Hospital Teaching Status and Medicare Expenditures for Complex Surgery

Market Factors, Not Quality, Influence Reimbursement for Pancreaticoduodenectomy in an Era of Price Transparency

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) price transparency rule tries to facilitate cost-conscious decision-making. For surgical services, such as pancreaticoduodenectomy (PD), factors mediating transparency and real-world reimbursement are not well described.

METHODS

The Leapfrog Survey was used to identify United States hospitals performing PD. Financial and operational data were obtained from Turquoise Health and CMS Cost Reports. Chi-square tests and modified Poisson regression evaluated associations with reimbursement disclosure. Two-part logistic and gamma regression models estimated effects of hospital factors on commercial, Medicare, and self-pay reimbursements for PD.

RESULTS

Of 452 Leapfrog hospitals, 295 (65%) disclosed PD hospital or procedure reimbursements. Disclosing hospitals were larger (beds > 200: 81.0% vs. 71.3%, p = 0.04), reported higher net margins (0.7% vs. - 2.1%, p = 0.04), more likely for-profit (26.1% vs. 6.4%, p < 0.001), and teaching-affiliated (82.0% vs. 65.6%, p < 0.001). Nonprofit status conferred hospitalization reimbursement increases of $8683-$12,329, while moderate market concentration predicted savings up to $5066. Teaching affiliation conferred reimbursement increases of $4589-$16,393 for hospitalizations and $644 for procedures. Top Leapfrog volume ratings predicted an increase of up to $7795 for only Medicare hospitalization reimbursement.

CONCLUSIONS

Nondisclosure of hospital and procedural reimbursements for PD remains a major issue. Transparency was noted in hospitals with higher margins, size, and academic affiliation. Factors associated with higher reimbursement were non-profit status, academic affiliation, and more equitable market share. Reimbursement inconsistently tracked with PD quality or volume measures. Policy changes may be required to incentivize reimbursement disclosure and translate transparency into increased value for patients.

Hospital teaching status is an independent predictor of surgical intervention of distal radius fractures

Background

Distal radius fractures are among the most common orthopaedic injuries and are managed both surgically and non-surgically. To date, no study has examined the role hospital teaching status plays in the rates of surgical intervention.

Methods

The Nationwide Inpatient Sample (NIS) was queried for years 2003-2014. Patients with a distal radius fracture were identified using International Classification for Disease, Ninth Revision (ICD-9) disease codes. Surgical intervention was determined using ICD-9 procedure codes. Exclusion criteria were patients younger than age 18, polytrauma, open fractures, records with missing data, and records where the primary procedure was something other than open reduction of a radius or ulna fracture, closed reduction of a radius or ulna fracture, or blank. Chi-squared tests were run for demographic and socioeconomic data to identify significant variables. Significant variables were then included alongside hospital teaching status in a binomial logistic regression model. Significance was defined as P < 0.05.

Results

A weighted total of 98,831 patients were included in the study. Of those, 45,234 (45.8 %) were treated at teaching hospitals. Patients in teaching hospitals were more likely to be younger, male, non-white, and non-Medicare insured than non-teaching hospitals. Injuries were treated surgically in 64.6 % of total cases. Surgical intervention was more common in teaching hospitals than non-teaching hospitals (69.1 % vs. 60.8 %, P < 0.01). After controlling for demographic and socioeconomic factors, patients at teaching hospitals were 31 % more likely to undergo surgical treatment than those at non-teaching hospitals. Other factors that were independently predictive of surgical treatment were age, race, and insurance type.

Conclusion

In the setting of distal radius fractures, teaching hospitals have higher rates of surgical intervention than non-teaching hospitals. These results suggest that the involvement of medical trainees may play a role in the surgical decision-making process.

Delving into public-expenditure elasticity: Evidence from a National Health Service acute-care hospital network

INTRODUCTION

The sustainability of public hospital financing in Spain is a recurring issue, given its representativeness in annual public healthcare budgets which must adapt to the macroeconomic challenges that influence the evolution of spending. Knowing whether the responsiveness of hospital expenditure to its determinants (need, utilisation, and quasi-prices) varies according to the type of hospital could help better design strategies aimed at optimising performance.

METHODS

Using SARIMAX models, we dynamically assess unique nationwide monthly activity data over a 14-year period from 274 acute-care hospitals in the Spanish National Health Service network, clustering these providers according to the average severity of the episodes treated.

RESULTS

All groups showed seasonal patterns and increasing trends in the evolution of expenditure. The fourth quartile of hospitals, treating the most severe episodes and accounting for more than 50% of expenditure, is the most sensitive to quasi-price factors, particularly the number of beds per hospital. Meanwhile, the first quartile of hospitals, which treat the least severe episodes and account for 10% of expenditure, is most sensitive to quantity factors, for which expenditure showed an elasticity above one, while factors of production were not affected.

CONCLUSIONS

Belonging to one or another cluster of hospitals means that the determinants of expenditure have a different impact and intensity. The system should focus on these differences in order to optimally modulate expenditure not only according to the needs of the population, but also according to the macroeconomic situation, while leaving hospitals room for manoeuvre in case of unforeseen events. The findings suggest strengthening a network of smaller hospitals (Group 1)-closer to their reference population, focused on managing and responding to chronicity and stabilising acute events-prior to transfer to tertiary hospitals (Group 4)-larger but appropriately sized, specialising in solving acute and complex health problems-when needed.

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.

Association of Skilled Nursing Facility Ownership by Health Care Networks With Utilization and Spending

IMPORTANCE

Health care mergers and acquisitions have increased vertical integration of skilled nursing facilities (SNFs) in health care networks. While vertical integration may result in improved care coordination and quality, it may also lead to excess utilization, as SNFs are paid a per diem rate.

OBJECTIVE

To determine the association of vertical integration of SNFs within hospital networks with SNF utilization, readmissions, and spending for Medicare beneficiaries undergoing elective hip replacement.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study evaluated 100% Medicare administrative claims for nonfederal acute care hospitals performing at least 10 elective hip replacements during the study period. Fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent elective hip replacement between January 1, 2016, and December 31, 2017, with continuous Medicare coverage for 3 months before and 6 months after surgery were included. Data were analyzed from February 2 to August 8, 2022.

EXPOSURES

Treatment at a hospital within a network that also owns at least 1 SNF based on the 2017 American Hospital Association survey.

MAIN OUTCOMES AND MEASURES

Rates of SNF utilization, 30-day readmissions, and price-standardized 30-day episode payments. Hierarchical multivariable logistic and linear regression clustered at hospitals was performed with adjusting for patient, hospital, and network characteristics.

RESULTS

A total of 150 788 patients (61.4% women; mean [SD] age, 74.3 [6.4] years) underwent hip replacement. After risk adjustment, vertical SNF integration was associated with a higher rate of SNF utilization (21.7% [95% CI, 20.4%-23.0%] vs 19.7% [95% CI, 18.7%-20.7%]; adjusted odds ratio [aOR], 1.15 [95% CI, 1.03-1.29]; P = .01) and lower 30-day readmission rate (5.6% [95% CI, 5.4%-5.8%] vs 5.9% [95% CI, 5.7%-6.1%]; aOR, 0.94 [95% CI, 0.89-0.99]; P = .03). Despite higher SNF utilization, the total adjusted 30-day episode payments were slightly lower ($20 230 [95% CI, $20 035-$20 425] vs $20 487 [95% CI, $20 314-$20 660]; difference, -$275 [95% CI, -$15 to -$498]; P = .04) driven by lower postacute payments and shorter SNF length of stays. Adjusted readmission rates were particularly low for patients not sent to an SNF (3.6% [95% CI, 3.4%-3.7%]; P < .001) but were significantly higher for patients with an SNF length of stay less than 5 days (41.3% [95% CI, 39.2%-43.3%]; P < .001).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of Medicare beneficiaries undergoing elective hip replacements, vertical integration of SNFs in a hospital network was associated with higher rates of SNF utilization and lower rates of readmissions without evidence of higher overall episode payments. These findings support the purported value of integrating SNFs into hospital networks but also suggest that there is room for improving the postoperative care of patients in SNFs early in their stay.

