Hospital Teaching Status and Medicare Expenditures for Complex Surgery (original) (raw)
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Journal of Surgical Research, 2014
Background The impact of regionalization on morbidity, failure to rescue (FTR), length of stay (LOS), and readmission remains unclear. We sought to examine hospital-volume-related differences in outcomes following complex hepato-pancreatico-biliary (HPB) surgery and define potential benefits of regionalization across quality metrics. Methods Patients undergoing HPB surgery in the Surveillance, Epidemiology and End Results (SEER)-Medicare linked data from 1986 to 2002 were identified. Hospital volume was stratified into tertiles (low volume [LV] <4 cases/year; intermediate volume [IV] 4-10 cases/year; high volume [HV] ≥11 cases/year). The incidence of complications, FTR (mortality following a complication), and LOS was compared across hospital-volume strata. A counterfactual model examined hypothetical outcomes assuming all patients had been treated at HV centers. Results Ten thousand two hundred eight patients underwent pancreatic (46.1 %), hepatic (36.2 %), or biliary (17.8 %) procedures. Overall mean age ranged from 72.7 years at HV centers to 73.4 at LV centers (P<0.001), and patients at HV centers (75.4 %) were more likely to have ≥3 comorbidities versus IV (70.0 %) or LV (64.7 %) centers (P<0.001). The incidence of post-operative complications was lower at HV (39.1 %) compared with IV (41.9 %) or LV (44.8 %) centers. Major complications included hemorrhagic anemia (7.3 %), failure to thrive (5.1 %), and respiratory infection/failure (3.5 %); each was less common in HV hospitals (P<0.05). FTR after major complication tended to be higher at LV (36.7 %) and IV (37.3 %) hospitals compared with HV hospitals (29.7 %) (P=0.10). Mortality was higher at LV (10.5 %) and IV (8.1 %) hospitals versus HV centers (5.4 %) (P<0.001). HV hospital patients had shorter median LOS (10 days) compared with IV (12 days) or LV (12 days) hospital patients (P<0.001). Readmission varied across centers (HV 19.1 % vs. IV 19.2 % vs. 16.7 %; P=0.02). In a counterfactual model with all patients treated at a HV center, 6.4 % fewer complications and a 26.0 % increase in post-complication rescue would be expected, along with a 32.0 % reduction in index mortality and an 8.1 % reduction in total patient-days. A minor increase in readmissions (7.1 %) would be anticipated with 13.3 % fewer deaths during readmission. Conclusion Although patients treated at HV hospitals had more medical comorbidities, outcomes across a wide spectrum of quality metrics were better than at IV or LV hospital following complex HPB surgery. A 20-30 % reduction in morbidity and mortality and an 8 % reduction in hospital patient-days could be anticipated had all patients been treated at HV hospitals.
Journal of the American College of Surgeons, 2009
BACKGROUND: Although the relationship between hepato-pancreato-biliary (HPB) procedure volume and outcomes is established, the relative importance of hospital and surgeon effects and the specificity of the volume-outcomes effect remain ill-defined. We sought to comprehensively characterize the hospital and surgeon volume-outcomes relationships in high-risk HPB surgery. STUDY DESIGN: The 1998 to 2005 State Inpatient Databases for Florida, Maryland, and New York were used to identify patients undergoing complex HPB surgery and to quantify hospital and surgeon procedure volumes. The effects of hospital and surgeon procedure volumes on casemix-adjusted inpatient mortality were analyzed using multilevel logistic regression models.
Annals of Surgery, 2014
To determine the relationship between complications after 3 common general surgery procedures and per-episode hospital finances. Background: With impending changes in health care reimbursement, maximizing the value of care delivered is paramount. Data on the relative clinical and financial impact of postoperative complications are necessary for directing surgical quality improvement efforts. Methods: We reviewed the medical records of patients enrolled in the American College of Surgeons' National Surgical Quality Improvement Program who underwent pancreaticoduodenectomy, hepatectomy, and colectomy at a single academic institution between September 2009 and August 2012. Clinical outcomes data were subsequently linked with hospital billing data to determine hospital finances associated with each episode. We describe the association between postoperative complications, hospital length of stay, and different financial metrics. Multivariable linear regression modeling tested linear association between postoperative outcomes and cost data. Results: There was a positive association between the number of surgical complications, payments, length of stay, total charges, total costs, and contribution margin for the three procedures. Multivariable models indicated that complications were independently associated with total cost among the selected procedures. Payments increased with complications, offsetting increased costs. Conclusions: In the current fee-for-service environment, the financial incentives are misaligned with quality improvement efforts. As we move to a valuedriven method of reimbursement, administrators and health care providers alike will need to focus on improving the quality of patient care while remaining conscious of the cost of care delivered. Reducing complications effectively improves value.
