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Dualeh SHA, Schaefer SL, Kunnath N, Ibrahim AM, Scott JW. Health Insurance Status and Unplanned Surgery for Access-Sensitive Surgical Conditions. JAMA Surg 2024; 159:420-427. [PMID: 38324286 PMCID: PMC10851136 DOI: 10.1001/jamasurg.2023.7530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/14/2023] [Indexed: 02/08/2024]
Abstract
Importance Access-sensitive surgical conditions, such as abdominal aortic aneurysm, ventral hernia, and colon cancer, are ideally treated with elective surgery, but when left untreated have a natural history requiring an unplanned operation. Patients' health insurance status may be a barrier to receiving timely elective care, which may be associated with higher rates of unplanned surgery and worse outcomes. Objective To evaluate the association between patients' insurance status and rates of unplanned surgery for these 3 access-sensitive surgical conditions and postoperative outcomes. Design, Setting, and Participants This cross-sectional cohort study examined a geographically broad patient sample from the Healthcare Cost and Utilization Project State Inpatient Databases, including data from 8 states (Arizona, Colorado, Florida, Kentucky, Maryland, North Carolina, Washington, and Wisconsin). Participants were younger than 65 years who underwent abdominal aortic aneurysm repair, ventral hernia repair, or colectomy for colon cancer between 2016 and 2020. Patients were stratified into groups by insurance status. Data were analyzed from June 1 to July 1, 2023. Exposure Health insurance status (private insurance, Medicaid, or no insurance). Main Outcomes and Measures The primary outcome was the rate of unplanned surgery for these 3 access-sensitive conditions. Secondary outcomes were rates of postoperative outcomes including inpatient mortality, any hospital complications, serious complications (a complication with a hospital length of stay longer than the 75th percentile for that procedure), and hospital length of stay. Results The study included 146 609 patients (mean [SD] age, 50.9 [10.3] years; 73 871 females [50.4%]). A total of 89 018 patients (60.7%) underwent elective surgery while 57 591 (39.3%) underwent unplanned surgery. Unplanned surgery rates varied significantly across insurance types (33.14% for patients with private insurance, 51.46% for those with Medicaid, and 72.60% for those without insurance; P < .001). Compared with patients with private insurance, patients without insurance had higher rates of inpatient mortality (1.29% [95% CI, 1.04%-1.54%] vs 0.61% [0.57%-0.66%]; P < .001), higher rates of any complications (19.19% [95% CI, 18.33%-20.05%] vs 12.27% [95% CI, 12.07%-12.47%]; P < .001), and longer hospital stays (7.27 [95% CI, 7.09-7.44] days vs 5.56 [95% CI, 5.53-5.60] days, P < .001). Conclusions and Relevance Findings of this cohort study suggest that uninsured patients more often undergo unplanned surgery for conditions that can be treated electively, with worse outcomes and longer hospital stays compared with their counterparts with private health insurance. As efforts are made to improve insurance coverage, tracking elective vs unplanned surgery rates for access-sensitive surgical conditions may be a useful measure to assess progress.
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Affiliation(s)
- Shukri H. A. Dualeh
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Sara L. Schaefer
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Nicholas Kunnath
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Andrew M. Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Taubman College of Architecture and Urban Planning, University of Michigan, Ann Arbor
| | - John W. Scott
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Division of Trauma, Burn, and Critical Care Surgery, Department of Surgery, University of Washington, Seattle
- Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, University of Washington, Seattle
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Jayadevappa R, Malkowicz SB, Vapiwala N, Guzzo TJ, Chhatre S. Association between hospital competition and quality of prostate cancer care. BMC Health Serv Res 2023; 23:828. [PMID: 37543580 PMCID: PMC10403840 DOI: 10.1186/s12913-023-09851-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 07/26/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND Hospitals account for approximately 6% of United States' gross domestic product. We examined the association between hospital competition and outcomes in elderly with localized prostate cancer (PCa). We also assessed if race moderated this association. METHODS Retrospective study using Surveillance, Epidemiology, and End Results (SEER) - Medicare database. Cohort included fee-for-service, African American and white men aged ≥ 66, diagnosed with localized PCa between 1998 and 2011 and their claims between 1997 and 2016. We used Hirschman-Herfindahl index (HHI) to measure of hospital competition. Outcomes were emergency room (ER) visits, hospitalizations, Medicare expenditure and mortality assessed in acute survivorship phase (two years post-PCa diagnosis), and long-term mortality. We used Generalized Linear Models for analyzing expenditure, Poisson models for ER visits and hospitalizations, and Cox models for mortality. We used propensity score to minimize bias. RESULTS Among 253,176 patients, percent change in incident rate of ER visit was 17% higher for one unit increase in HHI (IRR: 1.17, 95% CI: 1.15-1.19). Incident rate of ER was 24% higher for whites and 48% higher for African Americans. For one unit increase in HHI, hazard of short-term all-cause mortality was 7% higher for whites and 11% lower for African Americans. The hazard of long-term all-cause mortality was 10% higher for whites and 13% higher for African Americans. CONCLUSIONS Lower hospital competition was associated with impaired outcomes of localized PCa care. Magnitude of impairment was higher for African Americans, compared to whites. Future research will explore process through which competition affects outcomes and racial disparity.
