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Offodile AC, Lin YL, Shah SA, Swisher SG, Jain A, Butler CE, Aliu O. Is the Centralization of Complex Surgical Procedures an Unintended Spillover Effect of Global Capitation? - Insights from the Maryland Global Budget Revenue Program. Ann Surg 2023; 277:535-541. [PMID: 36512741 PMCID: PMC9994796 DOI: 10.1097/sla.0000000000005737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine if global budget revenue (GBR) models incent the centralization of complex surgical care. SUMMARY BACKGROUND In 2014, Maryland initiated a statewide GBR model. While prior research has shown improvements in cost and outcomes for surgical care post-GBR implementation, the mechanism remains unclear. METHODS Utilizing state inpatient databases, we compared the proportion of adults undergoing elective complex surgeries (gastrectomy, pneumonectomy/lobectomy, proctectomies, and hip/knee revision) at high-concentration hospitals (HCHs) in Maryland and control states. Annual concentration, per procedure, was defined as hospital volume divided by state volume. HCHs were defined as hospitals with a concentration at least at the 75 th percentile in 2010. We estimated the difference-in-differences (DiD) of the probability of patients undergoing surgery at HCHs before and after GBR implementation. FINDINGS Our sample included 122,882 surgeries. Following GBR implementation, all procedures were increasingly performed at HCHs in Maryland. States satisfied the parallel trends assumption for the centralization of gastrectomy and pneumonectomy/lobectomy. Post-GBR, patients were more likely to undergo gastrectomy (DiD: 5.5 p.p., 95% CI [2.2, 8.8]) and pneumonectomy/lobectomy (DiD: 12.4 p.p., 95% CI [10.0, 14.8]) at an HCH in Maryland compared with control states. For our hip/knee revision analyses, we assumed persistent counterfactuals and noted a positive DiD post-GBR implementation (DiD: 4.8 p.p., 95% CI [1.3, 8.2]). No conclusion could be drawn for proctectomy due to different pre-GBR trends. CONCLUSIONS GBR implementation is associated with increased centralization for certain complex surgeries. Future research is needed to explore the impact of centralization on patient experience and access.
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Affiliation(s)
- Anaeze C. Offodile
- Department of Plastic Surgery
- Department of Health Services Research
- Baker Institute for Public Policy, Rice University, Houston, TX
| | - Yu-Li Lin
- Department of Health Services Research
| | | | - Stephen G. Swisher
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center
| | | | | | - Oluseyi Aliu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD
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De Swart ME, Zonderhuis BM, Hellingman T, Kuiper BI, Dickhoff C, Heineman DJ, Hendrickx JJ, Kouwenhoven MC, Van Moorselaar RJA, Schuur M, Tenhagen M, Van Der Velde S, De Witt Hamer PC, Zijlstra JM, Kazemier G. Incomplete patient information exchange and unnecessary repeat diagnostics during oncological referrals in the Netherlands: exploring the role of information exchange. Health Informatics J 2023; 29:14604582231153795. [PMID: 36708072 DOI: 10.1177/14604582231153795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Data management in transmural care is complex. Without digital innovations like Health Information Exchange (HIE), patient information is often dispersed and inaccessible across health information systems between hospitals. The extent of information loss and consequences remain unclear. We aimed to quantify patient information availability of referred oncological patients and to assess its impact on unnecessary repeat diagnostics by observing all oncological multidisciplinary team meetings (MDTs) in a tertiary hospital. During 84 multidisciplinary team meetings, 165 patients were included. Complete patient information was provided in 17.6% (29/165, CI = 12.3-24.4) of patients. Diagnostic imaging was shared completely in 52.5% (74/141, CI = 43.9-60.9), imaging reports in 77.5% (100/129, CI = 69.2-84.2), laboratory results in 55.2% (91/165, CI = 47.2-62.8), ancillary test reports in 58.0% (29/50, CI = 43.3-71.5), and pathology reports in 60.0% (57/95, CI = 49.4-69.8). A total of 266 tests were performed additionally, with the main motivation not previously performed followed by inconclusive or insufficient quality of previous tests. Diagnostics were repeated unnecessarily in 15.8% (26/165, CI = 10.7-22.4) of patients. In conclusion, patient information was provided incompletely in majority of referrals discussed in oncological multidisciplinary team meetings and led to unnecessary repeat diagnostics in a small number of patients. Additional research is needed to determine the benefit of Health Information Exchange to improve data transfer in oncological care.