Hospital Volume and the Costs Associated with Surgery for Pancreatic Cancer
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, 2017
Data evaluating the financial implications of volume-based referral are lacking. This study sought to compare in-hospital costs for pancreatic surgery by annual hospital volume. Eleven thousand and eighty-one patients aged ≥18 years undergoing an elective pancreatic resection for cancer were identified using the Nationwide Inpatient Sample 2002-2011. Multivariable regression analysis was performed to compare length-of-stay (LOS), postoperative morbidity and mortality, failure-to-rescue (FTR), and inpatient costs by annual hospital volume group. Patients undergoing surgery at high-volume hospitals (HVH) demonstrated 23% lower odds (odds ratio [OR] = 0.77, 95% confidence interval [95%CI] 0.63-0.95) of developing a postoperative complication, 59% lower odds of experiencing an LOS > 14 days (OR = 0.41, 95%CI 0.34-0.50), 51% lower odds of postoperative mortality (OR = 0.49, 95%CI 0.34-0.71), and 47% lower odds of FTR (OR = 0.53, 95%CI 0.37-0.76; all p<0.05). The overall mean in-hos...
HPB : the official journal of the International Hepato Pancreato Biliary Association, 2018
Pancreatic surgery outcomes are associated with surgeon and center experience. Anesthesiologists as potential value drivers for pancreatic surgery have not been explored. We sought to evaluate whether anesthesiologists impact perioperative costs for pancreatic surgery. Within an integrated health care system, 796 pancreatic surgeries (526 PDs and 270 DPs) were performed from January 2014 to June 2017. Mean direct operative and anesthesia costs driven by anesthesiologists (operating room (OR) time, anesthesia billing and anesthesia procedures) were determined for each case. The volumes of pancreatic cases per anesthesiologist were calculated, and those above the 75th percentile for volume (4 cases) were considered high-volume. A multivariable analysis of OR/anesthesia costs was performed. Mean OR and anesthesia costs for PD were 7064forlow−volumeanesthesiologists(LVA),higherthan7064 for low-volume anesthesiologists (LVA), higher than 7064forlow−volumeanesthesiologists(LVA),higherthan5968 for high-volume anesthesiologists (HVA) (p < 0.001). By multivariable analysis, HVA were a...
Journal of The American College of Surgeons, 1999
Background: Commonly performed elective gastrointestinal surgical procedures are carried out with low morbidity and mortality in hospitals throughout the United States. Complex operative procedures on the alimentary tract are performed with a relatively low frequency and are associated with higher mortality. Volume and experience of the surgical provider team have been correlated with better clinical and economic outcomes for one complex gastrointestinal surgical procedure, pancreaticoduodenectomy. This study evaluated whether provider volume and experience were important factors influencing clinical and economic outcomes for a variety of complex gastrointestinal surgical procedures in one state.
Variations in payment patterns for surgical care in the centers for Medicare and Medicaid Services
Surgery, 2016
We investigated provider and regional variation in payments made to surgeons by the Centers for Medicare & Medicaid Services (CMS) by indexing payments to unique beneficiaries treated and examined the proportion of charges that resulted in payments. Understanding variation in care within CMS may prove actionable by identifying modifiable, and potentially unwarranted, variations. We analyzed the Medicare Part B Provider Utilization and Payment Data released by CMS for 2012. We included Medicare B participants in the fee-for-service program. We calculated for each provider the ratio of number of services provided to individual beneficiaries, and the ratio of total submitted charges to total Medicare payments. We also categorized each provider into deciles of total Medicare payments, and calculated the means per decile of total Medicare payment for surgeons and urologists. To determine any associations with ratio of services to beneficiaries, we conducted multivariate linear regression...
HPB : the official journal of the International Hepato Pancreato Biliary Association, 2017
A cost analyses of complications following pancreaticoduodenectomy (PD) was performed in a high volume hepato-biliary-pancreatic service. We hypothesised that costs are increased with both severity and number of complications; we investigated the relationship between complications and specific cost centres. 100 patients from 2011 to 2016 were included. Data relating to their perioperative course were collected. Complications were documented by the Clavien-Dindo classification and costs were inflated and converted to 2017 USD. Mean hospital costs in complicated patients more than doubled those of uncomplicated patients ($28 330 vs. $57 150, p < 0.0001). Total hospital costs significantly increased with both severity and number of complications. This cost increase was influenced by medical consult, pathology, pharmacy, radiology, ward, intensive care, and allied health costs, but not operating theatre or anaesthesia costs. Postoperative pancreatic fistula, postoperative haemorrhage...