The impact of statistical adjustment on economic profiles of interventional cardiologists

Variability drivers of treatment costs in hospitals: A systematic review

OBJECTIVES

Studies on variability drivers of treatment costs in hospitals can provide the necessary information for policymakers and healthcare providers seeking to redesign reimbursement schemes and improve the outcomes-over-cost ratio, respectively. This systematic literature review, focusing on the hospital perspective, provides an overview of studies focusing on variability in treatment cost, an outline of their study characteristics and cost drivers, and suggestions on future research methodology.

METHODS

We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane Handbook for Systematic Reviews of Interventions. We searched PubMED/MEDLINE, Web of Science, EMBASE, Scopus, CINAHL, Science direct, OvidSP and Cochrane library. Two investigators extracted and appraised data for citation until October 2020.

RESULTS

90 eligible articles were included. Patient, treatment and disease characteristics and, to a lesser extent, outcome and institutional characteristics were identified as significant variables explaining cost variability. In one-third of the studies, the costing method was classified as unclear due to the limited explanation provided by the authors.

CONCLUSION

Various patient, treatment and disease characteristics were identified to explain hospital cost variability. The limited transparency on how hospital costs are defined is a remarkable observation for studies wherein cost variability is the main focus. Recommendations relating to variables, costs, and statistical methods to consider when designing and conducting cost variability studies were provided.

Understanding the Extent and Drivers of Interphysician Cost Variation for Spine Procedures

STUDY DESIGN

Retrospective analysis of billing data, medical records, and hospital cost data.

OBJECTIVE

To quantify intersurgeon variation for hospital costs of four spine procedures while adjusting for patient comorbidities and demographic factors.

SUMMARY OF BACKGROUND DATA

Spine care accounts for $90 billion in health care expenditures in the United States. Past findings demonstrate regional variation in surgery rates and high intersurgeon variation for anterior cervical discectomies/fusions. However, less has been done to examine intersurgeon variation in resource use across multiple procedures while adjusting for patient characteristics outside of a surgeon's control.

METHODS

We examined intersurgeon variation for 1241 elective spine procedures at one facility for 3 years. The procedures included 1 to 2 level cases of anterior cervical discectomies/fusions, posterior lumbar decompressions/fusions, posterior laminectomies, and lumbar discectomies. We isolated mean and median costs by surgeon and adjusted for patient demographics, comorbidities, and procedure types. Finally, we examined variation in subcategories such as instrumentation and inpatient stay costs to determine which contribute to total cost variation.

RESULTS

Unadjusted costs per surgeon varied by a factor of 1.32 to 1.81 between lowest and highest cost surgeon depending on procedure. After adjusting for patient features and procedure, variation was reduced to 1.31x. Of the seven surgeons who had sufficient patient volume, one was significantly less costly (-$1,462 per procedure) whereas three were significantly more costly than mean (+$685, +$839, +$702 per procedure). Intersurgeon differences in supply and operating room costs largely accounted for total variation, though actual drivers of variation were surgeon-specific.

CONCLUSION

Surgeons vary in average cost for spine procedures, though variation is more modest once adjusted for patient characteristics. Data on procedure-level variation should be discussed with individual surgeons to shift practice patterns. Finally, the comparison methodology can be applied to other procedures and specialties.

LEVEL OF EVIDENCE

4.

Managing care? Medicare managed care and patient use of cardiologists

OBJECTIVE

To examine the impact of Medicare managed care (MMC) versus Medicare fee for service (MFFS) on stent patients' use of physicians with lower resource use and better outcomes.

DATA SOURCES/STUDY SETTING

Retrospective secondary data from 2003 through 2006 for 67,476 patients without acute myocardial infarction, staying 2 or more days in hospital, and treated by 486 physicians in Florida performing 10 or more cases per quarter.

STUDY DESIGN

Analysis was at the patient level. Multivariate logistic models estimated the probability of an MMC patient using a physician with a particular risk-adjusted profile rank with respect to hospital peers.

PRINCIPAL FINDINGS

No differences were found in usage of physicians with shorter admissions. Compared with MFFS, MMC patients were significantly less likely to use physicians whose average mortality was the lowest/lowest quartiles/below median among facility peers, and more likely to use a physician ranked below median on live discharges directly home (not needing home health care, skilled nursing care, or a subacute hospital convalescence). Similar results were found with emergency admissions, and where physicians both attended and treated.

CONCLUSIONS

Florida percutaneous coronary interventions patients insured by MMC used physicians with worse outcome profiles than those of MFFS patients. Results were not consistent with hospital care differences, physician-patient, or payor-physician selection, but they were consistent with selection of unobservably sicker members into MMC and concentration of MMC among physicians.

Influence of gender on the evaluation of internal medicine residents

OBJECTIVE

To determine if gender of resident or faculty influences performance ratings of residents on general medicine ward rotations.

METHODS

Secondary analysis from an observational cohort study of residents and faculty who participated in a randomized, controlled trial of a focused educational intervention on resident evaluations in two internal medicine residency programs. The study included 88 faculty and 160 residents (postgraduate years [PGY] 1-3) of the Yale University department of medicine assigned to inpatient general ward rotations in four different hospitals during academic year 1997-1998. The methods included a hierarchical linear model (HLM) with the male faculty-male resident dyad as reference comparison to investigate the influence of gender on numeric ratings in four domains of competence.

RESULTS

Seventy male and 18 female faculty provided 262 resident evaluations during the study. Factor analysis identified four distinct domains of competence (interpersonal skills, teaching, clinical performance, overall performance). After adjustment for potential confounders, no significant gender influences in evaluation were found in any domain, and there was no consistent pattern of a gender effect on evaluation for the observed trends.

CONCLUSIONS

Our results did not identify any gender effects influencing evaluation of residents rotating on a general medicine ward service. If gender influences are present within the evaluation process, identification will likely require more sophisticated methodology to tease apart. Future research incorporating direct observation and qualitative methods may be helpful in delineating potential gender influences on performance evaluation.

A practical cost analysis of bivalirudin

Despite advances in percutaneous coronary intervention (PCI) techniques and adjunctive therapies, the risks of ischemic and bleeding complications with PCI remain significant. These complications are associated with significant morbidity and mortality, as well as substantially higher costs. Bivalirudin is the only antithrombotic agent that has been shown to reduce both ischemic and hemorrhagic complications associated with PCI. Cost models drawn from the results of three clinical trials of bivalirudin have estimated its potential impact on total medical costs. In addition, the number needed to treat to avoid a bleeding complication has been calculated based on patients shown to have a heightened risk of bleeding in the Bivalirudin Angioplasty Trial. In all models assessed, the use of bivalirudin offset most of its own cost through reductions in bleeding and ischemic complications.