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Affiliation(s)
- Ravishankar Jayadevappa
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US.
- Department of Surgery, Division of Urology, Perelaman School of Medicine, University of Pennsylvania, Philadelphia, PA, US.
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, US.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, US.
| | - S Bruce Malkowicz
- Department of Surgery, Division of Urology, Perelaman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, US
| | - Neha Vapiwala
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, US
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, US
| | - Thomas J Guzzo
- Department of Surgery, Division of Urology, Perelaman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, US
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Sumedha Chhatre
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, US
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, US
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Rochlin DH, Rizk NM, Matros E, Wagner TH, Sheckter CC. Commercial Price Variation for Breast Reconstruction in the Era of Price Transparency. JAMA Surg 2023; 158:152-160. [PMID: 36515928 PMCID: PMC9856784 DOI: 10.1001/jamasurg.2022.6402] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Breast reconstruction is costly, and negotiated commercial rates have been hidden from public view. The Hospital Price Transparency Rule was enacted in 2021 to facilitate market competition and lower health care costs. Breast reconstruction pricing should be analyzed to evaluate for market effectiveness and opportunities to lower the cost of health care. Objective To evaluate the extent of commercial price variation for breast reconstruction. The secondary objective was to characterize the price of breast reconstruction in relation to market concentration and payer mix. Design, Setting, and Participants This was a cross-sectional study conducted from January to April 2022 using 2021 pricing data made available after the Hospital Price Transparency Rule. National data were obtained from Turquoise Health, a data service platform that aggregates price disclosures from hospital websites. Participants were included from all hospitals with disclosed pricing data for breast reconstructive procedures, identified by Current Procedural Terminology (CPT) code. Main Outcomes and Measures Price variation was measured via within- and across-hospital ratios. A mixed-effects linear model evaluated commercial rates relative to governmental rates and the Herfindahl-Hirschman Index (health care market concentration) at the facility level. Linear regression was used to evaluate commercial rates as a function of facility characteristics. Results A total of 69 834 unique commercial rates were extracted from 978 facilities across 335 metropolitan areas. Commercial rates increased as health care markets became less competitive (coefficient, $4037.52; 95% CI, $700.12 to $7374.92; P = .02; for Herfindahl-Hirschman Index [HHI] 1501-2500, coefficient $3290.21; 95% CI, $878.08 to $5702.34; P = .01; both compared with HHI ≤1500). Commercial rates demonstrated economically insignificant associations with Medicare and Medicaid rates (Medicare coefficient, -$0.05; 95% CI, -$0.14 to $0.03; P = .23; Medicaid coefficient, $0.14; 95% CI, $0.07 to $0.22; P < .001). Safety-net and nonprofit hospitals reported lower commercial rates (coefficient, -$3269.58; 95% CI, -$3815.42 to -$2723.74; P < .001 and coefficient, -$1892.79; -$2519.61 to -$1265.97; P < .001, respectively). Extra-large hospitals (400+ beds) reported higher commercial rates compared with their smaller counterparts (coefficient, $1036.07; 95% CI, $198.29 to $1873.85, P = .02). Conclusions and Relevance Study results suggest that commercial rates for breast reconstruction demonstrated large nationwide variation. Higher commercial rates were associated with less competitive markets and facilities that were large, for-profit, and nonsafety net. Privately insured patients with breast cancer may experience higher premiums and deductibles as US hospital market consolidation and for-profit hospitals continue to grow. Transparency policies should be continued along with actions that facilitate greater health care market competition. There was no evidence that facilities increase commercial rates in response to lower governmental rates.