Total Ankle Arthroplasty Can Be Safely and Effectively Performed in the Community Hospital Setting: A Case Series of 65 Patients

The use of total ankle arthroplasty has expanded over the past decade, primarily due to improvements in implant design and survivorship that have significantly reduced the high failure rates observed in first-generation implants. A retrospective review of 65 consecutive patients undergoing primary total ankle arthroplasty with a single senior orthopedic surgeon in a community hospital from January 2014 to December 2019 was performed. All procedures were performed for end stage osteoarthritis, with the most common secondary diagnoses being Achilles contracture (23%), retained hardware (17%) and calcaneovalgus deformity (11%). Preoperatively, patients averaged 10.45 ̊ ± 10.00 ̊ of non-weightbearing dorsiflexion and 30.00 ̊ ± 8.79 ̊ of plantarflexion. Postoperatively, patients averaged 13.33 ̊ ± 7.62 ̊ dorsiflexion, and 25.48 ̊ ± 7.87 ̊ of plantarflexion. A total of 8 (12.3%) patients required reoperation, and average time to reoperation was 1.55 ± 1.58 years. Implant failure, defined as reoperation requiring prosthesis removal, occurred in 2 (3.1%) patients, with an average time to failure of 342 days (105 days in failure due to periprosthetic joint infection and 582 days in failure due to subsidence). Patients undergoing total ankle arthroplasty at our institution had a 12.3% reoperation rate, and a 96.9% implant survival rate over an average follow-up period of 2.42 years, results that compare favorably with previously reported outcomes. Based on these findings, we suggest that this procedure, which is often offered only in academic tertiary care facilities, can be safely and effectively performed by experienced surgeons in the community hospital setting.

Association of Dual Medicare and Medicaid Eligibility With Outcomes and Spending for Cancer Surgery in High-Quality Hospitals

IMPORTANCE

Although dual eligibility (DE) status for Medicare and Medicaid has been used for social risk stratification in value-based payment programs, little is known about the interplay between hospital quality and disparities in outcomes and spending by social risk.

OBJECTIVE

To assess whether treatment at high-quality hospitals mitigates DE-associated disparities in outcomes and spending for cancer surgery.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study from January 1, 2014, to December 31, 2018, evaluating inpatient surgery at acute care hospitals. A total of 119 757 Medicare beneficiaries aged 65 years or older who underwent colectomy, rectal resection, lung resection, or pancreatectomy were evaluated. Data were analyzed between November 1, 2020, and April 30, 2021.

EXPOSURES

Medicare and Medicaid DE status and hospital quality.

MAIN OUTCOMES AND MEASURES

Postoperative complications, readmission, and mortality by DE status and hospital quality.

RESULTS

Overall, 119 757 Medicare beneficiaries underwent colectomy, rectal resection, lung resection, or pancreatectomy. The mean (SD) age was 75.3 (6.7) years, 61 617 (51.5%) were women, 7677 (6.4%) were Black, 106 099 (88.6%) were White, and 5981 (5.0%) identified as another race or ethnicity; 11.3% had DE status. Dually eligible patients were more likely to be discharged to a facility (colectomy, 15.0% [95% CI, 14.7%-15.3%] vs 23.9% [95% CI, 22.9%-24.9%]; proctectomy, 18.7% [95% CI, 18.0%-19.3%] vs 26.9% [95% CI, 24.9%-28.9%]; lung resection, 11.0% [95% CI, 10.7%-11.3%] vs 17.9% [95% CI, 16.8%-18.9%]; pancreatectomy, 23.5% [95% CI, 22.5%-24.4%] vs 30.0% [95% CI, 26.5%-33.5%]). Differences in postacute care use persisted even after accounting for postoperative complications and contributed to variation in spending. Compared with the lowest-quality hospitals, DE patients had improved rates of discharge to a facility (22.7% vs 19.3%) and spending ($22 577 vs $20 100) but rates remained increased compared with Medicare patients even at the highest-quality hospitals.

CONCLUSIONS AND RELEVANCE

The findings of this study indicate that, even among the highest-quality hospitals, DE patients had poorer outcomes and higher spending. Dually eligible patients were more likely to be discharged to a facility and therefore incurred higher postacute care costs. Although treatment at high-quality hospitals is associated with reduced differences in outcomes, DE patients remain at high risk for adverse postoperative outcomes and increased readmissions and postacute care use.

Pancreatic Neuroendocrine Tumors: The Effect of Facility Type on Patient Survival

OBJECTIVES

During the last decades, significant progress has been made in the management of patients with pancreatic neuroendocrine tumors (pNETs). It is unclear how the type of the treating health care facility alters patient outcomes.

METHODS

Data from pNETs reported to the National Cancer Database between 2004 and 2016 were examined. Types of institutions were as follows: academic/research cancer program (ARP), comprehensive community cancer program (CCCP), integrated network cancer program (INCP), and community cancer program (CCP).

RESULTS

A total of 17,887 patients with pNETs were analyzed. Treatment at ARPs was significantly associated with receipt of surgery (ARP, 61.9%; CCCP, 45.6%; CCP, 29.9%; INCP, 55.5%; P < 0.001), both for patients with very early tumors ≤2 cm (ARP, 74.7%; CCCP, 66.5%; CCP, 52.4%; INCP, 71.6%; P < 0.001) and for patients with liver metastases (ARP, 21.3%; CCCP, 10.6%; CCP, 5%; INCP, 16.8%; P < 0.001). Treatment at ARPs was associated with improved survival (median overall survival: ARP, 91 mo; CCCP, 47 mo; CCP, 24.5 mo; INCP, 72 mo; P < 0.001).

CONCLUSIONS

Treatment of pNETs at academic/research programs is associated with more frequent resections and best survival outcomes. This survival benefit exists for early and late stages and after adjusting for known cofactors.

Association of Beneficiary-Level Risk Factors and Hospital-Level Characteristics With Medicare Part B Drug Spending Differences Between 340B and Non-340B Hospitals

Importance

Critics of the federal 340B Drug Pricing Program raised concerns that the program might provide financial incentives for participating hospitals to prescribe more and/or more expensive drugs because the revenue generated from Medicare reimbursement exceeds the purchase price by a substantial margin. Studies showing higher Medicare Part B drug spending at hospitals that are 340B hospitals, which can purchase outpatient drugs from manufacturers at discounted prices, compared with non-340B hospitals were used by the Centers for Medicare & Medicaid Services to justify their 340B payment policy that reduced Medicare payments for drugs in the 340B program in 2018 and thereafter. The Centers for Medicare & Medicaid Services attributed higher spending to the 340B benefit and believed that payment cuts would reduce the financial incentives associated with higher spending. However, the lack of sufficient risk adjustments is a significant concern of study validity.

