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Azimuddin A, Tzeng CWD, Prakash LR, Bruno ML, Arvide EM, Dewhurst WL, Newhook TE, Kim MP, Ikoma N, Snyder RA, Lee JE, Perrier ND, Katz MH, Maxwell JE. Postoperative Global Period Cost Reduction Using 3 Successive Risk-Stratified Pancreatectomy Clinical Pathways. J Am Coll Surg 2024; 238:451-459. [PMID: 38180055 DOI: 10.1097/xcs.0000000000000944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
BACKGROUND We hypothesized that iterative revisions of our original 2016 risk-stratified pancreatectomy clinical pathways would be associated with decreased 90-day perioperative costs. STUDY DESIGN From a single-institution retrospective cohort study of consecutive patients with 3 iterations: "version 1" (V1) (October 2016 to January 2019), V2 (February 2019 to October 2020), and V3 (November 2020 to February 2022), institutional data were aggregated using revenue codes and adjusted to constant 2022-dollar value. Grand total perioperative costs (primary endpoint) were the sum of pancreatectomy, inpatient care, readmission, and 90-day global outpatient care. Proprietary hospital-based costs were converted to ratios using the mean cost of all hospital operations as the denominator. RESULTS Of 814 patients, pathway V1 included 363, V2 229, and V3 222 patients. Accordion Grade 3+ complications decreased with each iteration (V1: 28.4%, V2: 22.7%, and V3: 15.3%). Median length of stay decreased (V1: 6 days, interquartile range [IQR] 5 to 8; V2: 5 [IQR 4 to 6]; and V3: 5 [IQR 4 to 6]) without an increase in readmissions. Ninety-day global perioperative costs decreased by 32% (V1 cost ratio 12.6, V2 10.9, and V3 8.6). Reduction of the index hospitalization cost was associated with the greatest savings (-31%: 9.4, 8.3, and 6.5). Outpatient care costs decreased consistently (1.58, 1.41, and 1.04). When combining readmission and all outpatient costs, total "postdischarge" costs decreased (3.17, 2.59, and 2.13). Component costs of the index hospitalization that were associated with the greatest savings were room or board costs (-55%: 1.74, 1.14, and 0.79) and pharmacy costs (-61%: 2.20, 1.61, and 0.87; all p < 0.001). CONCLUSIONS Three iterative risk-stratified pancreatectomy clinical pathway refinements were associated with a 32% global period cost savings, driven by reduced index hospitalization costs. This successful learning health system model could be externally validated at other institutions performing abdominal cancer surgery.
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Affiliation(s)
- Ahad Azimuddin
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
- Texas A&M School of Medicine, Houston, TX (Azimuddin)
| | - Ching-Wei D Tzeng
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Laura R Prakash
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Morgan L Bruno
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Elsa M Arvide
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Whitney L Dewhurst
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Timothy E Newhook
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Michael P Kim
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Naruhiko Ikoma
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Rebecca A Snyder
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Jeffrey E Lee
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Nancy D Perrier
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Matthew Hg Katz
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
| | - Jessica E Maxwell
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (Azimuddin, Tzeng, Prakash, Bruno, Arvide, Dewhurst, Newhook, Kim, Ikoma, Snyder, Lee, Perrier, Katz, Maxwell)
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Offodile AC, Lin YL, Melamed A, Rauh-Hain JA, Kinzer D, Keating NL. Association of Maryland Global Budget Revenue With Spending and Outcomes Related to Surgical Care for Medicare Beneficiaries With Cancer. JAMA Surg 2022; 157:e220135. [PMID: 35385085 PMCID: PMC8988019 DOI: 10.1001/jamasurg.2022.0135] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance In 2014, Maryland initiated the global budget revenue (GBR) model, placing caps on total hospital expenditures across all care sites. The GBR program aims to reduce unnecessary utilization while maintaining or improving care quality. To date, there has been limited examination of program effects on cancer care. Objective To compare changes in spending, clinical outcomes, and acute care utilization through 4 years of the GBR program among Medicare beneficiaries who undergo cancer-directed surgery in Maryland vs matched control states. Design, Setting, and Participants Drawing from a matched pool of hospitals in Maryland (n = 35) and 24 control states with a similar timing of Medicaid expansion (n = 101), we identified Medicare beneficiaries from Maryland and control states who underwent any cancer-directed surgery from 2011 through 2018. Using difference-in-differences analysis, we compared changes in