Assessing post-discharge costs of hepatopancreatic surgery: an evaluation of Medicare expenditure

Association of Minority-Serving Hospital Status with Post-Discharge Care Utilization and Expenditures in Gastrointestinal Cancer

BACKGROUND

Disparities in utilization of post-discharge care and overall expenditures may relate to site of care and race/ethnicity. We sought to define the impact of minority-serving hospitals (MSHs) on postoperative outcomes, discharge disposition, and overall expenditures associated with an episode of surgical care.

METHODS

Patients who underwent resection for esophageal, colon, rectal, pancreatic, and liver cancer were identified from Medicare Standard Analytic Files (2013-2017). A MSH was defined as the top decile of facilities treating minority patients (Black and/or Hispanic). The impact of MSH on outcomes of interest was analyzed using multivariable logistic regression and generalized linear regression models. Textbook outcome (TO) was defined as no postoperative complications, no prolonged length of stay, and no 90-day mortality or readmission.

RESULTS

Among 113,263 patients, only a small subset of patients underwent surgery at MSHs (n = 4404, 3.9%). While 52.3% of patients achieved TO, rates were lower at MSHs (MSH: 47.2% vs. non-MSH: 52.5%; p < 0.001). On multivariable analysis, receiving care at an MSH was associated with not achieving TO (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.76-0.87) and concomitantly higher odds of additional post-discharge care (OR 1.10, 95% CI 1.01-1.20). Patients treated at an MSH also had higher median post-discharge expenditures (MSH: $8400, interquartile range [IQR] $2300-$22,100 vs. non-MSH: $7000, IQR $2200-$17,900; p = 0.002). In fact, MSHs remained associated with a 11.05% (9.78-12.33%) increase in index expenditures and a 16.68% (11.44-22.17%) increase in post-discharge expenditures.

CONCLUSIONS

Patients undergoing surgery at a MSH were less likely to achieve a TO. Additionally, MSH status was associated with a higher likelihood of requiring post-discharge care and higher expenditures.

The Long-Term Effects of Hospitalization on Health Care Expenditures: An Empirical Analysis for the Young-Old Population in Lombardy

As the burden of acute care on government budgets is mounting in many countries, documenting the evolution of health costs following patients' hospital admission is essential for assessing overall hospital-related costs. In this paper, we investigate the short- and long-term effects of hospitalization on different types of health care expenditures. We specify and estimate a dynamic DID model using register data of the entire population of individuals aged 50-70 residing in Milan, Italy, over the period 2008-2017. We find evidence of a large and persistent effect of hospitalization on total health care expenditures, with future medical expenses mostly accounted for by inpatient care. Considering all health treatments, the overall effect is sizable and is about twice the cost of a single hospital admission. We show that chronically ill and disabled individuals require greater post-discharge medical assistance, especially for inpatient care, and that cardiovascular and oncological diseases together account for more than half of expenditures on future hospitalizations. Alternative out-of-hospital management practices are discussed as a post-admission cost-containment measure.

Development and validation of risk stratification tool for prediction of increased dependence using preoperative frailty after hepatopancreatic surgery

BACKGROUND

Despite the known association between frailty and postoperative morbidity, the use of preoperative frailty in surgical practice remains limited. We sought to develop a risk tool to predict postoperative increase in functional dependence.

METHODS

Patients of ≥65 years in the National Surgical Quality Improvement Project database who had a primary hepatopancreatic surgery between 2015 and 2019 were used to identify predictors of increased dependence and development of a simplified tool to calculate the risk stratification score for increased discharge care level (https://ktsahara.shinyapps.io/care_discharge/).