Objective

To examine whether per-beneficiary Medicare Part B drug spending is significantly different between 340B and non-340B hospitals while adequately controlling for patient-level and hospital-level risk factors.

Design, Setting, and Participants

A cross-sectional study was conducted from October 1, 2020, to May 30, 2021, using 2017 administrative claims data from a random 5% sample of Medicare fee-for-service beneficiaries. Included beneficiaries had at least 1 separately payable non-pass-through drug claim in 2017, were fully enrolled in Part A and Part B through 2017, and did not die in 2017.

Main Outcomes and Measures

The outcome was separately payable Part B drug spending.

Results

The sample included 35 364 beneficiaries (21 825 women [61.7%]; 29 996 White patients [84.8%]; mean [SD] age, 70.6 [12.0] years) and 2446 hospitals. A total of 918 hospitals (37.5%) were in the 340B program and 938 hospitals (38.3%) were teaching hospitals. There was a higher percentage of teaching hospitals among 340B hospitals (517 of 918 [56.3%]) than non-340B hospitals (421 of 1528 [27.6%]), and beneficiaries who went to 340B hospitals were more likely to be non-White than those who went to non-340B hospitals (3360 of 19 139 [17.6%] vs 1583 of 13 710 [11.5%]). The Part B drug spending difference between 340B and non-340B hospitals was not statistically significant after controlling for beneficiary-level risk factors and hospital-level characteristics ($568; 95% CI, -$283 to $1419; P = .19).

Conclusions and Relevance

The results show that the differences in patient population and hospital-level characteristics may explain drug spending differences between 340B and non-340B hospitals, which raises doubt about the financial incentive theory of the 340B program drug discount and the justification for the Centers for Medicare & Medicaid Services's 340B payment policy.

Relationship Between Health Care Spending and Clinical Outcomes in Bariatric Surgery: Implications for Medicare Bundled Payments

OBJECTIVE

To evaluate sources of 90-day episode spending variation in Medicare patients undergoing bariatric surgery and whether spending variation was related to quality of care.

SUMMARY OF BACKGROUND DATA

Medicare's bundled payments for care improvement-advanced program includes the first large-scale episodic bundling program for bariatric surgery. This voluntary program will pay bariatric programs a bonus if 90-day spending after surgery falls below a predetermined target. It is unclear what share of bariatric episode spending may be due to unnecessary variation and thus modifiable through care improvement.

METHODS

Retrospective analysis of fee-for-service Medicare claims data from 761 acute care hospitals providing inpatient bariatric surgery between January 1, 2011 and September 30, 2016. We measured associations between patient and hospital factors, clinical outcomes, and total Medicare spending for the 90-day bariatric surgery episode using multivariable regression models.

RESULTS

Of 64,537 patients, 46% underwent sleeve gastrectomy, 22% revisited the emergency department (ED) within 90 days, and 12.5% were readmitted. Average 90-day episode payments were $14,124, ranging from $12,220 at the lowest-spending quintile of hospitals to $16,887 at the highest-spending quintile. After risk adjustment, 90-day episode spending was $11,447 at the lowest quintile versus $15,380 at the highest quintile (difference $3932, P < 0.001). The largest components of spending variation were readmissions (44% of variation, or $2043 per episode), post-acute care (19% or $871), and index professional fees (15% or $450). The lowest spending hospitals had the lowest complication, ED visit, post-acute utilization, and readmission rates (P < 0.001).

CONCLUSIONS AND RELEVANCE

In this retrospective analysis of Medicare patients undergoing bariatric surgery, the largest components of 90-day episode spending variation are readmissions, inpatient professional fees, and post-acute care utilization. Hospitals with lower spending were associated with lower rates of complications, ED visits, post-acute utilization, and readmissions. Incentives for improving outcomes and reducing spending seem to be well-aligned in Medicare's bundled payment initiative for bariatric surgery.

Association of Teaching Status and Mortality After Cancer Surgery

OBJECTIVE

To examine patient outcomes for nine cancer-specific procedures performed in teaching versus non-teaching hospitals.

SUMMARY BACKGROUND DATA

Few contemporary studies have evaluated patient outcomes in teaching versus non-teaching hospitals across a comprehensive set of cancer-specific procedures.

METHODS

Use of national Medicare data to compare 30-, 60-, and 90-day mortality rates in teaching and non-teaching hospitals for cancer-specific procedures. Risk-adjusted 30-day, all-cause, postoperative mortality overall and for each specific surgery, as well as overall 60- and 90-day mortality rates, were assessed.

RESULTS

The sample consisted of 159,421 total cancer surgeries at 3,151 hospitals. Overall thirty-day mortality rates, adjusted for procedure type, state, and invasiveness of procedure were 1.3% lower at major teaching hospitals (95%CI=-1.6% to -1.1%; p<0.001) relative to non-teaching hospitals. After accounting for patient characteristics, major teaching hospitals continued to demonstrate lower mortality rates compared with non-teaching hospitals (-1.0% difference [95%CI -1.2% to -0.7%]; p<0.001). Further adjustment for surgical volume as a mediator reduced the difference to -0.7% (95%CI -0.9% to -0.4%, p<0.001). Cancer surgeries for four of the nine disease sites (bladder, lung, colorectal and ovarian) followed this overall trend. Sixty- and ninety-day overall mortality rates, adjusted for procedure type, state, and invasiveness of procedure showed that major teaching hospitals had a 1.7% (95%CI -2.1% to -1.4%; p<0.001) and 2.0% (95%CI -2.4 to -1.6%, p<0.001) lower mortality relative to non-teaching hospitals. These trends persisted after adjusting for patient characteristics.

CONCLUSIONS

Among cancer-specific procedures for Medicare beneficiaries, major teaching hospital status was associated with lower 30-, 60-, and 90-day mortality rates overall and across four of the nine cancer types.

Patient Social Vulnerability and Hospital Community Racial/Ethnic Integration: Do All Patients Undergoing Pancreatectomy Receive the Same Care Across Hospitals?

OBJECTIVE

The objective of the current study was to characterize the role of patient social vulnerability relative to hospital racial/ethnic integration on postoperative outcomes among patients undergoing pancreatectomy.

BACKGROUND

The interplay between patient- and community-level factors on outcomes after complex surgery has not been well-examined.

METHODS

Medicare beneficiaries who underwent a pancreatectomy between 2013 and 2017 were identified utilizing 100% Medicare inpatient files. P-SVI was determined using the Centers for Disease Control and Prevention criteria, whereas H-REI was estimated using Shannon Diversity Index. Impact of P-SVI and H-REI on "TO" [ie, no surgical complication/extended length-of-stay (LOS)/90-day mortality/90-day readmission] was assessed.

RESULTS

Among 24,500 beneficiaries who underwent pancreatectomy, 12,890 (52.6%) were male and median age was 72 years (Interquartile range: 68-77); 10,619 (43.3%) patients achieved a TO. The most common adverse postoperative outcome was 90-day readmission (n = 8,066, 32.9%), whereas the least common was 90-day mortality (n = 2282, 9.3%). Complications and extended LOS occurred in 30.4% (n = 7450) and 23.3% (n = 5699) of the cohort, respectively. Patients from an above average SVI county who underwent surgery at a below average REI hospital had 18% lower odds [95% confidence interval (CI): 0.74-0.95] of achieving a TO compared with patients from a below average SVI county who underwent surgery at a hospital with above average REI. Of note, patients from the highest SVI areas who underwent pancreatectomy at hospitals with the lowest REI had 30% lower odds (95% CI: 0.54-0.91) of achieving a TO compared with patients from very low SVI areas who underwent surgery at a hospital with high REI. Further comparisons of these 2 patient groups indicated 76% increased odds of 90-day mortality (95% CI: 1.10-2.82) and 50% increased odds of an extended LOS (95% CI: 1.07-2.11).

