Hospitals with greater diversities of physiologically complex procedures do not achieve greater surgical growth in a market with stable numbers of such procedures

Incremental Societal Costs of Perioperative Complications Following Adult Elective Inpatient Major Therapeutic Surgery in the State of Florida: A Seven-Year Retrospective Epidemiological Analysis

Introduction There is an expanding role for anesthesiologists in the preoperative optimization and postoperative management of patients, often in the context of a so-called perioperative surgical home. Such efforts typically include enhanced recovery after surgery (ERAS) protocols and often an anesthesiologist-led team for perioperative management. Studies of the cost-effectiveness of such approaches have generally been conducted at single institutions, with most patients cared for by small numbers of surgeons. This limitation creates generalizability issues as to whether improvement was related mostly to organizational culture or the studied surgeons' practices (non-generalizable) versus the procedures (generalizable). We studied whether other organizations can rely on achieving similar benefits following the adoption of a studied process improvement strategy at a single institution. Methods All patients undergoing elective major therapeutic inpatient surgery discharged between October 2015 and June 2022 at non-federal hospitals in the state of Florida were included. For each discharge, the United States Medicare Severity Diagnosis-Related Group (MS-DRG) weighting factor (i.e., the multiplier for the hospital's base rate for admissions that determines reimbursement) and the Clinical Classification Software Refined (CCSR) code for the principal procedure were determined at admission and discharge from the state's inpatient healthcare database based on the diagnoses present at those time points. An increase in the weighting factor from admission to discharge represents societal costs from perioperative complications. Statewide, by hospital, and by surgeon, we calculated the total increase for each CCSR's weighting factor. Our primary hypothesis was that surgeon variability would be statistically greater than CCSR variability but that the incremental effect would be <5%. If CCSR and surgeon variability were comparable, this would be supportive of generalizability. In contrast, if there were a predominant effect related to the surgeon, results from one institution might not be applicable to others. Results Among the 1,482,344 discharges studied, the pooled (N=7 years) contributions to MS-DRG weighting factor increases from the upper 20% of surgeons were 2.8% more than from the upper 20% of CCSRs (95% CI 1.9%-3.9%, p=0.0006). Those CCSRs accounted for 85.5% (95% CI 79.4%-91.7%, p<0.0001) of the total increase in the MS-DRG weighting factor. The average contribution of the top two surgeons at each hospital to that hospital's increase in the weighting factor ranged among CCSRs from 68% to 97%. The median and 75th percentile of surgeons performing at least 10% of the total number of cases at each hospital was similar to those values for the contributions to the increases in the MS-DRG weighting factor, median 2.0 to 3.0, and 75th percentile 1.75 to 4.0. Conclusions Because variability among surgeons in their contributions to increases in the MS-DRG weighting factor only slightly exceeded the variability among CCSR surgical categories, perioperative surgical home and ERAS study research results involving single institutions and a small number of surgeons would likely be generalizable to other hospitals and healthcare systems. Funding agencies should not be hesitant to fund single-center perioperative surgical home studies and ERAS interventions based on concerns related to lack of generalizability.

Decline of Pediatric Ambulatory Surgery Cases Performed at Florida General Hospitals Between 2010 and 2018: An Historical Cohort Study

BACKGROUND

In the province of Ontario, nonphysiologically complex surgical procedures have increased at 4 pediatric hospitals with a reciprocal decline among the other (general) hospitals performing pediatric surgery. Given the differences between the Canadian and US health systems, we studied whether a similar shift occurred in the state of Florida and examined the age dependence of the shift.

METHODS

We used outpatient pediatric surgery data from all nonfederal hospitals, hospital-owned facilities, and independent ambulatory surgery centers in Florida, 2010-2018. Inferential analyses were performed comparing 2010-2011 with 2017-2018. Annual caseloads are reported as cases per workday by dividing by 250 workdays per year.

RESULTS

Statewide, comparing 2010-2011 with 2017-2018, among children 1-17 years, pediatric hospitals' caseload increased overall by 50.7 cases per workday, overall meaning collectively among all hospitals combined. The caseload at general hospitals and ambulatory surgery centers, combined, decreased by 97.7 cases per workday. The general hospitals performed 54.7 fewer cases per workday. Among the 112 general hospitals, the mean pairwise decline was -0.49 cases per workday (99% confidence interval, -0.87 to -0.10; P < .0001). The changes were due to multiple categories of procedures, not just a few. Comparing 2010-2011 with 2017-2018, among 3 age cohorts (1-5, 6-12, and 13-17 years), the pediatric hospitals, statewide, performed overall 16.2, 15.1, and 19.3 more cases per workday, respectively. The general hospitals and ambulatory surgery centers, combined, performed fewer cases per workday for each cohort: 49.4, 21.4, and 26.9, respectively. The general hospitals overall performed fewer cases per workday for each cohort: 27.3, 12.1, and 15.4, respectively. Among general hospitals, the mean pairwise difference in the declines between patients 1-5 years vs 6-17 years was 0.00 cases per workday (99% confidence interval, -0.13 to +0.14).

CONCLUSIONS

The decline across all age groups was inconsistent with multiple general hospitals increasing their minimum age threshold for surgical patients because, otherwise, the younger patients would have accounted for a larger share of the decreases in caseload. Pediatric hospitals and their anesthesiologists have greater surgical growth than expected from population demographics. Many general hospitals can expect either needing fewer pediatric anesthesiologists or that their pediatric anesthesiologists, who also care for adults, will have smaller proportions of pediatric patients in their practices.

