Local referrals as a strategy for increasing value of surgical care among medicare patients undergoing liver and pancreatic surgery

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.

Travel Patterns among Patients Undergoing Hepatic Resection in California: Does Driving Further for Care Improve Outcomes?

BACKGROUND

Better outcomes at high-volume surgical centers have driven regionalization of complex surgical care. In turn, access to high-volume centers often requires travel over longer distances. We sought to characterize travel patterns among patients who underwent a hepatectomy.

METHODS

The California Office of Statewide Health Planning database was used to identify patients who underwent hepatectomy between 2005 and 2016. Total distance traveled and whether a patient bypassed the nearest hospital that performed hepatectomy to get to a higher-volume center were assessed. Multivariate analyses were used to identify factors associated with bypassing a local hospital for a higher-volume center.

RESULTS

Overall, 13,379 adults underwent a hepatectomy in 229 hospitals; only 26 hospitals were high volume (> 15 cases/year). Median travel time to a hospital that performed hepatectomy was 25.2 min (IQR: 13.1-52.0). The overwhelming majority of patients (91.6%) bypassed the nearest providing hospital to seek care at a destination hospital. Among patients who bypassed a closer hospital, 75.5% went to a high-volume hospital. Outcomes at destination hospitals were improved compared with nearest hospitals (incidence of complications: 20.4% vs. 22.9% %; failure-to-rescue: 7.1% vs 10.9%; mortality 1.5% vs. 2.6%). Medicaid beneficiaries (OR 0.69, 95%CI 0.56-0.85) were less likely to bypass the nearest hospital to go to a high-volume hospital; additionally, Medicaid patients were less likely to undergo hepatectomy at a high-volume hospital independent of bypassing the nearest hospital (OR 0.60, 95%CI 0.48-0.76). Among the 3703 patients who underwent hepatectomy at a low-volume center, 2126 patients had actually bypassed a high-volume hospital. Among the remaining 1577 patients, 95% of individuals would have needed to travel less than 1 additional hour to reach a high-volume center.

CONCLUSION

Roughly, one-quarter of patients undergoing hepatectomy received care at a low-volume center; nearly all of these patients either bypassed a high-volume hospital or would have needed to travel less than an additional hour to reach a high-volume center. Travel distance needs to be considered in policies and healthcare delivery design to improve care of patients undergoing hepatic resection.

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.

Accessing surgical care for esophageal cancer: patient travel patterns to reach higher volume center

While better outcomes at high-volume surgical centers have driven the regionalization of complex surgical care, access to high-volume centers often requires travel over longer distances. We sought to evaluate the travel patterns among patients undergoing esophagectomy to assess willingness of patients to travel for surgical care. The California Office of Statewide Health Planning database was used to identify patients who underwent esophagectomy between 2005 and 2016. Total distance traveled, as well as whether a patient bypassed the nearest hospital that performed esophagectomy to get to a higher volume center, was assessed. Overall 3,269 individuals underwent an esophagectomy for cancer in 154 hospitals; only five hospitals were high volume according to Leapfrog standards. Median travel time to a hospital that performed esophagectomy was 26 minutes (IQR: 13.1-50.7). The overwhelming majority of patients (85%) bypassed the nearest providing hospital to seek care at a destination hospital. Among patients who bypassed a closer hospital, only 36% went to a high-volume hospital. Of the 2,248 patients who underwent esophagectomy at a low-volume center, 1,491 patients had bypassed a high-volume hospital. Of the remaining 757 patients who did not bypass a high-volume hospital, half of the individuals would have needed to travel less than an additional hour to reach a high-volume center. Nearly two-thirds of patients undergoing an esophagectomy for cancer received care at a low-volume center; 85% of patients either bypassed a high-volume hospital or would have needed to travel less than an additional hour to reach a high-volume center.

Accessing surgical care for pancreaticoduodenectomy: Patient variation in travel distance and choice to bypass hospitals to reach higher volume centers

BACKGROUND

While better outcomes at high-volume surgical centers have driven regionalization of complex surgical care, access to high-volume centers often requires travel over longer distances. We sought to evaluate travel patterns of patients undergoing pancreaticoduodenectomy (PD) for pancreatic cancer to assess willingness of patients to travel for surgical care.

METHODS

The California Office of Statewide Health Planning database was used to identify patients who underwent PD between 2005 and 2016. Total distance traveled, as well as whether a patient bypassed the nearest hospital that performed PD to get to a higher-volume center was assessed. Multivariate analyses were used to identify factors associated with bypassing a local hospital for a higher-volume center.

RESULTS

Among 23 014 patients who underwent PD, individuals traveled a median distance of 18.0 miles to get to a hospital that performed PD. The overwhelming majority (84%) of patients bypassed the nearest providing hospital and traveled a median additional 16.6 miles to their destination hospital. Among patients who bypassed the nearest hospital, 13,269 (68.6%) did so for a high-volume destination hospital. Specifically, average annual PD volume at the nearest "bypassed" vs final destination hospital was 29.6 vs 56 cases, respectively. Outcomes at bypassed vs destination hospitals varied (incidence of complications: 39.2% vs 32.4%; failure-to-rescue: 14.5% vs 9.1%). PD at a high-volume center was associated with lower mortality (OR = 0.46 95% CI, 0.22-0.95). High-volume PD ( > 20 cases) was predictive of hospital bypass (OR = 3.8 95% CI, 3.3-4.4). Among patients who had surgery at a low-volume center, nearly 20% bypassed a high-volume hospital in route. Furthermore, among patients who did not bypass a high-volume hospital, one-third would have needed to travel only an additional 30 miles or less to reach the nearest high-volume hospital.

CONCLUSION

Most patients undergoing PD bypassed the nearest providing hospital to seek care at a higher-volume hospital. While these data reflect increased regionalization of complex surgical care, nearly 1 in 5 patients still underwent PD at a low-volume center.