CONCLUSION

Patients with high social vulnerability who underwent pancreatectomy in hospitals located in communities with low racial/ethnic integration had the lowest chance to achieve an "optimal" TO. A focus on both patient- and community-level factors is needed to ensure optimal and equitable patient outcomes.

A higher hospital case mix index increases the odds of achieving a textbook outcome after hepatopancreatic surgery in the Medicare population

BACKGROUND

The objective of the current study was to assess the impact of case mix index at the hospital level on postoperative outcomes among Medicare beneficiaries who underwent hepatopancreatic surgery.

METHODS

Medicare beneficiaries who underwent hepatopancreatic surgery between 2013 and 2017 were identified and analyzed. The primary independent variable, Case Mix Index, is a freely available metric; the primary outcome was textbook outcome defined as the absence of complications, extended length of stay, readmission, and mortality.

RESULTS

Among 37,412 Medicare beneficiaries, 64.9% (n = 24,299) underwent a pancreatectomy and 35.1% (n = 13,113) underwent hepatectomy. The overall incidence of textbook outcome was 47.2%, which varied by case mix index (low case mix index: 41.6% vs high case mix index: 51.3%), as did extended length of stay (low case mix index: 27.9% versus high case mix index: 19.3%), complications (low case mix index: 33.3% vs high case mix index: 24.7%), and 90-day mortality (low case mix index: 12.5% vs high case mix index: 6.3%). After controlling for hepatopancreatic-specific surgical volume and hospital teaching status, multivariable analyses revealed that patients who underwent surgery at a low case mix index hospital had 28% decreased odds (95% confidence interval 0.66-0.79) of achieving a textbook outcome versus patients from a high case mix index hospital. Moreover, patients at a low case mix index hospital had 39% increased odds of extended length of stay (95% confidence interval 1.23-1.59), 48% increased odds of experiencing a complication (95% confidence interval 1.32-1.65), and 56% increased odds of 90-day mortality (95% confidence interval 1.31-1.87).

CONCLUSION

Case mix index was strongly associated with the probability of achieving a textbook outcome after hepatopancreatic surgery. Hospitals with a higher case mix index were more likely to perform hepatopancreatic surgeries with no adverse postoperative outcomes.

Quality and Cost of Care by Hospital Teaching Status: What Are the Differences?

Policy Points In two respects, quality of care tends to be higher at major teaching hospitals: process of care and long-term survival of cancer patients following initial diagnosis. There is also evidence that short-term (30-day) mortality is lower on average at such hospitals, although the quality of evidence is somewhat lower. Quality of care is mulitdimensional. Empirical evidence by teaching status on dimensions other than survival is mixed. Higher Medicare payments for care provided by major teaching hospitals are partially offset by lower payments to nonhospital providers. Nevertheless, the payment differences between major teaching and nonteaching hospitals for hospital stays, especially for complex cases, potentially increase prices other insurers pay for hospital care.

CONTEXT

The relative performance of teaching hospitals has been discussed for decades. For private and public insurers with provider networks, an issue is whether having a major teaching hospital in the network is a "must." For traditional fee-for-service Medicare, there is an issue of adequacy of payment of hospitals with various attributes, including graduate medical education (GME) provision. Much empirical evidence on relative quality and cost has been published. This paper aims to (1) evaluate empirical evidence on relative quality and cost of teaching hospitals and (2) assess what the findings indicate for public and private insurer policy.

METHODS

Complementary approaches were used to select studies for review. (1) Relevant studies highly cited in Web of Science were selected. (2) This search led to studies cited by these studies as well as studies that cited these studies. (3) Several literature reviews were helpful in locating pertinent studies. Some policy-oriented papers were found in Google under topics to which the policy applied. (4) Several papers were added based on suggestions of reviewers.

FINDINGS

Quality of care as measured in process of care studies and in longitudinal studies of long-term survival of cancer patients tends to be higher at major teaching hospitals. Evidence on survival at 30 days post admission for common conditions and procedures also tends to favor such hospitals. Findings on other dimensions of relative quality are mixed. Hospitals with a substantial commitment to graduate medical education, major teaching hospitals, are about 10% to 20% more costly than nonteaching hospitals. Private insurers pay a differential to major teaching hospitals at this range's lower end. Inclusive of subsidies, Medicare pays major teaching hospitals substantially more than 20% extra, especially for complex surgical procedures.

CONCLUSIONS

Based on the evidence on quality, there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. Medicare payment for GME has long been a controversial policy issue. The actual indirect cost of GME is likely to be far less than the amount Medicare is currently paying hospitals.

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.

Quality Versus Costs Related to Gastrointestinal Surgery: Disentangling the Value Proposition

BACKGROUND

There has been a dramatic increase in worldwide health care spending over the last several decades. Operative procedures and perioperative care in the USA represent some of the most expensive episodes per patient. In view of both the rising cost of health care in general and the rising cost of surgical care specifically, policymakers and stakeholders have sought to identify ways to increase the value-improving quality of care while controlling (or diminishing) costs. In this context, we reviewed data relative to achieving the "value proposition" in the delivery of gastrointestinal surgical care.

METHODS

The National Library of Medicine online repository (PubMed) was text searched for human studies including "cost," "quality," "outcomes," "health care," "surgery," and "value." Results from this literature framed by the Donabedian conceptual model (identifying structures, processes, and outcomes), and the resulting impact of efforts to improve quality on costs.

RESULTS

The relationship between quality and costs was nuanced. Better quality care, though associated with better outcomes, was not always reported as concomitant with low costs. Moreover, some centers reported higher costs of surgical care commensurate with higher quality. Conversely, higher costs in health care delivery were not always linked to improved outcomes. While higher quality surgical care can lead to lower costs, higher costs of care were not necessarily associated with better outcomes. Strategies to improve quality, reduce cost, or achieve both simultaneously included regionalization of complex operations to high-volume centers of excellence, overall reduction in complications, introducing evidence-based improvements in perioperative care pathways including as enhanced recovery after surgery (ERAS), and elimination of inefficient or low-value care.

CONCLUSIONS

The relationship between quality and cost following gastrointestinal surgical procedure is complex. Data from the current study should serve to highlight the various means available to improve the value proposition related to surgery, as well as encourage surgeons to become more engaged in the national conversation around the Triple Aim of better health care quality, lower costs, and improved health care outcomes.

Variations in surgical spending within hospital systems for complex cancer surgery

BACKGROUND

Approximately 70% of hospitals today are part of larger health systems. Proponents of hospital consolidation tout its potential to reduce health spending and improve outcomes, but to the authors' knowledge the available evidence has suggested that this promise is unrealized. Variations in costs and outcomes within systems may highlight opportunities for collaborative quality improvement and practice standardization. To assess this potential, the authors sought to measure variations in episode spending within and across hospital systems among Medicare beneficiaries undergoing complex cancer surgery.

METHODS

Using 100% Medicare claims data, the authors identified fee-for-service Medicare patients who were undergoing elective pancreatectomy, lung resection, or colectomy for cancer from 2014 through 2016. Risk-adjusted, price-standardized payments for the surgical episode from admission through 30 days after discharge were calculated. The authors then assessed the reliability-adjusted variations at the hospital and system levels.