Patient health status and case complexity of outpatient surgeries at various facility types in the United States: An analysis using the National Anesthesia Clinical Outcomes Registry

STUDY OBJECTIVE

Among the various types of outpatient surgery centers, there are differences in higher American Society of Anesthesiologists Physical Status (ASA PS) scores and surgical complexity among patients who are undergoing surgery. The primary objective of this study was to describe the differences performed at various types of outpatient surgery facilities.

DESIGN

We performed a retrospective analysis of the National Anesthesia Clinical Outcomes Registry (NACOR) data.

SETTING

NACOR from 2012 to 2017.

PATIENTS

From 2012 to 2017, there were a total of 13,053,115 outpatient surgeries in the database. After removing cases with unknown facility type, the final study sample was 9,217,336.

INTERVENTIONS

None.

MEASUREMENTS

To calculate the probability of either American Society of Anesthesiologists Physical Status (ASA PS) score ≥ 3 or physiologically complex cases (defined as Common Procedural Terminology start-up units ≥8), we performed mixed effects logistic regression for each institution per facility type, controlling for year and using facility identification as the random effect. We present the mean rate of these two classifications as case per 10,000 cases and report the 99.9% confidence interval (CI), to control for multiple comparisons.

MAIN RESULTS

Among all cases, 5,919,844 (64.2%) were classified as ASA PS 1 or 2 and 254,110 (2.8%) of surgical procedures were considered physiologically complex. The mean rate of cases with ASA PS ≥ 3in the university setting was 2982 per 10,000 cases [99.9% CI 2701-3278 per 10,000 cases]. Large community hospitals had a higher proportion of ASA PS ≥3 patients, medium-sized hospitals had no difference, and all other facility types had a decreased proportion. The mean rate of cases that were physiologically complex in the university setting was 133 per 10,000 cases [99.9% CI 117-151 per 10,000 cases]. Large community hospitals had a higher proportion of physiologically complex cases, medium-sized and small-sized hospitals had no difference, and all other facility types had a decreased proportion.

CONCLUSIONS

Freestanding and attached surgery centers exhibited smaller rates of patients that were ASA PS ≥ 3, as well as a decrease in surgically complex cases, when compared to university settings. This suggests that the level of conservativeness for patient and surgery appropriateness for outpatient surgery differs across various facility types.

Building a Brain Tumor Practice: Objective Analysis of Referral Patterns and Implications for the Growth of a Subspecialty Surgical Program

Introduction Growth of surgical caseload among specialties with a large contribution margin is an important financial objective for hospitals. In this study, we examined the diversity of referral patterns to a neurosurgeon over an eight-year interval and examined practice attributes related to surgical growth. Methods The electronic records of all patients undergoing an intracranial surgical procedure between August 2011 and August 2019 by an academic neurosurgeon were reviewed retrospectively. The Herfindahl-Hirschman index (HHI) was used to assess the distribution of referrals among community physicians who referred such patients; a value of HHI <0.15 indicates diversity. The yearly HHI trend was evaluated using meta-regression. Results The neurosurgeon's brain surgery caseload progressively increased on an annual basis from 1.4 to 12.5 cases per week between 2012 and 2018. Among the 1540 cases referred by 1775 different physicians, 78% were from three counties in southeast Florida and 8.1% from two counties in southwest Florida. The HHI declined between 2013 and 2018 by 0.023 per year (0.0046 standard error [SE], p = 0.0073) with the estimated value 0.0063 (0.0014 SE) < 0.15 in 2018 (p < 0.0001). The findings indicate that the base of referring physicians was highly diverse and that growth in caseload was accompanied by significantly less concentration of referrals. Conclusion Surgical growth in the neurosurgeon's practice resulted from a small number of referrals from many physicians, not from many referrals from a small number of physicians. Few physicians referred a sufficient number of patients to warrant attribution of the referral itself to personal knowledge of their patients' eventual outcomes. Rather, factors promoting timely access to patient care appear to have been the driving force for growth.

Development and Validation of an Algorithm to Classify as Equivalent the Procedures in ICD-10-PCS That Differ Only by Laterality

BACKGROUND

The switch from International Classification of Diseases, Ninth Revision, Clinical Modification to International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) for coding of inpatient procedures in the United States increased the number of procedural codes more than 19-fold, in large part due to the addition of laterality. We examined ICD-10-PCS codes for pairs of mirror-image procedures that are surgically equivalent.

METHODS

We developed an algorithm in structured query language (SQL) to identify ICD-10-PCS codes differing only by laterality. We quantified the impact of laterality on the number of commonly performed major therapeutic procedures (ie, surgical diversity) using 2 quarters of discharge abstracts from Texas.

RESULTS

Of the 75,789 ICD-10-PCS codes from federal fiscal year 2017, 16,839 (22.3%) pairs differed only by laterality (with each pair contributing 2 codes). With the combining of equivalent codes, diversity in the state of Texas decreased from 78.2 to 74.1 operative procedures (95% confidence interval, 5.1 to -3.1; P < .001).

CONCLUSIONS

Our algorithm identifies ICD-10-PCS codes that differ only by laterality. However, laterality had a small effect on surgical diversity among major therapeutic procedures. Our SQL code and the lookup table will be useful for all US inpatient analyses of ICD-10-PCS surgical data, because combining procedures differing only by laterality will often be desired.