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Affiliation(s)
- Merijn E De Swart
- Department of Surgery, Cancer Center Amsterdam, Ringgold: 1209Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Barbara M Zonderhuis
- Department of Surgery, Cancer Center Amsterdam, Ringgold: 1209Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Tessa Hellingman
- Department of Surgery, Cancer Center Amsterdam, Ringgold: 1209Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Babette I Kuiper
- Department of Surgery, Cancer Center Amsterdam, Ringgold: 1209Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Chris Dickhoff
- Department of Surgery, Cancer Center Amsterdam, Ringgold: 1209Amsterdam UMC, VU University Medical Center, The Netherlands
| | - David J Heineman
- Department of Surgery, Cancer Center Amsterdam, Ringgold: 1209Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Jan J Hendrickx
- Department of Otolaryngology-Head and Neck Surgery, Cancer Center Amsterdam, Ringgold: 1209Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Mathilde Cm Kouwenhoven
- Department of Neurology, Cancer Center Amsterdam, Ringgold: 1209Amsterdam UMC, VU University Medical Center, The Netherlands
| | - R Jeroen A Van Moorselaar
- Department of Urology, Cancer Center Amsterdam, Ringgold: 1209Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Maaike Schuur
- Department of Neurology, Cancer Center Amsterdam, Ringgold: 1209Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Mark Tenhagen
- Department of Surgery, Cancer Center Amsterdam, Ringgold: 1209Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Susanne Van Der Velde
- Department of Surgery, Cancer Center Amsterdam, Ringgold: 1209Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Philip C De Witt Hamer
- Department of Neurosurgery, Cancer Center Amsterdam, Ringgold: 1209Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Josée M Zijlstra
- Department of Hematology, Cancer Center Amsterdam, Ringgold: 1209Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Ringgold: 1209Amsterdam UMC, VU University Medical Center, The Netherlands
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Stenger M, Jakobsen E, Wright G, Zalcberg J, Stirling RG. A comparison of outcomes and survival between Victoria and Denmark in lung cancer surgery: opportunities for international benchmarking. ANZ J Surg 2021; 92:1050-1055. [PMID: 34676962 DOI: 10.1111/ans.17302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/25/2021] [Accepted: 09/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUNDS Victoria (Australia) and Denmark have comparable population sizes and high-quality healthcare systems. Lung cancer surgery, however, is performed in more than 20 Victorian hospitals compared to four in Denmark. Such differences in centralization may influence outcomes. We engaged clinical quality registries to enable international benchmarking by exploring patterns of lung cancer surgery including mortality and survival. METHODS All patients undergoing lung cancer surgery between 2015 and 2018 registered in the Victorian Lung Cancer Registry and the Danish Lung Cancer Registry were included. Analyses on stage concordance, 30 and 90-day mortality, and overall survival were restricted to a selected subgroup with NSCLC and no neo-adjuvant therapy or metastatic disease and only one operation. RESULTS We included 1554 Victorian and 4319 Danish patients. The resection rate was 26.3% in Victoria and 28% in Denmark, but a higher proportion of Victorian patients underwent wedge resection (19.1% versus 8.8%). Stage concordance was 59.6% and 54.9% in Victoria and Denmark, respectively. The 30- and 90-day mortality was 1.3% and 2.6% in Victoria, compared to 1.4% and 2.8% in Denmark with no difference in overall survival (p = 0.28) or risk-adjusted survival (HR: 1.10 (95% CI: 0.89-1.37); p = 0.38). CONCLUSION High-quality surgical lung cancer care was confirmed by similar high resection and low mortality rates including no overall survival difference. The drivers and consequences of stage discordance and differences in patterns of resection deserve further exploration. This study provides a model for international benchmarking using clinical quality registries, although caution remains in the interpretation given disparities in data completeness.
