Does Surgical Volume and Complexity Affect Cost and Mortality in Otolaryngology–Head and Neck Surgery?

Objectives

(1) To evaluate whether admission volume and case complexity are associated with mortality rates and (2) evaluate whether admission volume and case complexity are associated with cost per admission.

Study Design

Retrospective case series.

Setting

Tertiary academic hospital.

Subjects and Methods

The Vizient database was queried for inpatient admissions between July 2015 and March 2017 to an otolaryngology–head and neck surgery service. Data collected included admission volume, length of stay, intensive care unit (ICU) status, complication rates, case mix index (CMI), and cost data. Regression analysis was performed to evaluate the relationship between cost, CMI, admission volume, and mortality rate.

Results

In total, 338 hospitals provided data for analysis. Mean hospital admission volume was 182 (range, 1-1284), and mean CMI was 1.69 (range, 0.66-6.0). A 1-point increase in hospital average CMI was associated with a 40% increase in odds for high mortality. Admission volume was associated with lower mortality, with 1% lower odds for each additional case. A 1-point increase in CMI produces a $4624 higher total cost per case (95% confidence interval, $4550-$4700), and for each additional case, total cost per case increased by $6.

Conclusion

For otolaryngology inpatient services at US academic medical centers, increasing admission volume is associated with decreased mortality rates, even after controlling for CMI and complication rates. Increasing CMI levels have an anticipated correlation with higher total costs per case, but admission volume is unexpectedly associated with a significant increase in average cost per case.

Utilization and reimbursements for sinus procedures: A five-year analysis

OBJECTIVES/HYPOTHESIS

Balloon sinuplasty has become an increasingly popular option for patients undergoing surgical treatment of sinusitis. This study analyzes utilization and growth of these procedures across a large cohort of patients over a 5-year period.

STUDY DESIGN

Retrospective data review.

METHODS

This was a retrospective review of Medicare utilization and billing data. Utilization and payment values were obtained from Medicare claims data using Centers for Medicare and Medicaid Services datasets. All Medicare claims were analyzed from 2012 to 2016. Data were extracted for balloon sinuplasty and endoscopic sinus surgery claims. Procedure location, total submitted claims, charges, and payments were compared.

RESULTS

From 2012 to 2016, the number of balloon procedures increased from 5,603 to 25,640. Traditional endoscopic sinus surgery procedures increased from 15,509 to 18,164. Aggregate Medicare payments to otolaryngologists for endoscopic sinus surgery have remained relatively stable, whereas there has been a 450% increase in total payments to providers of balloon sinuplasty. In 2016, total payments to providers of balloon procedures ($40.5 million) were substantially higher than payments to providers of non-balloon-based endoscopic sinus surgery ($4.7 million). The number of providers performing balloon procedures has increased 277% versus 17% for traditional sinus surgery.

CONCLUSIONS

There has been a rapid expansion in the number of sinus procedures in the Medicare population from 2012 to 2016. Office-based balloon procedures account for the overwhelming majority of the increases in procedures and payments. Per procedure and aggregate payments are now higher for sinuplasty procedures than for traditional sinus surgery.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2224-2229, 2019.

Analyzing Medicare payments to otologists

The study objective was to analyze Medicare payment data to otologists compared to otolaryngologists, using the publicly released Centers for Medicare and Medicaid Services dataset. Charges, payments, and common Current Procedural Terminology codes were obtained. Otology providers were selected from the roster of the American Otological Society. Descriptive statistics and unequal variance two-tailed t tests were used for comparisons between otologists (n = 147) and otolaryngologists (n = 8,318). The mean overall submitted charge was $204,851 per otology provider and was $211,209 per other otolaryngology providers (non-otologists) (p = 0.92). The mean payment to otologists was $56,191 (range: $297 to $555,274, standard deviation [SD] ±$68,540) and significantly lower (p = 0.005) than $77,275 to otolaryngologists (range: $94 to $2,123,900, SD ±$86,423). The mean submitted charge-to-payment ratio (fee multiplier) per otology provider was 3.87 (range 1.50 to 9.10, SD ±1.70), which was significantly higher (p < 0.0001) than the ratio for otolaryngologists (mean 2.91; range: 1.25 to 17.51, SD ±1.22). Office visit evaluation and management (E&M) codes made up the majority in terms of use and payments. Interestingly, allergy-based services comprised a substantial amount of repeat use among a small subset of otologists. Audiology services were billed by a similar percentage of otologists and other otolaryngologists (52%), but otologists received a significantly higher overall payment for these services.