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Affiliation(s)
- Danielle H. Rochlin
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California,Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nada M. Rizk
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Todd H. Wagner
- S-SPIRE, Department of Surgery, Stanford University, Palo Alto, California
| | - Clifford C. Sheckter
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California,S-SPIRE, Department of Surgery, Stanford University, Palo Alto, California
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Shammas RL, Hollenbeck ST. Using Data Price Transparency to Evaluate Autologous and Alloplastic Breast Reconstruction-Does It Tell the Whole (S)tory? JAMA Surg 2023; 158:160-161. [PMID: 36515961 DOI: 10.1001/jamasurg.2022.6525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Ronnie L Shammas
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Scott T Hollenbeck
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
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Han L, Boyle JM, Walker K, Kuryba A, Braun MS, Fearnhead N, Jayne D, Sullivan R, van der Meulen J, Aggarwal A. Impact of patient choice and hospital competition on patient outcomes after rectal cancer surgery: A national population-based study. Cancer 2023; 129:130-141. [PMID: 36259432 PMCID: PMC10092598 DOI: 10.1002/cncr.34504] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/10/2022] [Accepted: 09/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The objective of the current national cohort study was to analyze the correlation between choice and competition on outcomes after cancer surgery in rectal cancer. METHODS The analysis included all men who underwent rectal cancer surgery in the English National Health Service between March 2015 and April 2019 (n = 13,996). Multilevel logistic regression was used to assess the effect of a rectal cancer surgery center being located in a competitive environment (based on the number of centers within a threshold distance) and being a successful competitor (based on the ability to attract patients from other hospitals) on eight patient-level outcomes: 30- and 90-day emergency readmissions, 30-day re-operation rates, 90-day postoperative mortality, length of stay >14 days, circumferential resection margin status, rates of primary procedure with a permanent stoma, and rates of persistent stoma 18 months after anterior resection. RESULTS With adjustment for patient characteristics, patients who underwent surgery in centers located in a stronger competitive environment were less likely to have an abdominoperineal excision or a Hartman's procedure (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.55-0.97, p = .04). Additionally, individuals who received treatment at hospitals that were successful competitors had a lower risk of a 90-day readmission following rectal cancer surgery (OR, 0.86; 95% CI, 0.76-0.97, p = .03) and were less likely to have a persistent stoma at 18 months after anterior resection (OR, 0.75; 95% CI, 0.61-0.93, p = .02). CONCLUSIONS Hospitals located in areas of high competition are associated with better patient outcomes and improved processes of care for rectal cancer surgery.
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Affiliation(s)
- Lu Han
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Jemma M Boyle
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Kate Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Angela Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Michael S Braun
- Department of Oncology, The Christie NHS Foundation Trust, Manchester, UK.,School of Medical Sciences, University of Manchester, Manchester, UK
| | - Nicola Fearnhead
- Department of Colorectal Surgery, Cambridge University Hospitals, Cambridge, UK
| | | | - Richard Sullivan
- Institute of Cancer Policy, King's College London, London, UK.,Department of Oncology, Guy's & St. Thomas' NHS Trust, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Department of Oncology, Guy's & St. Thomas' NHS Trust, London, UK
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Berlin NL, Chopra Z, Bryant A, Agius J, Singh SR, Chhabra KR, Schulz P, West BT, Ryan AM, Kullgren JT. Individualized Out-of-Pocket Price Estimators for "Shoppable" Surgical Procedures: A Nationwide Cross-Sectional Study of US Hospitals. ANNALS OF SURGERY OPEN 2022; 3:e162. [PMID: 36936723 PMCID: PMC10013173 DOI: 10.1097/as9.0000000000000162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/12/2022] [Indexed: 11/25/2022] Open
Abstract
To estimate the nationwide prevalence of individualized out-of-pocket (OOP) price estimators at US hospitals, characterize patterns of inclusion of 14 specified "shoppable" surgical procedures, and determine hospital-level characteristics associated with estimators that include surgical procedures. Background Price transparency for shoppable surgical services is a key requirement of several recent federal policies, yet the extent to which hospitals provide online OOP price estimators remains unknown. Methods We reviewed a stratified random sample of 485 U.S. hospitals for the presence of a tool to allow patients to estimate individualized OOP expenses for healthcare services. We compared characteristics of hospitals that did and did not offer online price estimators and performed multivariable modeling to identify facility-level predictors of hospitals offering price estimator with and without surgical procedures. Results Nearly two-thirds (66.0%) of hospitals in the final sample (95% confidence interval 61.6%-70.1%) offered an online tool for estimating OOP healthcare expenses. Approximately 58.5% of hospitals included at least one shoppable surgical procedure while around 6.6% of hospitals included all 14 surgical procedures. The most common price reported was laparoscopic cholecystectomy (55.1%), and the least common was recurrent cataract removal (20.0%). Inclusion of surgical procedures varied by total annual surgical volume and health system membership. Only 26.9% of estimators explicitly included professional fees. Conclusions Our findings highlight an ongoing progress in price transparency, as well as key areas for improvement in future policies to help patients make more financially informed decisions about their surgical care.