RESULTS

Average episode payments varied nearly as much within hospital systems for pancreatectomy ($1946 between the lowest and highest spending systems; 95% CI, $1910-$1972), lung resection ($625 between the lowest and highest spending systems; 95% CI, $621-$630), and colectomy ($813 between the lowest and highest spending systems; 95% CI, $809-$817) as they did between the lowest and highest spending hospitals (pancreatectomy: $2034; lung resection: $1789; and colectomy: $770). For pancreatectomy, this variation was driven by index hospitalization spending whereas both index hospitalization and postacute care use drove variations for lung resection and colectomy.

CONCLUSIONS

In this analysis of Medicare patients undergoing complex cancer surgery, wide variations in surgical episode spending were noted both within and across hospital systems. System leaders may seek to better understand variations in practices among their hospitals to standardize care and reduce variations in outcomes, use, and costs.

Determinants of 90-day readmission following ventral hernia repair with and without myocutaneous flap reconstruction: a National Readmissions Database analysis

BACKGROUND

Readmission status is an important clinical component of healthcare outcomes. 90-day readmission following complex open ventral hernia repair has not been well studied with national level data. This study aims to compare readmission rates for patients undergoing standard vs. complex (myocutaneous flap-based) ventral hernia repair. We hypothesize that complexity of reconstruction will be an independent predictor of readmission after ventral hernia repair.

METHODS

A retrospective cohort study was performed with 1:1 matching of hernia repair type using the National Readmissions Database. Patients were selected using ICD-9 codes corresponding to ventral hernia repair with or without myocutaneous flap. 90-day readmissions were determined on patients within the first through third quarters of each year. After matching, a multivariable logistic regression analysis was performed using confounding variables including hospital setting, comorbidities, type of repair, urgency of repair, sociodemographic status, and payer. Likelihood of 90-day readmission was calculated from odds ratios.

RESULTS

Readmission rates were 19.1% (38,313 out of 200,266) and 22.5% (692 out of 3075) at 90-day for standard ventral hernia repair and complex ventral hernia repair, respectively. 3116 standard ventral hernia repair patients were matched with 3074 complex ventral hernia repair patients. After matching there was a significantly increased readmission rate for repairs involving myocutaneous flaps, with odds ratio (OR) 1.30 (95% CI 1.22-1.60). Payer status (OR 1.82; 95% CI 1.21-2.74), teaching hospital status (OR 1.42; 95% CI 1.23-1.64) and income quartile (OR 1.35; CI 1.10-1.65) were independent predictors of readmission.

CONCLUSIONS

Patients undergoing myocutaneous flap-based reconstruction have higher readmission rates than those undergoing less complex ventral hernia repair. Socioeconomic disparity as reflected in payer status is a particularly strong predictor of readmission. The data support the concept that focused efforts are needed to optimize patient outcomes for patients requiring more complex repair, including socioeconomically disadvantaged patient populations.

Photocatalytic Activity of Zn x Mn3-x O4 Oxides and ZnO Prepared From Spent Alkaline Batteries

Oxides with Zn x Mn3-xO4 stoichiometries and ZnO were synthesized from the "black mass" material recovered from spent alkaline batteries. The oxides were characterized by XRF, XRD with Rietveld refinement, SEM, and TEM methods. Optical characterization included diffuse reflectance (DRS) and photoluminescence (PL) measurements. ZnO presented a clear band edge in the UV region, and PL signals were detected. The Zn/Mn oxides showed strong absorption in the UV region and a continuous absorption band in the Vis-IR regions. There is a non-detected PL signal due to excited charges being trapped on sub-band energy states and/or transfer by non-radiative paths. Photocatalytic activity under both irradiation conditions was evaluated using the resazurin dye test, terephthalic acid fluorescence probe method, and NOx air purification evaluation. In the three photoactivity tests, ZnO performed well under both UV and Vis irradiation, whereas no evidence of any appreciable photocatalytic activity was observed for the Zn/Mn oxides. The results are discussed in terms of the findings of previously reported optical measurements.

Clavien-Dindo Analysis of NSQIP Data Objectively Measures Patient-Focused Quality

Current quality measures intended to drive improved clinical performance are perceived as an inappropriate administrative burden. Surgeon-constructed quality measures, including the NSQIP, are more closely aligned with provider performance and relevant outcome. We hypothesized that NSQIP participation would be associated with measurable improvement in surgical outcomes. Elective general surgical cases were compared by case volume and incidence of postoperative adverse events (AEs) from 2014 to 2017. Using the Clavien-Dindo severity scaling system, we summed the grades for each AE and defined the patient population burden of these AEs as this sum divided by case volume. Case volume samples increased 67 per cent from 2014 (n = 526, 30 day complete) to 2017 (n = 878). Ratio of patient burden to case volume improved from 0.92 (2014) to 0.73 (2017). Comparison of AE incidence was not significantly different; however, the majority decreased over time. Analysis of individual AE interval change identified sepsis-related respiratory care as the top priority performance improvement target. These data reflect improved performance for a growing volume of surgical procedures. The impact of perioperative morbidity and their associated burden on affected patients has decreased, demonstrating the value of combining NSQIP with Clavien-Dindo to measure the quality of surgical care in objective and patient-specific terms.

Relationship between Hospital Characteristics and Value-Based Program Measure Performance: A Literature Review

Determining if the Centers for Medicare and Medicaid's value-based programs accurately represent the quality of care provided by acute-care hospitals is critical. We performed an integrative literature review to summarize research articles examining hospital characteristics associated with overall performance on the value-based program measures. The literature review was conducted by searching the PubMed and CINAHL databases. The initial search returned 18 relevant articles, 12 of which met all inclusion criteria. The emergent hospital characteristics that heavily influenced value-based program performance included size, safety-net status, geographical location, and teaching status. This review determined that many factors largely outside of acute-care hospitals' control create observed differences in value-based program performance. Additional factors such as a hospital's patient populations, socioeconomic status, and level of acuity may need to be considered prior to assigning financial penalties to under-performing hospitals.

Variation in value among hospitals performing complex cancer operations

BACKGROUND

While variation in outcomes has driven centralization of complex cancer surgery, variation in cost and value remains unexplored. We evaluated outcomes relative to cost among hospitals performing esophageal and pancreatic resection for cancer.

METHODS

Using 100% Medicare claims data, we identified fee-for-service Medicare patients undergoing elective esophagectomy and pancreatectomy for cancer from 2014 to 2016. Risk- and reliability-adjusted, price-standardized payments for the surgical episode from admission through 30 days post discharge, as well as risk- and reliability-adjusted complication rates for each hospital, were calculated. Hospitals were separated into quintiles relative to payments and outcomes. Highest-value hospitals were defined as hospitals in the top 2 quartiles for both cost and outcomes.

RESULTS

Among 11,586 Medicare beneficiaries who underwent a complex oncologic operation between 2014 and 2016, 66% had a pancreatic neoplasm, while 33% had an esophageal neoplasm. Overall, 31.1% patients underwent an operation at a high-value hospital. Among patients who underwent pancreatectomy, the risk-adjusted postoperative complication rate was 31.4% at the lowest-value hospitals vs 22.7% at highest-value hospitals (odds ratio: 0.57, 95% confidence interval 0.47-0.70). The esophagectomy, risk-adjusted postoperative complication rate was 48.3% at lowest-value hospitals versus 29.8% at highest-value hospitals (odds ratio: 0.36, 95% confidence interval 0.27-0.47). The average difference in episode cost of care for an esophagectomy at lowest- versus highest-value hospitals was $5,617; the difference for pancreatectomy was $2,748.