Predictors of regional Medicare expenditures for otolaryngology physician services

OBJECTIVE

To describe geographic variation in spending and evaluate regional Medicare expenditures for otolaryngologist services with population- and beneficiary-related factors, physician supply, and hospital system factors.

STUDY DESIGN

Cross-sectional study.

METHODS

The average regional expenditures for otolaryngology physician services were defined as the total work relative value units (wRVUs) collected by otolaryngologists in a hospital referral region (HRR) per thousand Medicare beneficiaries in the HRR. A multivariable linear regression model tested associations with regional sociodemographics (age, sex, race, income, education), the physician and hospital bed supply, and the presence of an otolaryngology residency program.

RESULTS

In 2012, the mean Medicare expenditure for otolaryngology provider services across HRRs was 224 wRVUs per thousand Medicare beneficiaries (standard deviation [SD] 104), ranging from 31 to 604 wRVUs per thousand Medicare beneficiaries. In 2013, the average Medicare expenditures for each HRR was highly correlated with expenditures collected in 2012 (Pearson correlation coefficient .997, P = .0001). Regional Medicare expenditures were independently and positively associated with otolaryngology, medical specialist, and hospital bed supply in the region, and were negatively associated with the supply of primary care physicians and presence of an otolaryngology residency program after adjusting for other factors. The magnitude of associations with physician supply and hospital factors was stronger than any population or Medicare beneficiary factor.

CONCLUSION

Wide variations in regional Medicare expenditures for otolaryngology physician services, highly stable over 2 years, were strongly associated with regional health system factors. Changes in health policy for otolaryngology care may require coordination with other physician specialties and integrated hospital systems.

LEVEL OF EVIDENCE

NA. Laryngoscope, 127:1312-1317, 2017.

Geographic Variation of Endoscopic Sinus Surgery in Canada: An Alberta-Based Small Area Variation Analysis

OBJECTIVE

With an estimated 10,000 to 15,000 endoscopic sinus surgery (ESS) cases performed in Canada each year, identifying potential unwarranted practice patterns is important. The objective of this study is to examine the rates and geographic variation of ESS in the province of Alberta, Canada.

STUDY DESIGN

Small area variation analysis.

SETTING

Province of Alberta, Canada.

SUBJECTS AND METHODS

The National Ambulatory Care Reporting System database was searched to identify all patients who received ESS between April 1, 2010, and March 31, 2013, in Alberta, Canada. The annual adjusted rates of ESS per 1000 people were calculated for each Alberta health zone and health status area. Geographic variations were evaluated with the extremal quotient, weighted coefficient of variation, and systematic component of variance. Chi-squared-test was used to quantify the significance of variation of the adjusted ESS rates across regions.

RESULTS

The annual adjusted rate of ESS was 0.33 per 1000 people in Alberta, Canada. The mean extremal quotient for health status areas was 6.9, indicating a 7-fold difference between the highest and lowest regions. The mean coefficient of variation was 41.0, and the mean systematic component of variance was 10.5, which demonstrates "very high" variation.

CONCLUSION

This study observed very high geographic variation in the rates of ESS across the province of Alberta. Given the negative impact of unwarranted surgical variation on quality of care, outcomes from this study indicate a need to further evaluate the delivery of care for ESS in Canada to improve overall health system performance.

From tonsils to scopes: 80 years of variation in the practice of otolaryngology

Variation in medicine and surgery is a critical contemporary health policy issue. Recent research demonstrates that variation in Medicare payments to otolaryngologists in a single metropolitan area was attributable to differences in health care resource utilization among physicians and that the hospital with the highest Medicare payments per physician had a higher proportion of office endoscopy-related relative value units than that of other providers, relying less on evaluation and management office visits for revenue. This study is the latest in a line of fascinating case records of variation in otolaryngology and other surgical specialties dating back to the work of J. Alison Glover in 1938.