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Nanashima A, Hiyoshi M, Imamura N, Yano K, Hamada T, Kai K, Nishida T, Uchise Y, Sakamoto R, Inomata M. Preoperative Prognostic Nutritional Index is a significant predictive factor for posthepatectomy bile leakage. Ann Hepatobiliary Pancreat Surg 2021; 25:477-484. [PMID: 34845119 PMCID: PMC8639299 DOI: 10.14701/ahbps.2021.25.4.477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/19/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims It is known that preoperative nutritional status can influence patient outcomes after hepatectomy. Prognostic Nutritional Index (PNI) is a useful parameter to reflect patient outcomes undergoing gastro-intestinal surgery. The aim of this study was to retrospectively evaluate relationships of nutritional parameters, demographics, and surgical records with postoperative outcomes in a cohort study. Methods Curative hepatectomy was performed for 182 patients at the University of Miyazaki between 2015 and 2018. Each preoperative level of albumin, prealbumin, lymphocyte, total cholesterol, or the comprehensively calculated Onodera's PNI was examined as a nutritional parameter. Results The mean PNI was 39.6 ± 5.1, with PNI below 40 observed in 91 (50.0%) patients. Nutritional parameters were not different among patients with various liver diseases. Serum albumin or prealbumin level was significantly correlated with each hepatic parameter (p < 0.01). Prealbumin and total cholesterol levels were significantly correlated with postoperative prothrombin activity (p < 0.05). Albumin or prealbumin levels and PNI were significantly lower in patients with posthepatectomy complications, particularly bile leakage in comparison those without such complications (p < 0.05). Multiple logistic analysis showed that albumin level was an independent risk factor for complications after hepatectomy (risk ratio [RR]: 1.33) and that lymphocyte count was an independent risk factor for bile leakage (RR: 1.28) (p < 0.05). The cut-off level of albumin was approximately 3.8 mg/dL and that of lymphocyte count was 1,320/mm3. Conclusions Preoperative PNI reflected perioperative liver functional status. It was a predictive parameter for postoperative complications, particularly biliary leakage.
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Affiliation(s)
- Atsushi Nanashima
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Masahide Hiyoshi
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Naoya Imamura
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Koichi Yano
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Takeomi Hamada
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Kengo Kai
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Takahiro Nishida
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Yukako Uchise
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Risa Sakamoto
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Mayu Inomata
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
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Diaz A, Chhabra KR, Dimick JB, Nathan H. Variations in surgical spending within hospital systems for complex cancer surgery. Cancer 2020; 127:586-597. [PMID: 33141926 DOI: 10.1002/cncr.33299] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/07/2020] [Accepted: 10/10/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Approximately 70% of hospitals today are part of larger health systems. Proponents of hospital consolidation tout its potential to reduce health spending and improve outcomes, but to the authors' knowledge the available evidence has suggested that this promise is unrealized. Variations in costs and outcomes within systems may highlight opportunities for collaborative quality improvement and practice standardization. To assess this potential, the authors sought to measure variations in episode spending within and across hospital systems among Medicare beneficiaries undergoing complex cancer surgery. METHODS Using 100% Medicare claims data, the authors identified fee-for-service Medicare patients who were undergoing elective pancreatectomy, lung resection, or colectomy for cancer from 2014 through 2016. Risk-adjusted, price-standardized payments for the surgical episode from admission through 30 days after discharge were calculated. The authors then assessed the reliability-adjusted variations at the hospital and system levels. RESULTS Average episode payments varied nearly as much within hospital systems for pancreatectomy ($1946 between the lowest and highest spending systems; 95% CI, $1910-$1972), lung resection ($625 between the lowest and highest spending systems; 95% CI, $621-$630), and colectomy ($813 between the lowest and highest spending systems; 95% CI, $809-$817) as they did between the lowest and highest spending hospitals (pancreatectomy: $2034; lung resection: $1789; and colectomy: $770). For pancreatectomy, this variation was driven by index hospitalization spending whereas both index hospitalization and postacute care use drove variations for lung resection and colectomy. CONCLUSIONS In this analysis of Medicare patients undergoing complex cancer surgery, wide variations in surgical episode spending were noted both within and across hospital systems. System leaders may seek to better understand variations in practices among their hospitals to standardize care and reduce variations in outcomes, use, and costs.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University, Columbus, Ohio.,Institute for Healthcare Policy and Innovation Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Karan R Chhabra