RESULTS

Among 31,338 patients who underwent primary hepatopancreatic surgery, 4,259 (13.6%) had an increased level of care at discharge compared to their preadmission care. Patients with increased discharge care had a higher proportion of patients with a modified frailty index of at least 2 (n = 1496; 35.1%) compared with individuals with unchanged care (n = 6,760; 25.0%). In addition, 12.3% (n = 3,858) were discharged to a skilled nursing or rehabilitation facility. Of note, the odds of increased care at discharge were increased by 1.41 (95% confidence interval: 1.32-1.50), 1.11 (95% confidence interval :1.11-1.12), and 1.95 (95% confidence interval:1.86-2.04) times with every unit increase in modified frailty index, age beyond 65 years, and the number of in-hospital complications, respectively. Area under receiver operative curve for the parsimonious model used to develop the risk calculator was 0.7486 (95% confidence interval: 0.7405-0.7566) (all P < .001).

CONCLUSION

Approximately, 1 in 7 patients required an increased level of care at the time of discharge compared with their preadmission status. A simplified web-based risk tool can be used in clinical practice as a surgical decision aid in post-discharge planning after complex elective surgery.

Emergency Department Utilization Following Hepatopancreatic Surgery Among Medicare Beneficiaries

BACKGROUND

Care delivered in hospital-based emergency departments (ED) is a target for cost savings. ED utilization following hepatopancreatic surgery remains poorly defined. We sought to define the rate of ED utilization following liver and pancreatic resection, as well as to identify factors associated with ED visits post-discharge.

METHODS

The Medicare 100% Standard Analytic Files were used to identify Medicare beneficiaries who underwent hepatectomy or pancreatectomy between 2013 and 2017. Claims associated with ED services were identified using the relevant Revenue Center Codes. Patient characteristics and postoperative outcomes associated with ED care within 30 days of discharge were investigated.

RESULTS

Among 37,707 patients who underwent hepatopancreatic surgery, 10,323 (27.4%) had at least one ED visit within 30 days of discharge. Patients presenting to the ED were more likely to be male (OR 1.13, 95%CI 1.07-1.18). Patients undergoing a pancreatectomy (OR 1.39, 95%CI 1.32-1.47), as well as patients who had a perioperative complication (OR 1.16, 95%CI 1.10-1.23) and patients not discharged home (OR 1.41, 95%CI 1.33-1.49), were more likely to require ED care. In contrast, patients undergoing resection for cancer or surgery for an elective basis were less likely to present to the ED postoperatively (OR 0.92, 95%CI 0.87-0.97 and OR 0.22, 95%CI 0.20-0.23, respectively). Patients often had multiple ED visits within 30 days of discharge as 37.2% of patients presented to the ED with at least 2 visits. Visits were also most common in the immediate postoperative period, with 30.9% of ED visits taking place in the first 2 days from discharge. Among patients requiring postoperative ED care, 53.9% were readmitted within 30 days.

CONCLUSION

More than 1 in 4 patients undergoing hepatopancreatic surgery presented to the ED within 30 days of discharge, with most patients returning to the ED within the first week of discharge. A subset of patients had multiple ED visits. Future efforts should target patients most likely to be high ED utilizers to avoid the need for early post-discharge ED use.

Trends in Discharge Disposition Following Hepatectomy for Hepatocellular Carcinoma Among Medicare Beneficiaries

BACKGROUND

Post-acute care (PAC) services can include home healthcare, long-term care hospitals, and skilled nursing facilities. We sought to define factors associated with PAC discharge disposition among Medicare beneficiaries who underwent hepatectomy for hepatocellular carcinoma (HCC).

METHODS

Data for Medicare beneficiaries with a diagnosis of HCC and who underwent a hepatectomy between 2004 and 2015 were retrieved from the SEER-Medicare database. Discharge disposition was defined as routine (HSC: discharged to home) or non-routine (SNF/ICF, discharged to skilled nursing/intermediate care facilities, or HHA, discharge to home with home health agency). The Cochran-Mantel-Haenszel test and multivariable logistic regression were used to assess trends in discharge disposition.