CONCLUSION

There was wide variation in complication rates and average costs among lowest- versus highest-value hospitals performing esophagectomy and pancreatectomy for cancer. Even among highest quality hospitals, wide variation in average episode costs was noted. Surgeons should seek to better understand practice variation to standardize care and decrease variation in outcomes, utilization, and costs.

Influence of hospital teaching status on the chance to achieve a textbook outcome after hepatopancreatic surgery for cancer among Medicare beneficiaries

BACKGROUND

Assessing composite measures of quality such as textbook outcome may be superior to focusing on individual parameters when evaluating hospital performance. The aim of the current study was to assess the impact of teaching hospital status on the occurrence of a textbook outcome after hepatopancreatic surgery.

METHODS

The Medicare Inpatient Standard Analytic Files were used to identify patients undergoing hepatopancreatic surgery from 2013 to 2015 for a malignant indication. Stratified and multivariable regression analyses were performed to determine the relationship between teaching hospital status, hospital surgical volume and textbook outcome.

RESULTS

Among 8,035 Medicare patients (hepatectomy; 41.8%, pancreatectomy; 58.2%), 6,196 (77.1%) patients underwent surgery at a major teaching hospital, whereas 1,839 (22.9%) patients underwent surgery at a minor teaching hospital. Patients undergoing surgery for pancreatic cancer at a major teaching hospital had a greater likelihood of achieving a textbook outcome compared with patients treated at a minor teaching hospital (minor teaching hospital: 456, 40% versus major teaching hospital: 1,606, 45.4%; P = .002). The likelihood of textbook outcome was also greater among patients undergoing hepatopancreatic surgery at high-volume centers (pancreas, low volume: 875, 40.5% versus high volume: 1,187, 47.1% P < .001; liver, low volume: 608, 41.8% versus high volume: 886, 46.6%; P = .005). When examining only major teaching hospitals, patients undergoing a pancreatectomy at a high-volume center had 29% greater odds of achieving a textbook outcome (odds ratio 1.29, 95% confidence interval 1.12-1.49). In contrast, among patients undergoing pancreatic resection at high-volume centers, the odds of achieving a textbook outcome was comparable among major versus minor teaching hospital (odds ratio 1.17, 95% confidence interval 0.89-1.53).

CONCLUSION

The odds of achieving a textbook outcome after pancreatic and hepatic surgery was greater at major versus minor teaching hospitals; however, this effect was largely mediated by hepatopancreatic procedural volume. Patients and payers should focus on regionalization of pancreatic and liver resection to high-volume centers in an effort to optimize the chances of achieving a textbook outcome.

The Association Between Wait Times for Colorectal Cancer Treatment and Health Care Costs: A Population-Based Analysis

BACKGROUND

Health care costs and wait times for colorectal cancer treatment are increasing in Canada, but the association between the 2 remains unclear.

OBJECTIVE

This study aimed to determine the association between wait times and health care costs and utilization.

DESIGN

This is a population-based retrospective cohort study.

SETTING

This study was conducted in Manitoba, Canada.

PATIENTS

Patients diagnosed with colorectal cancer between 2004 and 2014 were sorted and ranked into quintiles based on the time from index contact for a colorectal cancer-related symptom to first treatment.

MAIN OUTCOME MEASURES

The primary outcome is risk-adjusted health care costs, and the secondary outcomes include health care utilization and overall mortality.

RESULTS

We included a total of 6936 patients. Total wait times ranged between 0 and 762 days. In comparison with very short wait times, longer wait times were associated with significantly increased costs (short: mean cost ratio 1.21; 95% CI, 1.10-1.32; moderate: mean cost ratio 1.30; 95% CI, 1.19-1.43; long: mean cost ratio 1.48; 95% CI, 1.33-1.64; and very long: mean cost ratio 1.39; 95% CI, 1.26-1.54). Compared with very short wait times, longer wait times were associated with significantly lower risk of mortality (short: HR, 0.78; 95% CI, 0.71-0.86; moderate: HR, 0.72; 95% CI, 0.65-0.80; long: HR, 0.73; 95% CI, 0.66-0.82; very long: HR, 0.76; 95% CI, 0.68-0.85). The median number of pretreatment radiological and endoscopic investigations and surgeon clinic visits increased over the study period across all wait time categories.

LIMITATIONS

This is a nonrandomized, retrospective cohort study with potentially limited generalizability.

CONCLUSION

Patients with very short and short wait times are likely those diagnosed with life-threatening complications of colorectal cancer. Outside this window, patients with longer wait times experience increased health care costs and utilization with similar overall mortality. Improved care coordination and patient navigation may help contain the increasing wait times and associated increasing health care costs and utilization. See Video Abstract at http://links.lww.com/DCR/B81. ASOCIACIÓN ENTRE LOS TIEMPOS DE ESPERA PARA EL TRATAMIENTO DE UN CÁNCER COLORRECTAL Y LOS COSTOS DE ATENCIÓN MÉDICA: UN ANÁLISIS DE POBLACIÓN: los costos de atención médica y los tiempos de espera para el tratamiento del cáncer colorrectal están aumentando en Canadá, pero la asociación entre los dos sigue sin estar clara.determinar la asociación entre los tiempos de espera y los costos y la utilización de la atención médicaun estudio de cohorte retrospectivo basado en la población.Manitoba, Canadálos pacientes diagnosticados con cáncer colorrectal entre 2004-2014 se clasificaron y sub-clasificaron en quintiles según el tiempo desde el primer contacto índice de síntomas relacionados con cáncer colorrectal hasta el primer tratamiento.El resultado primario son los costos de atención médica ajustados al riesgo, y los resultados secundarios incluyen la utilización de la atención médica y la mortalidad general.Incluimos un total de 6,936 pacientes. Los tiempos de espera totales oscilaron entre 0-762 días. En comparación con los tiempos de espera muy cortos, los tiempos de espera más largos se asociaron con costos significativamente mayores (Corto: relación de costo promedio 1.21, intervalo de confianza del 95% 1.10-1.32; Moderado: relación de costo promedio 1.30, intervalo de confianza del 95% 1.19-1.43; Largo: media relación de costo 1.48, intervalo de confianza del 95% 1.33-1.64; Muy largo: relación de costo promedio 1.39, intervalo de confianza del 95% 1.26-1.54). En comparación con tiempos de espera muy cortos, los tiempos de espera más largos se asociaron con un riesgo de mortalidad significativamente menor (Corto: razón de riesgo 0.78, intervalo de confianza del 95% 0.71-0.86; Moderado: razón de riesgo 0.72, intervalo de confianza del 95% 0.65-0.80; Largo: peligro cociente 0.73, intervalo de confianza del 95% 0.66-0.82; Muy largo: cociente de riesgos 0.76, intervalo de confianza del 95% 0.68-0.85). La mediana del número de investigaciones radiológicas y endoscópicas previas al tratamiento y las visitas al cirujano aumentaron durante el período de estudio en todas las categorías de tiempo de espera.estudio de cohortes retrospectivo, no aleatorio con generalización potencialmente limitadalos pacientes con tiempos de espera « muy cortos » y « cortos » son probablemente aquellos diagnosticados con complicaciones potencialmente mortales del cáncer colorrectal. Fuera de esta ventana, los pacientes con tiempos de espera más largos experimentan mayores costos de atención médica y utilización con una mortalidad general similar. La coordinación mejorada de la atención y la navegación del paciente pueden ayudar a contener el aumento de los tiempos de espera y el aumento de los costos y la utilización de la atención médica. Consulte Video Resumen en http://links.lww.com/DCR/B81. (Traducción-Dr. Edgar Xavier Delgadillo).

