Is quality costly? Patient and hospital cost drivers in vascular surgery

Time is money: An analysis of cost drivers in ambulatory sinus surgery

BACKGROUND

Functional endoscopic sinus surgery (FESS) is one of the most commonly performed otolaryngologic procedures and is associated with significant cost variability.

METHODS

We performed a retrospective analysis of all inflammatory sinus surgeries at a single tertiary care medical center from July 2021 to July 2023. The electronic medical record was reviewed for patient factors and cost variables for each procedure, and multivariable analysis was performed.

RESULTS

A total of 221 patients were included in analysis with a mean age of 48.2 years. There was a 44.8% incidence (n = 99) of nasal polyps and 31.2% (n = 69) of cases were revision surgeries. The average total cost for the surgical encounter was $8960.31 (standard deviation $1967.97). Operating room time represented $4912.46 (54.8% of all costs), while average operating room supply costs were $1296.06 (14.5%) and recovery room costs were $919.48 (10.3%). Total costs were significantly associated with length of surgery ($7.83/min, p = 0.04), in addition to presence of nasal polyps ($531.96, p = 0.04). There was no significant association between total costs and the remaining clinical and demographic factors.

CONCLUSIONS

Costs associated with ambulatory FESS for inflammatory sinus disease vary across patients and this cost variability is predominantly driven by time efficiency within the operating room, as well as supply utilization and nasal polyposis to a lesser degree. As a result, operating room efficiency represents a primary target for cost-related interventions. Additionally, our data provide a framework for surgeons and hospitals to make evidence-based decisions on intraoperative equipment in a tradeoff between efficiency and supply costs. Our findings indicate that an approach focused on streamlining efficiency across the entire ambulatory surgery encounter will have the greatest impact on reducing healthcare expenses for both the patient and the health system.

Assessment of Determinants of Value in Carotid Endarterectomy

OBJECTIVE

Over 150,000 carotid endarterectomies (CEA) are performed annually worldwide, accounting for $900 million in the US alone. How cost/spending and quality are related is not well understood but remains an essential component in maximizing value. We sought to identify determinants of variability in hospital 90-day episode value for CEA.

METHODS

Medicare and private-payer admissions for CEA from January 2^nd, 2014 to August 28^th, 2020 were linked to retrospective clinical registry data for hospitals in Michigan performing vascular surgery. Hospital-specific risk-adjusted 30-day composite complications (defined as reoperation, new neurologic deficit, myocardial infarction, additional procedure including CEA or carotid artery stenting, readmission, or mortality) and 30-day risk-adjusted, price standardized total episode payments were used to categorize hospitals into low or high value by defining the intersection between complications and spending.

RESULTS

A total of 6595 patients across 39 hospitals were identified across both datasets. Patients at low-value hospitals had a higher rate of 30-day composite complications (17.9% vs 10.1%, p<0.001) driven by a significantly higher rate of reoperation (3.0% vs 1.4%, p=0.016), readmission (10.7% vs 6.2%, p=0.012), new neurologic deficit (4.6% vs 2.3%, p=0.017), and mortality (1.6% vs 0.6%, p<0.049). Mean total episode payments were $19,635 at low-value hospitals compared to $15,709 at high-value hospitals driven by index hospitalization ($10,800 vs $9587, p= 0.002), professional ($3421 vs $2827, p < 0.001), readmission ($3011 vs $1826, p < 0.001) and post-acute care payments ($2335 vs $1486, p < 0.001). Findings were similar when only including patients who did not suffer a complication.

CONCLUSIONS

There is tremendous variation in both quality and payments across hospitals included for CEA. Importantly, costs were higher at low-value hospitals independent of post-operative complication. There appears to be little to no relationship between total episode spending and surgical quality, suggesting that improvements in value may be possible by decreasing total episode cost without affecting surgical outcomes.

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.

A Systematic Review of the Association Between Hospital Cost/price and the Quality of Care

BACKGROUND

Limited empirical evidence exists regarding the effect of price changes on hospital behavior and, ultimately, the quality of care. Additionally, an overview of the results of prior literature is lacking.

OBJECTIVE

This study aims to provide a synthesis of existing research concerning the relationship between hospital cost/price and the quality of care.

METHODS

Searches for literature related to the effect of hospital cost and price on the quality of care, including studies published between 1990 and March 2019, were carried out using four electronic databases. In total, 47 studies were identified, and the data were extracted and summarized in different tables to identify the patterns of the relationships between hospital costs/prices and the quality of care.