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Affiliation(s)
- Nicholas L. Berlin
- From the National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Zoey Chopra
- University of Michigan Medical School, Ann Arbor, MI
- University of Michigan, Ann Arbor, MI
| | - Arrice Bryant
- University of Michigan Medical School, Ann Arbor, MI
| | | | - Simone R. Singh
- School of Public Health, University of Michigan, Ann Arbor, MI
| | | | - Paul Schulz
- Institute for Social Research, University of Michigan, Ann Arbor, MI
| | - Brady T. West
- Institute for Social Research, University of Michigan, Ann Arbor, MI
| | - Andrew M. Ryan
- School of Public Health, University of Michigan, Ann Arbor, MI
| | - Jeffrey T. Kullgren
- School of Public Health, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
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Chen Y, Wang L, Cui X, Xu J, Xu Y, Yang Z, Jin C. COVID-19 as an opportunity to reveal the impact of large hospital expansion on the healthcare delivery system: evidence from Shanghai, China. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1297. [PMID: 34532434 PMCID: PMC8422135 DOI: 10.21037/atm-21-2793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/16/2021] [Indexed: 01/10/2023]
Abstract
Background The expansion of large hospitals on the medical service market's supply side has always been an intensely debated topic. In this study, we conducted statistical analysis on the natural shock of COVID-19 to investigate whether the large hospitals will draw health demand from the small hospitals when a supply capacity surplus is present, a phenomenon otherwise known as the "siphon effect". Methods We collected the monthly hospital income and service data, including outpatient income, inpatient income, number of visits, and discharges, from all public hospitals, from January 2018 to July 2020 in Shanghai. A difference-in-differences (DIDs) method was applied to analyze the existence of the large hospitals' siphon effect by identifying the differences in the healthcare service market share change between large and small hospital groups at the height of pandemic (February and March, 2020) and the postpandemic period (April and May, 2020). Case mix index (CMI) was used to verify whether the reduction in healthcare amount and market share of small hospitals was due to unnecessary care. Results In total, 156 public hospitals, including 46 large hospitals and 110 small hospitals, with an average number of beds of 1,079.21 and 345.25, respectively, were involved in this study. At the height of the pandemic, the healthcare service volume and revenue in public hospitals in Shanghai experienced a sharp decline, especially for large hospitals and inpatient services. Compared to small hospitals at the height of the COVID-19 pandemic, large hospitals' market share decreased significantly in outpatient and inpatient services for overall and nonlocal patients (P<0.05). During the postpandemic period, large hospitals' market share increased significantly in outpatient and inpatient services for overall and local patients (P<0.05). This increase was more substantial in inpatient services. Conclusions Under conditions of the COVID-19 pandemic of higher care-seeking costs in the large hospitals, some of the healthcare services typically provided by large hospitals were then supplied by small hospitals. Furthermore, the siphon effect of large hospitals could be clearly observed when a supply capacity surplus was present and external constraint on patients' care-seeking behavior was absent.