Who Will be the Costliest Patients? Using Recent Claims to Predict Expensive Surgical Episodes

INTRODUCTION

Surgery accounts for almost half of inpatient spending, much of which is concentrated in a subset of high-cost patients. To study the effects of surgeon and hospital characteristics on surgical expenditures, a way to adjust for patient characteristics is essential.

DESIGN

Using 100% Medicare claims data, we identified patients aged 66-99 undergoing elective inpatient surgery (coronary artery bypass grafting, colectomy, and total hip/knee replacement) in 2014. We calculated price-standardized Medicare payments for the surgical episode from admission through 30 days after discharge (episode payments). On the basis of predictor variables from 2013, that is, Elixhauser comorbidities, hierarchical condition categories, Medicare's Chronic Conditions Warehouse (CCW), and total spending, we constructed models to predict the costs of surgical episodes in 2014.

RESULTS

All sources of comorbidity data performed well in predicting the costliest cases (Spearman correlation 0.86-0.98). Models on the basis of hierarchical condition categories had slightly superior performance. The costliest quintile of patients as predicted by the model captured 35%-45% of the patients in each procedure's actual costliest quintile. For example, in hip replacement, 44% of the costliest quintile was predicted by the model's costliest quintile.

CONCLUSIONS

A significant proportion of surgical spending can be predicted using patient factors on the basis of readily available claims data. By adjusting for patient factors, this will facilitate future research on unwarranted variation in episode payments driven by surgeons, hospitals, or other market forces.

Development of comorbidity score for patients undergoing major surgery

OBJECTIVE

To develop and validate a claims-based comorbidity score for patients undergoing major surgery, and compare its performance with established comorbidity scores.

DATA SOURCE

Five percent Medicare data from 2007 to 2014.

STUDY DESIGN

Retrospective cohort study of patients aged ≥65 years undergoing six major operations (N = 99 250).

DATA COLLECTION

One-year mortality was the primary outcome. Secondary outcomes were hospital mortality, 30-day mortality, 30-day readmission, and length of stay. The comorbidity score was developed in the derivation cohort (70 percent sample) using logistic regression model. The comorbidity score was calibrated and validated in the validation cohort (30 percent sample), and compared against the Charlson, Elixhauser, and Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC) comorbidity scores using c-statistic, net reclassification improvement, and integrated discrimination improvement.

PRINCIPAL FINDINGS

In the validation cohort, the surgery-specific comorbidity score was well calibrated and performed better than the Charlson, Elixhauser, and CMS-HCC comorbidity scores for all outcomes; the performance was comparable to the CMS-HCC for 30-day readmission. For example, the surgery-specific comorbidity score (c-statistic = 0.792; 95% CI, 0.785-0.799) had greater discrimination than the Charlson (c-statistic = 0.747; 95% CI, 0.739-0.755), Elixhauser (c-statistic = 0.747; 95% CI, 0.735-0.755), or CMS-HCC (c-statistic = 0.755; 95% CI, 0.747-0.763) scores in predicting 1-year mortality. The net reclassification improvement and integrated discrimination improvement were greater for surgery-specific comorbidity score compared to the Charlson, Elixhauser, and CMS-HCC scores.

CONCLUSIONS

Compared to commonly used comorbidity measures, a surgery-specific comorbidity score better predicted outcomes in the surgical population.

A Comparison of Costs: How California Teaching Hospitals Achieved Slower Growth Than Nonteaching Hospitals in Operating Room Costs From 2005 to 2014

PURPOSE

Historically, teaching hospitals have had higher costs than nonteaching hospitals, introducing potential financial risk in value-based payment models. This study compared risk-adjusted operating room (OR) costs between California teaching and nonteaching hospitals.

METHOD

Using 2,992 financial statements from fiscal years (FYs) 2005-2014, the authors extracted data for OR total costs, components of direct costs, and indirect costs. Cross-sectional and longitudinal models estimated OR costs per minute of surgery by teaching status, ownership, case mix index, and geographic area.

RESULTS

Risk-adjusted cost was $9.44 per minute less in teaching than nonteaching hospitals in FY 2014 (95% CI, 3.03-15.85, P = .004). Between FY 2005 and FY 2014, OR costs grew more slowly at teaching hospitals because of slower wage growth and indirect costs per minute (-$0.13 and -$0.77 per minute per year, respectively, P = .005 and P < .001). Hourly pay rose more at teaching hospitals ($0.26 per hour per year, P = .008) but was offset by slower full-time equivalents growth (-0.002 per 10,000 OR minutes per year, P = .001). Between FY 2005 and FY 2014, operative volume increased at teaching hospitals and decreased at nonteaching hospitals.

CONCLUSIONS

By 2014, California teaching hospitals had lower OR costs per minute than nonteaching hospitals because of relative labor productivity gains and slower indirect cost growth. The latter likely resulted from a volume shift from nonteaching to teaching facilities. These trends will help teaching hospitals compete under value-based models. Implications for patients and nonteaching hospitals warrant evaluation.

A national assessment of the utilization, quality and cost of laparoscopic liver resection

BACKGROUND

Despite recent enthusiasm for the use of laparoscopic liver resection, data evaluating costs associated with laparoscopic liver resections are lacking. We sought to examine the use of laparoscopic liver surgery, and investigate variations in cost among hospitals performing these procedures.

METHODS

A nationally representative sample of 12,560 patients who underwent a liver resection in 2012 was identified. Multivariable analyses were performed to compare outcomes associated with liver resection.

RESULTS

Among the 12,560 patients who underwent liver resection, 685 (5.4%) underwent a laparoscopic liver resection. The proportion of liver resections performed laparoscopically varied among hospitals ranging from 4.6% to 20.0%; the median volume of laparoscopic liver resections was 10 operations/year. Although laparoscopic surgery was associated with lower postoperative morbidity (aOR = 0.60, 95%CI: 0.36-0.99) and shorter lengths of stay [(LOS) aIRR = 0.83, 95%CI: 0.70-0.97], it was not associated with inpatient mortality (p = 0.971) or hospital costs (p = 0.863). Costs associated with laparoscopic liver resection varied ranging from $5,907 (95%CI: $5,140-$6,674) to $67,178 (95%CI: $66,271-$68,083). The observed variations between hospitals were due to differences in morbidity (coefficient: $20,415, 95%CI: $16,000-$24,830) and LOS (coefficient: $24,690, 95%CI: $21,688-$27,692).

CONCLUSIONS

Although laparoscopic liver resection was associated with improved short-term perioperative clinical outcomes, utilization of laparoscopic liver resection remains low.

Outcomes for urologic oncology procedures: are there differences between academic and community hospitals?

OBJECTIVE

To compare the rate of hospital-based outcomes including costs, 30-day readmission, mortality, and length of stay in patients who underwent major urologic oncologic procedures in academic and community hospitals.

METHODS

We retrospectively reviewed the Vizient Database (Irving, Texas) from September 2014 to December 2017. Vizient includes ~ 97% of academic hospitals (AH) and more than 60 community hospitals (CH). Patients aged ≥ 18 with urologic malignancies who underwent surgical treatment were included. Chi square and Student t tests were used to compare categorical and continuous variables, respectively.