- Institute for Healthcare Policy and Innovation Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan.,Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Hari Nathan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan.,Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Merath K, Cerullo M, Farooq A, Canner JK, He J, Tsilimigras DI, Mehta R, Paredes AZ, Sahara K, Dillhoff M, Tsung A, Cloyd J, Ejaz A, Pawlik TM. Routine Intensive Care Unit Admission Following Liver Resection: What Is the Value Proposition? J Gastrointest Surg 2020; 24:2491-2499. [PMID: 31630368 DOI: 10.1007/s11605-019-04408-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/09/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The value of routine ICU admission after elective surgery has been debated due to the lack of robust evidence supporting its benefit, as well as the increased incurred costs. We sought to analyze outcomes of patients undergoing hepatectomy who were routinely admitted to the intensive care unit (ICU) compared with surgical ward admission. METHODS Patients were identified in the Truven Health Analytics MarketScan Commercial Claims and Encounters Database from 2010 to 2016. Routine postoperative ICU admission was defined as ICU admission for ≤ 24 h on postoperative day 0. Potential association between routine ICU admission with extended length-of-stay (LOS), failure-to-rescue, and total inpatient costs was analyzed. RESULTS In total 7970 patients underwent hepatectomy; 37.7% (n = 3001) had routine ICU admission and 62.3% (n = 4969) surgical ward admission. Among the 3001 patients who had routine ICU admission, 1137 (37.9%) had a major and 1864 (62.1%) had a minor hepatectomy. Routine ICU admission was not associated with lower failure-to-rescue (routine ICU 4.9% vs. ward 1.8%; p < 0.001). Patients routinely admitted to the ICU had longer median LOS (routine ICU 7 days, IQR 5-15 days vs. ward 5 days, IQR 4-7 days; p < 0.001). Median payments were higher for routine ICU admission than for surgical ward admission ($50,501, IQR $34,270-$80,459 vs. $39,774, IQR $28,555-$58,270, respectively). CONCLUSION Routine ICU admission was associated with longer LOS and higher hospital payments, yet did not translate into lower failure-to-rescue among patients undergoing hepatectomy.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | | | - Ayesha Farooq
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Jen He
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Anghela Z Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Kota Sahara
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Allan Tsung
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA.
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Merath K, Chen Q, Johnson M, Mehta R, Beal EW, Dillhoff M, Cloyd J, Pawlik TM. Hot spotting surgical patients undergoing hepatopancreatic procedures. HPB (Oxford) 2019; 21:765-772. [PMID: 30497897 DOI: 10.1016/j.hpb.2018.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 09/23/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The burden of health care spending in the United States is a major concern, as health care costs have exponentially increased during the last three decades. The objective of the current study was to investigate the degree of cost-concentration among Medicare patients undergoing liver and pancreatic surgery. METHODS Medicare claims data from 2013 to 2015 were used to identify patients undergoing elective liver and pancreatic resections. Patients were divided into four groups: 1) non-complex pancreatic procedures; 2) complex pancreatic procedures; 3) non-complex liver procedures; and 4) complex liver procedures. Unadjusted price-standardized Medicare payments were calculated and payments were divided into quintiles. Patient-level factors associated with payments were analyzed by multivariable linear regression. RESULTS A total of 17,125 patients were included in the study. Patients in the top quintile of spending accounted for over 40% of payments for all liver and pancreatic procedures. Patients with comorbidity scores ≥5, male sex, open surgical approach and a diagnosis of congestive heart failure were associated with higher costs. CONCLUSION Patients undergoing liver and pancreatic resections on the top 20% of payments were responsible for a disproportionate share of Medicare payments - over 40% of total expenditures. Overall hospital surgical volume was lower among the highest quintile of payments.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Qinyu Chen
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Morgan Johnson
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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5
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Nanashima A, Hiyoshi M, Imamura N, Yano K, Hamada T, Hamada R, Nagatomo K, Ikenoue M, Tobinaga S, Nagayasu T. Clinical significance of preoperative nutritional parameter and patient outcomes after pancreatectomy: A retrospective study at two academic institute. Ann Hepatobiliary Pancreat Surg 2019; 23:168-173. [PMID: 31225419 PMCID: PMC6558137 DOI: 10.14701/ahbps.2019.23.2.168] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/14/2018] [Accepted: 12/15/2018] [Indexed: 01/09/2023] Open
Abstract
Backgrounds/Aims Preoperative nutritional status has been reported to influence patient outcomes after pancreatectomy. The Prognostic Nutritional Index (PNI) is a useful parameter to reflect the outcomes of patients undergoing gastrointestinal surgery. Therefore, the relationship between the PNI and clinicopathological factors, surgical data, and postoperative morbidity were retrospectively evaluated at two academic institutes in a cohort study. Methods Curative pancreatectomy was performed on 222 patients at the University of Nagasaki between 1995 and March 2015, and 101 at the University of Miyazaki between April 2015and March 2018. The PNI was calculated using preoperative albumin and total cholesterol levels. Results The mean PNI in our series was 39.2±5.4 and the prevalence of PNIs less than 40 was observed in 134 patients (44%). The PNI was not significantly different between normal, hard, and fatty architecture of the pancreatic parenchyma. The PNIs were significantly negatively correlated with higher age (p<0.01), but not with gender, co-morbidity, or habits. The PNI was significantly correlated with levels of hemoglobin, prothrombin activity, choline esterase, total protein, albumin and cholesterol (p<0.01), and with postoperative total protein and albumin levels (p<0.05). Although the preoperative PNI tended to be lower in patients with total postoperative complications, no significant differences for each complication were observed. Conclusions Although the preoperative PNIs reflect the perioperative nutritional status, its predictive usefulness for postoperative complications could not be significantly confirmed.