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Affiliation(s)
- Yuqian Chen
- Department of Health Policy Research, Shanghai Health Development Research Center, Shanghai, China
| | - Linan Wang
- Department of Health Policy Research, Shanghai Health Development Research Center, Shanghai, China.,School of Public Economics and Administration, Shanghai University of Finance and Economics, Shanghai, China
| | - Xin Cui
- Department of Data Service, Shanghai Information Center for Health, Shanghai, China
| | - Jiajie Xu
- Department of Health Policy Research, Shanghai Health Development Research Center, Shanghai, China
| | - Yingqi Xu
- School of Public Economics and Administration, Shanghai University of Finance and Economics, Shanghai, China
| | - Zhonghao Yang
- Department of Finance, Shanghai Hospital Development Center, Shanghai, China
| | - Chunlin Jin
- Department of Health Policy Research, Shanghai Health Development Research Center, Shanghai, China
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Tang OY, Rivera Perla KM, Lim RK, Yoon JS, Weil RJ, Toms SA. Interhospital competition and hospital charges and costs for patients undergoing cranial neurosurgery. J Neurosurg 2020; 135:361-372. [PMID: 33007751 DOI: 10.3171/2020.6.jns20732] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/01/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Research has documented significant growth in neurosurgical expenditures and practice consolidation. The authors evaluated the relationship between interhospital competition and inpatient charges or costs in patients undergoing cranial neurosurgery. METHODS The authors identified all admissions in 2006 and 2009 from the National Inpatient Sample. Admissions were classified into 5 subspecialties: cerebrovascular, tumor, CSF diversion, neurotrauma, or functional. Hospital-specific interhospital competition levels were quantified using the Herfindahl-Hirschman Index (HHI), an economic metric ranging continuously from 0 (significant competition) to 1 (monopoly). Inpatient charges (hospital billing) were multiplied with reported cost-to-charge ratios to calculate costs (actual resource use). Multivariate regressions were used to assess the association between HHI and inpatient charges or costs separately, controlling for 17 patient, hospital, severity, and economic factors. The reported β-coefficients reflect percentage changes in charges or costs (e.g., β-coefficient = 1.06 denotes a +6% change). All results correspond to a standardized -0.1 change in HHI (increase in competition). RESULTS In total, 472,938 nationwide admissions for cranial neurosurgery treated at 896 unique hospitals met inclusion criteria. Hospital HHIs ranged from 0.099 to 0.724 (mean 0.298 ± 0.105). Hospitals in more competitive markets had greater charge/cost markups (β-coefficient = 1.10, p < 0.001) and area wage indices (β-coefficient = 1.04, p < 0.001). Between 2006 and 2009, average neurosurgical charges and costs rose significantly ($62,098 to $77,812, p < 0.001; $21,385 to $22,389, p < 0.001, respectively). Increased interhospital competition was associated with greater charges for all admissions (β-coefficient = 1.07, p < 0.001) as well as cerebrovascular (β-coefficient = 1.08, p < 0.001), tumor (β-coefficient = 1.05, p = 0.039), CSF diversion (β-coefficient = 1.08, p < 0.001), neurotrauma (β-coefficient = 1.07, p < 0.001), and functional neurosurgery (β-coefficient = 1.11, p = 0.037) admissions. However, no significant associations were observed between HHI and costs, except for CSF diversion surgery (β-coefficient = 1.03, p = 0.021). Increased competition was not associated with important clinical outcomes, such as inpatient mortality, favorable discharge disposition, or complication rates, except for lower mortality for brain tumors (OR 0.78, p = 0.026), but was related to greater length of stay for all admissions (β-coefficient = 1.06, p < 0.001). For a sensitivity analysis adjusting for outcomes, all findings for charges and costs remained the same. CONCLUSIONS Hospitals in more competitive markets exhibited higher charges for admissions of patients undergoing an in-hospital cranial procedure. Despite this, interhospital competition was not associated with increased inpatient costs except for CSF diversion surgery. There was no corresponding improvement in outcomes with increased competition, with the exception of a potential survival benefit for brain tumor surgery.
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Affiliation(s)
- Oliver Y Tang
- 1The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Rachel K Lim
- 1The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - James S Yoon
- 2Yale School of Medicine, New Haven, Connecticut; and
| | - Robert J Weil
- 3Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island
| | - Steven A Toms
- 1The Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 3Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island
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Spotlight in Plastic Surgery. Plast Reconstr Surg 2020. [DOI: 10.1097/prs.0000000000006736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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