outcomes from before (2011-2013) to after (2015-2018) GBR implementation between patients treated in Maryland and control states. We also performed a subgroup analysis among patients who underwent major surgical procedures that are usually performed in the inpatient setting (cystectomy, esophagectomy, gastrectomy, colorectal resection, nephrectomy, pancreatectomy, and lung resection). Main Outcomes and Measures Thirty-day episode spending, mortality, readmissions, and emergency department (ED) visits. Results Relative to Medicare beneficiaries undergoing cancer surgery in control states (n = 4737; 3323 [70.1%] female; 571 [12.1%] dual-eligible; mean [SD] age 74.9 [6.5] years), patients in Maryland (n = 20 320; 14 068 [69.2%] female; 1705 [8.4%] dual-eligible; mean [SD] age 74.9 [6.5] years) had a statistically significant reduction of 2.2 percentage points (95% CI, -4.3 to -0.1) in the 30-day readmission rate. We found no statistically significant changes in 30-day spending, mortality, or ED visits. We report no significant results in the subgroup analysis of patients undergoing major surgical procedures. Conclusions and Relevance Global budget revenue was not associated with changes in expenditures, ED utilization, or clinical outcomes after cancer-directed surgery through 4 years. There was a modest decline in 30-day readmissions. Specialty-specific definitions of care quality and better alignment across the entire care delivery value chain (ie, physician incentives) may be strategies that could improve delivery of high-value care for beneficiaries undergoing cancer surgery.
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Affiliation(s)
- Anaeze C Offodile
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston.,Baker Institute for Public Policy, Rice University, Houston, Texas.,Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston
| | - Yu-Li Lin
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston
| | - Alexander Melamed
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - J Alejandro Rauh-Hain
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston.,Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston
| | | | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Kushner BS, Hall B, Pierce A, Mody J, Guth RM, Martin J, Blatnik JA, Eckhouse SR. Reducing Operating Room Cost: Comparing Attending and Surgical Trainee Perceptions About the Implementation of Supply Receipts. J Am Coll Surg 2021; 233:710-721. [PMID: 34530125 DOI: 10.1016/j.jamcollsurg.2021.08.690] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND As operating room (OR) expenditures increase, faculty and surgical trainees will play a key role in curbing future costs. However, supply cost utilization varies widely among providers and, despite requirements for cost education during surgical training, little is known about trainees' comfort discussing these topics. To improve OR cost transparency, our institution began delivering real-time supply "receipts" to faculty and trainees after each surgical case. This study compares faculty and surgical trainees' perceptions about supply receipts and their effect on individual practice and cultural change. STUDY DESIGN Faculty and surgical trainees (residents and fellows) from all adult surgical specialties at a large academic center were emailed separate surveys. RESULTS A total of 120 faculty (30.0% response rate) and 119 trainees (35.7% response rate) completed the survey. Compared with trainees, faculty are more confident discussing OR costs (p < 0.001). Two-thirds of trainees report discussing OR costs with faculty as opposed to 77.0% of faculty who acknowledge having these conversations (p = 0.08). Both groups showed a strong commitment to reduce OR expenditures, with 87.3% of faculty and 90.0% of trainees expressing a responsibility to curb OR costs (p = 0.84). After 1 year of implementation, faculty continue to have high interest levels in supply receipts (82.4%) and many surgeons review them after each case (67.7%). In addition, 74.3% of faculty are now aware of how to lower OR costs and 52.5% have changed the OR supplies they use. Trainees, in particular, desire additional cost-reducing efforts at our institution (p < 0.001). CONCLUSIONS Supply receipts have been well received and have led to meaningful cultural changes. However, trainees are less confident discussing these issues and desire a greater emphasis on OR cost in their curriculum.
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Affiliation(s)
| | - Bruce Hall
- Department of Surgery, Washington University; BJC HealthCare
| | - Andrew Pierce
- Perioperative Services, Barnes Jewish Hospital, St Louis, MO
| | - Jessica Mody
- Perioperative Services, Barnes Jewish Hospital, St Louis, MO
| | | | - Jackie Martin
- Perioperative Services, Barnes Jewish Hospital, St Louis, MO
| | | | - Shaina R Eckhouse
- Department of Surgery, Washington University; Perioperative Services, Barnes Jewish Hospital, St Louis, MO
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