RESULTS

We identified a total of 37,628 cases. There were 33,290 (88%) procedures performed in AH and 4330 (12%) in CH. These included prostatectomy (18,540), radical nephrectomy (rNx) 8059, partial nephrectomy (pNx) (5287), radical cystectomy (4421), radical nephroureterectomy (rNu) (1006), and partial cystectomy (321). There were no significant differences in 30-day readmission rates or mortality for any procedure between academic and community hospitals (Table 1), p > 0.05 for all. Length of stay was significantly lower for radical cystectomy and prostatectomy in AH (p < 0.01 for both) and lower for rNx in CH (p = 0.03). The mean direct cost for index admission was significantly higher in AH for rNx, pNx, rNu, and prostatectomy. Case mix index was similar between the community and academic hospitals.

CONCLUSION

Despite academic and community hospitals having similar case complexity, direct costs were lower in community hospitals without an associated increase in readmission rates or deaths. Length of stay was shorter for cystectomy in academic centers.

Differences in healthcare outcomes between teaching and non teaching hospitals for patients with delirium: a retrospective cohort study

BACKGROUND

The physician workforce at teaching hospitals differs compared to non-teaching hospitals, and data suggest that patient outcomes may also be dissimilar. Delirium is a common, costly disorder among hospitalized patients and approaches to care are not standardized.

OBJECTIVE

This study set out to explore differences in healthcare outcomes between teaching and non-teaching hospitals for patients admitted with delirium.

DESIGN

Retrospective cohort analysis.

SETTING AND PARTICIPANTS

We used the 2014 Nationwide Inpatient Sample database. Adult patients (≥18 years of age) hospitalized in acute-care hospitals in the USA with delirium (defined with ICD-9 code) were studied.

MAIN OUTCOME MEASURES

The primary outcome was in-hospital all-cause mortality. Secondary outcomes were discharge status and several measures of healthcare resource utilization: length of stay, total hospitalization costs and multiple procedures performed.

RESULTS

In 2014, out of 57 460 adult patients admitted to hospitals with delirium, 58.4% were hospitalized at teaching hospitals and the remainder 41.6% at non-teaching hospitals. The in-hospital mortality of delirium patients in teaching hospitals was 1.33% (95% CI 1.08%-1.63%), and 1.26% (95% CI 0.97%-1.63%) in non-teaching hospitals. The mean total hospital costs were $7642 (95% CI 7384-7900) in teaching hospitals, and $6650 (95% CI 6460-6840) in non-teaching hospitals. After adjustment for confounders, total hospitalization costs were statistically significantly different between the hospitals types-with non-teaching providing less expensive care.

CONCLUSIONS

Patients with delirium admitted to non-teaching hospitals had comparable clinical and process outcomes achieved at lower costs. Further research can be conducted to explore the contextual issues and reasons for these differences in healthcare costs.

Surgical Care for Women with Endometrial Cancer in Florida

Objective: The goal of this research was to analyze if disparities in route of hysterectomy for endometrial cancer exist in Florida. Materials and Methods: In this retrospective cohort study, Florida inpatient and ambulatory surgery databases (2014-2016) were examined to find cases of patients with endometrial cancer who underwent hysterectomy in the state. Logistic regression models were used to compare patient- and hospital-level factors associated with having minimally invasive surgery (MIS) versus open surgery, and complications in patients having open hysterectomy versus MIS. Results: Overall, 6513 patients met the inclusion criteria. MIS was performed in 81.4% of cases. The odds of using a minimally invasive approach to hysterectomy (vaginal, robotic, or laparoscopic) were significantly lower for black women (odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.34-0.50) as well as for other non-white patients (OR: 0.64; 95% CI: 0.49-0.84). Patients with Medicaid (OR: 0.42; 95% CI: 0.30-0.59) or Medicare managed care (OR: 0.73; 95% CI: 0.59-0.91), or who received care at a teaching hospital (OR: 0.82; 95% CI: 0.68-0.98) or government hospital (OR: 0.50; 95% CI: 0.38-0.65) were also less likely to receive MIS. Patients receiving care at a high-volume (OR: 1.69; 95% CI: 1.30-2.20) or medium-volume (OR: 3.11; 95% CI: 2.37-4.08) hospital, or patients who were located in the Central (OR: 1.71; 95% CI: 1.17-2.48) or Peninsula (OR: 1.73; 95% CI: 1.17-2.56) regions, compared to the Florida Panhandle, had greater odds of receiving MIS. Conclusions: Although Florida has a high adoption of MIS for treating endometrial cancer, disparities persist. Efforts of state-level entities should focus on improving access to minimally invasive hysterectomy for racial minorities with endometrial cancer.

A statewide comparison of opioid prescribing in teaching versus nonteaching hospitals

BACKGROUND

Postoperative opioid prescribing is often excessive, but the differences in opioid prescribing between teaching hospitals and nonteaching hospitals is not well understood. Given the workload of surgical training and frequent turnover of prescribers on surgical services, we hypothesized that postoperative opioid prescribing would be higher among teaching compared with nonteaching hospitals.

STUDY DESIGN

We used insurance claims from a statewide quality collaborative in Michigan to identify 17,075 opioid-naïve patients who underwent 22 surgical procedures across 76 hospitals from 2012 to 2016. Our outcomes included the following: (1) the amount of opioid prescribed for the initial postoperative prescription in oral morphine equivalents and (2) high-risk prescribing in the 30 days after surgery (high daily dose [≥ 100 oral morphine equivalents], new long-acting/extended-release opioid, overlapping prescriptions, or concurrent benzodiazepine prescription). Teaching hospital status was obtained from the 2014 American Hospital Association survey. Multilevel regression was used to adjust for patient and procedural factors and to perform reliability adjustment.

RESULTS

The amount of opioid prescribed per initial opioid prescription varied 4.7-fold across all hospitals from 130 oral morphine equivalents to 616 oral morphine equivalents. Patients discharged from teaching hospitals filled larger initial opioid prescriptions overall compared with nonteaching hospitals (251 oral morphine equivalents versus 232 oral morphine equivalents; P = .026). Teaching hospitals had higher risk-adjusted rates of high-risk prescribing compared with nonteaching hospitals (13.7% vs 10.3%; P = .034).

CONCLUSION

In Michigan, surgical patients discharged from teaching hospitals received significantly larger postoperative opioid prescriptions and had higher rates of high-risk prescribing compared with nonteaching hospitals. All hospitals, and particularly teaching institutions, should ensure that adequate resources are devoted to facilitating safe postoperative opioid prescribing.

Failure-to-Rescue in Thoracic Surgery

Variability in outcomes not attributable to case mix or chance is an indicator of low-quality care. Failure-to-rescue is an outcome measure defined as death during a hospitalization among patients who experience a complication. Researchers have used this measure to better understand the determinants of an untimely death-preventing complications, rescue, or both. Studies repeatedly find that complication rates vary little, if at all, across hospitals ranked by risk-adjusted mortality rates, suggesting that hospitals are equally capable (or incapable) of preventing complications. In contrast, variation in failure-to-rescue rates seems to explain much of the variation in risk-adjusted hospital-level mortality rates. These findings suggest that system-level interventions that allow for the early detection and treatment of complications (ie, rescue) may reduce variability in hospital-level outcomes and improve the quality of thoracic surgical care.