RESULTS

Among 1305 patients, the median patient age at diagnosis was 72 years (IQR: 68-76). Approximately 4 in 5 patients were discharged to HSC (77.4%; n = 1010). The odds of a non-routine discharge decreased by 7.0% annually from 2004 to 2015 (OR_trend, 0.93; 95%CI, 0.89-0.97; p_trend = 0.001). Several factors were associated with non-routine discharge, including patient age (OR 1.06, 95%CI 1.04-1.09) and longer LOS (OR 1.07, 95%CI 1.05-1.10). In contrast, patients who had a minor hepatectomy (OR 0.69, 95%CI 0.52-0.93) at a teaching hospital (OR 0.63, 95%CI 0.45-0.89) had lower odds of a non-routine discharge (all P < 0.05). HSC discharge increased over time (2004-2007 (n = 205, 68.1%) vs. 2008-2011 (n = 330, 77.8%) vs. 2012-2015 (n = 475, 81.9%); p_trend < 0.001). Over the same time period, there was a decreasing trend in 90-day readmission (2004-2007 (n = 91, 30.2%) vs. 2008-2011 (n = 107, 25.2%) vs. 2012-2015 (n = 129, 22.2%); p_trend = 0.03).

CONCLUSION

Utilization of PAC services following hepatic resection of HCC decreased by 57.0% between 2004 and 2015. These data highlight that decreased PAC utilization was not generally associated with higher readmission rates following resection of HCC.

Association of Depression with In-Patient and Post-Discharge Disposition and Expenditures Among Medicare Beneficiaries Undergoing Resection for Cancer

BACKGROUND

The impact of depression on utilization of post-discharge care and overall episode of care expenditures remains poorly defined. We sought to define the impact of depression on postoperative outcomes, including discharge disposition, as well as overall expenditures associated with the global episode of surgical care.

METHOD

The Medicare 100% Standard Analytic Files were used to identify patients undergoing resection for esophageal, colon, rectal, pancreatic, and liver cancer between 2013 and 2017. The impact of depression on inpatient outcomes, as well as home health care and skilled nursing facilities utilization and expenditures, was analyzed.

RESULTS

Among 113,263 patients, 14,618 (12.9%) individuals had depression. Patients with depression were more likely to experience postoperative complications (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.31-1.42), extended length of stay (LOS) (OR 1.41, 95% CI 1.36-1.47), readmission within 90 days (OR 1.20, 95% CI 1.14-1.25), as well as 90-day mortality (OR 1.35, 95% CI 1.27-1.42) (all p < 0.05). In turn, the proportion of patients who achieved a textbook outcome following cancer surgery was lower among patients with depression (no depression: 53.3% vs. depression: 45.3%; OR 0.70, 95% CI 0.68-0.73). Patients with a preexisting diagnosis of depression had higher odds of additional post-discharge expenditures compared with individuals without a diagnosis of depression (OR 1.42; 95% CI 1.35-1.50); patients with a preexisting diagnosis of depression ($10,500, IQR $3,200-$22,500) had higher median post-discharge expenditures versus patients without depression ($6600, IQR $2100-$17,400) (p < 0.001). On multivariable analysis, after controlling for other factors, depression remained associated with a 19.0% (95% confidence interval [CI] 15.7-22.3%) increase in post-discharge expenditures.

CONCLUSIONS

Patients with depression undergoing resection for cancer had worse in-patient outcomes and were less likely to achieve a TO. Patients with depression were more likely to require post-discharge care and had higher post-discharge expenditures.

Robotic total knee arthroplasty: A missed opportunity for cost savings in Bundled Payment for Care Improvement initiatives?

BACKGROUND

The use of robotic total knee arthroplasty has become increasingly prevalent. Proponents of robotic total knee arthroplasty tout its potential to not only improve outcomes, but also to reduce costs compared with traditional total knee arthroplasty. Despite its potential to deliver on the value proposition, whether robotic total knee arthroplasty has led to improved outcomes and cost savings within Medicare's Bundled Payment for Care Improvement initiative remains unexplored.

METHODS

Medicare beneficiaries who underwent total knee arthroplasty designated under Medicare severity diagnosis related group 469 or 470 in the year 2017 were identified using the 100% Medicare Inpatient Standard Analytic Files. Hospitals participating in the Bundled Payment for Care Improvement were identified using the Bundled Payment for Care Improvement analytic file. We calculated risk-adjusted, price-standardized payments for the surgical episode from admission through 90-days postdischarge. Outcomes, utilization, and spending were assessed relative to variation between robotic and traditional total knee arthroplasty.