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Affiliation(s)
- Atsushi Nanashima
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan.,Department of Surgical Oncology, Nagasaki University School of Biomedical Sciences, Nagasaki, Japan
| | - Masahide Hiyoshi
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Naoya Imamura
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Koichi Yano
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Takeomi Hamada
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Rouko Hamada
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Kenzo Nagatomo
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Makoto Ikenoue
- Division of Hepato-Biliary-Pancreas Surgery, University of Miyazaki Faculty of Medicine, Miyazaki, Japan
| | - Shuichi Tobinaga
- Department of Surgical Oncology, Nagasaki University School of Biomedical Sciences, Nagasaki, Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University School of Biomedical Sciences, Nagasaki, Japan
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6
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Zogg CK, Ottesen TD, Kebaish K, Galivanche A, Murthy S, Changoor NR, Zogg DL, Pawlik TM, Haider AH. The Cost of Complications Following Major Resection of Malignant Neoplasia. J Gastrointest Surg 2018; 22:1976-1986. [PMID: 29946953 PMCID: PMC6224301 DOI: 10.1007/s11605-018-3850-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/15/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rising healthcare costs have led to increased focus on the need to achieve a higher "value of care." As value-maximization efforts expand to include more complex surgical patients, evidence to support meaningful implementation of complication-based initiatives is lacking. The objective of this study was to compare incremental costs of complications following major gastrointestinal (GI) resections for organ-specific malignant neoplasia using nationally representative data. METHODS National (Nationwide) Inpatient Sample data, 2001-2014, were queried for adult (≥ 18 years) patients undergoing major resections for malignant neoplasia. Based on system-based complications considered relevant to the long-term treatment of GI disease, stratified differences in risk-adjusted incremental hospital costs and complication probabilities were compared. Differences in surgical outcomes and costs over time were also assessed. RESULTS A total of 293,967 patients were included, weighted to represent 1,408,117 patients nationwide. One fourth (26.1%; 95% CI, 25.7-26.4%) experienced ≥ 1 pre-discharge complication (range, 45.3% esophagectomy to 24.0% rectal resection). Resultant annual risk-adjusted incremental hospital costs totaled $540 million nationwide (19.5% of the overall cost of care and an average of $20,900 per patient). Costs varied substantially with both cancer/resection type and complication group, ranging from $76.7 million for colectomies with infectious complications to $0.2 million for rectal resections with urinary complications. For each resection type, infectious ($154.7 million), GI ($85.5 million), and pulmonary ($77.9 million) complications were among the most significant drivers of increased hospital cost. CONCLUSIONS Quantifying and comparing the impact of complications on an indication-specific level in more complex patients offers an important step toward allowing providers/payers to meaningfully prioritize the design of novel and adaptation of existing value-maximization approaches.
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Affiliation(s)
- Cheryl K. Zogg
- Yale School of Medicine, New Haven, CT,Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | | | | | | | - Shilpa Murthy
- Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, MA,Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Navin R. Changoor
- Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | | | - Timothy M. Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Adil H. Haider
- Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, MA
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Abstract
Recent debate has focused on which quality measures are appropriate for surgical oncology and how they should be implemented and incentivized. Current quality measures focus primarily on process measures (use of adjuvant therapy, pathology reporting) and patient-centered outcomes (health-related quality of life). Pay for performance programs impacting surgical oncology patients focus primarily on preventing postoperative complications, but are not specific to cancer surgery. Future pay for performance programs in surgical oncology will likely focus on incentivizing high-quality, low-cost cancer care by evaluating process measures, patient-centered measures, and costs of care specific to cancer surgery.
