cost and grouped into quintiles. All costs and charges were reliability and case-mix adjusted with the use of hierarchical multivariable regression.

RESULTS

In total, 8,848 patients underwent diaphragmatic hernia operations at 158 hospitals. The most expensive hospital quintile had lower surgical volume, location in rural settings, and fewer than 100 beds. There was a wide variation in costs after diaphragmatic hernia repair. On unadjusted comparison, index costs were $23,041 more expensive in hospitals in the highest quintile than in the lowest quintile. Cost differences were persistent even after case-mix and reliability adjustment. The variation in adjusted aggregate charges for associated outpatient and inpatient encounters in the first year after the index operation was considerably lower than that of the index hospitalization.

CONCLUSION

There is nearly a 2-fold variation in the cost of a diaphragmatic hernia repair across hospitals. Most of the variation occurs during the index surgical encounter and not for repeat encounters during the first postoperative year. As bundled payment models mature, hospitals and payers will need to target this variation to ensure cost-efficiency.