RESULTS

Overall, 198,371 patients underwent total knee arthroplasty (traditional total knee arthroplasty: n= 194,020, 97.8% versus robotic total knee arthroplasty: n = 4,351, 2.2%). Among the 3,272 hospitals that performed total knee arthroplasty, only 300 (9.3%) performed robotic total knee arthroplasty. Among the 183 participating in the Bundled Payment for Care Improvement, only 40 (19%) hospitals performed robotic total knee arthroplasty. Risk-adjusted 90-day episode spending was $14,263 (95% confidence interval $14,231-$14,294) among patients who underwent traditional total knee arthroplasty versus $13,676 (95% confidence interval $13,467-$13,885) among patients who had robotic total knee arthroplasty. Patients who underwent robotic total knee arthroplasty had a shorter length of stay (traditional total knee arthroplasty: 2.3 days, 95% confidence interval: 2.3-2.3 versus robotic total knee arthroplasty: 1.9 days, 95% confidence interval: 1.9-2.0), as well as a lower incidence of complications (traditional total knee arthroplasty: 3.3%, 95% confidence interval: 3.2-3.3 versus robotic total knee arthroplasty: 2.7%, 95% confidence interval: 2.3-3.1). Of note, patients who underwent robotic total knee arthroplasty were less often discharged to a postacute care facility than patients who underwent traditional total knee arthroplasty (traditional total knee arthroplasty: 32.4%, 95% confidence interval: 32.3-32.5 versus robotic total knee arthroplasty: 16.8%, 95% confidence interval 16.1-17.6). Both Bundled Payment for Care Improvement and non-Bundled Payment for Care Improvement hospitals with greater than 50% robotic total knee arthroplasty utilization had lower spending per episode of care versus spending at hospitals with less than 50% robotic total knee arthroplasty utilization.

CONCLUSION

Overall 90-day episode spending for robotic total knee arthroplasty was lower than traditional total knee arthroplasty (Δ $-587, 95% confidence interval: $-798 to $-375). The decrease in spending was attributable to shorter length of stay, fewer complications, as well as lower utilization of postacute care facility. The cost savings associated with robotic total knee arthroplasty was only realized when robotic total knee arthroplasty volume surpassed 50% of all total knee arthroplasty volume. Hospitals participating in the Bundled Payment for Care Improvement may experience cost-saving with increased utilization of robotic total knee arthroplasty.

Post hepatectomy liver failure (PHLF) - Recent advances in prevention and clinical management

BACKGROUND

Posthepatectomy liver failure (PHLF) is a relatively rare but feared complication following liver surgery, and associated with high morbidity, mortality and cost implications. Significant advances have been made in detailed preoperative assessment, particularly of the liver function in an attempt to predict and mitigate this complication.

METHODS

A detailed search of PubMed and Medline was performed using keywords "liver failure", "liver insufficiency", "liver resection", "postoperative", and "post-hepatectomy". Only full texts published in English were considered. Particular emphasis was placed on literature published after 2015. A formal systematic review was not found feasible hence a pragmatic review was performed.

RESULTS

The reported incidence of PHLF varies widely in reported literature due to a historical absence of a universal definition. Incorporation of the now accepted definition and grading of PHLF would suggest the incidence to be between 8 and 12%. Major risk factors include background liver disease, extent of resection and intraoperative course. The vast majority of mortality associated with PHLF is related to sepsis, organ failure and cerebral events. Despite multiple attempts, there has been little progress in the definitive and specific management of liver failure. This review article discusses recent advances made in detailed preoperative evaluation of liver function and evidence-based targeted approach to managing PHLF.

CONCLUSION

PHLF remains a major cause of mortality following liver resection. In absence of a specific remedy, the best approach is mitigating the risk of it happening by detailed assessment of liver function, patient selection and general care of a critically ill patient.