Surgical Procedures in Health Professional Shortage Areas: Impact of a Surgical Incentive Payment Plan

Association of Health Professional Shortage Area Hospital Designation With Surgical Outcomes and Expenditures Among Medicare Beneficiaries

OBJECTIVE

To compare surgical outcomes and expenditures at hospitals located in Health Professional Shortage Areas to nonshortage area designated hospitals among Medicare beneficiaries.

BACKGROUND

More than a quarter of Americans live in federally designated Health Professional Shortage Areas. Although there is growing concern that medical outcomes may be worse, far less is known about hospitals providing surgical care in these areas.

METHODS

Cross-sectional retrospective study from 2014 to 2018 of 842,787 Medicare beneficiary patient admissions to hospitals with and without Health Professional Shortage Area designations for common operations including appendectomy, cholecystectomy, colectomy, and hernia repair. We assessed risk-adjusted outcomes using multivariable logistic regression accounting for patient factors, admission type, and year were compared for each of the 4 operations. Hospital expenditures were price-standardized, risk-adjusted 30-day surgical episode payments. Primary outcome measures included 30-day mortality, hospital readmissions, and 30-day surgical episode payments.

RESULTS

Patients (mean age=75.6 years, males=44.4%) undergoing common surgical procedures in shortage area hospitals were less likely to be White (84.6% vs 88.4%, P <0.001) and less likely to have≥2 Elixhauser comorbidities (75.5% vs 78.2%, P <0.001). Patients undergoing surgery at Health Professional Shortage Area hospitals had lower risk-adjusted rates of 30-day mortality (6.05% vs 6.69%, odds ratio=0.90, CI, 0.90-0.91, P <0.001) and readmission (14.99% vs 15.74%, odds ratio=0.94, CI, 0.94-0.95, P <0.001). Medicare expenditures at Health Professional Shortage Area hospitals were also lower than nonshortage designated hospitals ($28,517 vs $29,685, difference= -$1168, P <0.001).

CONCLUSIONS

Patients presenting to Health Professional Shortage Area hospitals obtain safe care for common surgical procedures without evidence of higher expenditures among Medicare beneficiaries. These findings should be taken into account as current legislative proposals to increase funding for care in these underserved communities are considered.

High-risk surgery among Medicare beneficiaries living in health professional shortage areas

PURPOSE

Americans who reside in health professional shortage areas currently have less than half of the needed physician workforce. While the shortage designation has been associated with poor outcomes for chronic medical conditions, far less is known about outcomes after high-risk surgical procedures.

METHODS

We performed a retrospective review of Medicare beneficiaries living in health professional shortage areas and nonshortage areas who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, esophagectomy, liver resection, pancreatectomy, or rectal resection between 2014 and 2018. Risk-adjusted multivariable logistic regression was used to determine whether rates of postoperative complications and 30-day mortality differed between patient cohorts. Beneficiary and hospital ZIP codes were used to quantify travel time to obtain care.

FINDINGS

Compared with patients living in nonshortage areas, patients living in health professional shortage areas traveled longer (median 60.0 vs 28.0 minutes, P<.001). There were no differences in risk-adjusted rates of complications (28.5% vs 28.6%, OR = 1.00, 95% CI 1.00-1.00, P = .59) and small differences in rates of 30-day mortality (4.2% vs 4.4%, OR = 0.95, 95% CI 0.95-0.95, P<.001) between beneficiaries living in shortage areas versus those not in shortage areas, respectively.

CONCLUSIONS

Patients living in health professional shortage area undergoing high-risk surgery traveled more than 2 times longer for their care to obtain similar outcomes. While reassuring for clinical outcomes, additional efforts may be needed to mitigate the travel burden experienced by shortage area patients.

Coronary Artery Bypass Surgery Among Medicare Beneficiaries in Health Professional Shortage Areas

OBJECTIVE

Health professional shortage areas (HPSAs) were created by the Health Resources and Services Administration to identify communities with a shortage of clinical providers. For medical conditions, these designations are associated with worse outcomes. However, far less is known about patients undergoing high-complexity surgical procedures, such as coronary artery bypass grafting (CABG).

BACKGROUND

The aim was to compare postoperative surgical outcomes of high-complexity surgery in beneficiaries living in HPSA versus non-HPSA designated areas.

METHODS

This study is a retrospective cohort review of Medicare beneficiaries who underwent CABG between 2014 and 2018. The authors compared risk-adjusted 30-day mortality, complication, reoperation, and readmission rates for beneficiaries living in a designated HPSA versus non-HPSA using a multivariable logistic regression model accounting for patient (eg, age, sex, comorbidities, surgery year) and hospital characteristics (eg, patient-to-nurse ratio, teaching status). Patient travel burden was measured based on the time and distance required to travel from the beneficiary's home zip code to the hospital zip code.

RESULTS

Of the 370,532 Medicare beneficiaries who underwent CABG, 30,881 (8.3%) lived in a HPSA. Beneficiaries in HPSAs were found to experience comparable 30-day mortality (3.50% vs. 3.65%, P <0.001), complication (32.67% vs. 33.54%, P <0.001), reoperation (1.58% vs. 1.66%, P <0.001), and readmission (14.72% vs. 14.86%, P <0.001) rates. Beneficiaries experienced greater mean travel times (91.2 vs. 64.0 minutes, P <0.001) and mean travel distances (85.0 vs. 59.3 miles, P <0.001).

CONCLUSIONS

Medicare beneficiaries living in designated HPSA experienced comparable surgical outcomes after CABG surgery but a significantly greater travel burden. The greater travel burden experienced by patients living in designated shortage areas to obtain comparable surgical care for complex procedures demonstrates important tradeoffs between access and quality.