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Affiliation(s)
- Jay S Lee
- Department of Surgery, University of Michigan, 2210A Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Hari Nathan
- Department of Surgery, University of Michigan, 2210A Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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8
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Shubeck SP, Thumma JR, Dimick JB, Nathan H. Hospital quality, patient risk, and Medicare expenditures for cancer surgery. Cancer 2017; 124:826-832. [DOI: 10.1002/cncr.31120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/12/2017] [Accepted: 10/16/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Sarah P. Shubeck
- National Clinician Scholars Program at the Institute for Healthcare Policy & Innovation; University of Michigan; Ann Arbor Michigan
- Department of Surgery; University of Michigan; Ann Arbor Michigan
| | - Jyothi R. Thumma
- Department of Surgery; University of Michigan; Ann Arbor Michigan
| | - Justin B. Dimick
- Department of Surgery; University of Michigan; Ann Arbor Michigan
| | - Hari Nathan
- Department of Surgery; University of Michigan; Ann Arbor Michigan
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9
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A Propensity Score Matched Analysis of Open Versus Minimally Invasive Transthoracic Esophagectomy in the Netherlands. Ann Surg 2017; 266:839-846. [DOI: 10.1097/sla.0000000000002393] [Citation(s) in RCA: 137] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Abstract
The quality of surgery is directly dependent on the quantity, more specifically, on the number of operations performed at a given hospital as well as on the designated surgeon. This fact is supported by numerous studies and meta-analyses that will be presented in the following text. Most of the convincing data for complex procedures can be obtained from visceral (upper and lower gastrointestinal) surgery studies. Mortality of large oncological procedures, such as esophageal or pancreatic surgery, can be reduced by 50% if a certain number of interventions are guaranteed per year. Centralizing these operations performed by specialized surgeons is the key to success. This also ensures that the minimum volume amounts within a given hospital are well above the required levels, thus enabling to teach the necessary expertise step by step. The obligatory 'learning curve' for complex interventions cannot be completed within the framework of reference figures during residency training. Together, surgeons and their respective societies have introduced a proposal for efficient case-oriented centralized surgery. Whether 'we are there yet' in surgery will depend in the end on how these efforts will be incorporated into administrative requirements and the guidelines that will then be implemented across the board.
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Affiliation(s)
| | - Kim C. Honselmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
- Andrew L. Warshaw, MD Institute for Pancreatic Cancer Research, Thier 623, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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11
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Ho V, Short MN, Aloia TA. Can postoperative process of care utilization or complication rates explain the volume-cost relationship for cancer surgery? Surgery 2017; 162:418-428. [PMID: 28438333 DOI: 10.1016/j.surg.2017.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 02/27/2017] [Accepted: 03/04/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Past studies identify an association between provider volume and outcomes, but less is known about the volume-cost relationship for cancer surgery. We analyze the volume-cost relationship for 6 cancer operations and explore whether it is influenced by the occurrence of complications and/or utilization of processes of care. METHODS Medicare hospital and inpatient claims for the years 2005 through 2009 were analyzed for 6 cancer resections: colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection. Regressions were first estimated to quantify the association of provider volume with costs, excluding measures of complications and processes of care as explanatory variables. Next, these variables were added to the regressions to test whether they weakened any previously observed volume-cost relationship. RESULTS Higher hospital volume is associated with lower patient costs for esophagectomy but not for other operations. Higher surgeon volume reduces costs for most procedures, but this result weakens when processes of care are added to the regressions. Processes of care that are frequently implemented in response to adverse events are associated with 14% to 34% higher costs. Utilization of these processes is more prevalent among low-volume versus high-volume surgeons. CONCLUSION Processes of care implemented when complications occur explain much of the surgeon volume-cost relationship. Given that surgeon volume is readily observed, better outcomes and lower costs may be achieved by referring patients to high-volume surgeons. Increasing patient access to surgeons with lower rates of complications may be the most effective strategy for avoiding costly processes of care, controlling expenditure growth.
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Affiliation(s)
- Vivian Ho
- Baker Institute for Public Policy, Rice University, Houston, TX; Department of Economics, Rice University, Houston, TX.
| | - Marah N Short
- Baker Institute for Public Policy, Rice University, Houston, TX
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
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