RESULTS

The study findings are highly heterogenous. The proportion of studies detecting a significant positive association between price/cost and the quality of care is higher when (a) price/reimbursement is used (instead of cost); (b) process measures are used (instead of outcome measures); (c) the focus is on acute myocardial infarction, congestive heart failure, and stroke patients (instead of patients with other clinical conditions or all patients); and (d) the methodological approach used to address confounding is more sophisticated.

CONCLUSION

Our results suggest that there is no general relationship between cost/price and the quality of care. However, the relationship seems to depend on the condition and specific resource utilization. Policy makers should be prudent with the measures used to reduce hospital costs to avoid endangering the quality of care, especially in resource-sensitive settings.

Multidimensional performance assessment of public sector organisations using dominance criteria

Public sector organisations pursue multiple objectives and serve a number of stakeholders. But stakeholders are rarely explicit about the valuations they attach to different objectives, nor are these valuations likely to be identical. This complicates the assessment of their performance because no single set of weights can be chosen legitimately to aggregate outputs into unidimensional composite scores. We propose the use of dominance criteria in a multidimensional performance assessment framework to identify best practice and poor performance under relatively weak assumptions about stakeholders' preferences. We use as an example providers of hip replacement surgery in the English National Health Service and estimate multivariate multilevel models to study their performance in terms of length of stay, readmission rates, post-operative patient-reported health status and waiting time. We find substantial correlation between objectives and demonstrate that ignoring the correlation can lead to incorrect assessments of performance.

The cost-quality relationship in European hospitals: a systematic review

Objective To determine the relationship between cost and quality in European hospitals. Methods Juran's cost-quality curve served as a theoretical framework, linked to basic efficiency concepts. Based on systematic database searches, citation searches and cross-referencing, we identify 1093 empirical studies. After exclusion of studies from outside Europe (699), non-hospital settings (10 studies), lack of a cost parameter (194) or a quality parameter (27 studies), 22 studies (28 analyses) were assessed for direction of association and methodological heterogeneity. Results There was evidence of positive, negative, two-directional and no association between cost and quality. We examined whether diagnosis, procedure, type of quality measure and specification of the econometric model could explain the inconsistent evidence, but no clear explanation is identified. Despite the significant policy relevance, evidence on the relationship between costs and quality is limited. The literature is characterized by substantial methodological heterogeneity and lack of explicit definitions of the chosen cost and quality parameters, the econometric model and the underlying hypothesis for the cost-quality relationship. Conclusion It has been more than 60 years since Juran introduced the idea of failure costs, which implied that the marginal costs of quality could be non-constant. It seems imperative to acknowledge this idea in future studies.

Differences between determinants of in-hospital mortality and hospitalisation costs for patients with acute heart failure: a nationwide observational study from Japan

OBJECTIVES

Although current case-mix classifications in prospective payment systems were developed to estimate patient resource usage, whether these classifications reflect clinical outcomes remains unknown. The efficient management of acute heart failure (AHF) with high mortality is becoming more important in many countries as its prevalence and associated costs are rapidly increasing. Here, we investigate the determinants of in-hospital mortality and hospitalisation costs to clarify the impact of severity factors on these outcomes in patients with AHF, and examine the level of agreement between the predicted values of mortality and costs.

DESIGN

Cross-sectional observational study.

SETTING AND PARTICIPANTS

A total of 19 926 patients with AHF from 261 acute care hospitals in Japan were analysed using administrative claims data.

MAIN OUTCOME MEASURES

Multivariable logistic regression analysis and linear regression analysis were performed to examine the determinants of in-hospital mortality and hospitalisation costs, respectively. The independent variables were grouped into patient condition on admission, postadmission procedures indicating disease severity (eg, intra-aortic balloon pumping) and other high-cost procedures (eg, single-photon emission CT). These groups of independent variables were cumulatively added to the models, and their effects on the models' abilities to predict the respective outcomes were examined. The level of agreement between the quartiles of predicted mortality and predicted costs was analysed using Cohen's κ coefficient.

RESULTS

In-hospital mortality was associated with patient's condition on admission and severity-indicating procedures (C-statistics 0.870), whereas hospitalisation costs were associated with severity-indicating procedures and high-cost procedures (R² 0.32). There were substantial differences in determinants between the outcomes. In addition, there was no consistent relationship observed (κ=0.016, p<0.0001) between the quartiles of in-hospital mortality and hospitalisation costs.

CONCLUSIONS

The determinants of mortality and costs for hospitalised patients with AHF were generally different. Our results indicate that the same case-mix classifications should not be used to predict both these outcomes.