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Affiliation(s)
- Michael Stenger
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark.,OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Erik Jakobsen
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark.,OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Gavin Wright
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - John Zalcberg
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Robert G Stirling
- Respiratory Medicine, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
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Evers J, de Jaeger K, Hendriks LEL, van der Sangen M, Terhaard C, Siesling S, De Ruysscher D, Struikmans H, Aarts MJ. Trends and variations in treatment of stage I-III non-small cell lung cancer from 2008 to 2018: A nationwide population-based study from the Netherlands. Lung Cancer 2021; 155:103-113. [PMID: 33774382 DOI: 10.1016/j.lungcan.2021.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION This Dutch population-based study describes nationwide treatment patterns and its variations for stage I-III non-small cell lung cancer (NSCLC). MATERIALS AND METHODS Patients diagnosed with clinical stage I-III NSCLC in the period 2008-2018 were selected from the Netherlands Cancer Registry. Treatment trends were studied over time and age groups. Use of radiotherapy versus surgery (stage I-II), and concurrent versus sequential chemoradiotherapy (stage III) were analyzed by logistic regression. RESULTS In stage I, the rate of surgery decreased from 58 % (2008) to 40 % (2018) while radiotherapy use increased over time (from 31 % to 52 %), which mostly concerned stereotactic body radiotherapy (74 %). In stage II, 54 % of patients received surgery, and use of radiotherapy alone increased from 18 % to 25 %. The strongest factors favoring radiotherapy over surgery were WHO performance status (OR ≥ 2 vs 0: 23.39 (95% CI: 18.93-28.90)), increasing age (OR ≥ 80 vs <60 years: 14.52 (95% CI: 13.02-16.18)) and stage (OR stage II vs I: 0.61 (95% CI: 0.57-0.65)). In stage III, the combined use of chemotherapy and radiotherapy increased from 35 % (2008) to 39 % (2018). In all years, 23 % received concurrent chemoradiotherapy, 9 % sequential chemoradiotherapy, 23 % radiotherapy or chemotherapy alone, and 25 % best supportive care. The strongest factors favoring concurrent over sequential chemoradiotherapy were age (OR ≥ 80 vs <60 years: 0.14 (95% CI: 0.10-0.19)), WHO Performance status (OR ≥ 2 vs 0: 0.33 (95% CI: 0.24-0.47)) and region (OR east vs north: 0.39 (95% CI: 0.30-0.50)). CONCLUSIONS The use of radiotherapy became more prominent over time in stage I NSCLC. Combined use of chemotherapy and radiotherapy marginally increased in stage III: only one third of patients received chemoradiotherapy, mainly concurrently. Treatment variation seen between patient groups suggests tailored treatment decision, while variation between hospitals and regions indicate differences in clinical practice.
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Affiliation(s)
- Jelle Evers
- Netherlands Comprehensive Cancer Organisation (IKNL), Department of Research and Development, Godebaldkwartier 419, 3511 DT Utrecht, the Netherlands; University of Twente, Department of Health Technology and Services Research, Hallenweg 5, 7522 NH Enschede, the Netherlands.
| | - Katrien de Jaeger
- Catharina Hospital, Department of Radiation Oncology, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands.
| | - Lizza E L Hendriks
- Maastricht University Medical Center, GROW School for Oncology and Developmental Biology, Department of Pulmonary Diseases, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands.
| | - Maurice van der Sangen
- Catharina Hospital, Department of Radiation Oncology, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands.
| | - Chris Terhaard
- Utrecht University Medical Center, Department of Radiation Oncology, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands.
| | - Sabine Siesling
- Netherlands Comprehensive Cancer Organisation (IKNL), Department of Research and Development, Godebaldkwartier 419, 3511 DT Utrecht, the Netherlands; University of Twente, Department of Health Technology and Services Research, Hallenweg 5, 7522 NH Enschede, the Netherlands.
| | - Dirk De Ruysscher
- Maastricht University Medical Center, GROW School for Oncology and Developmental Biology, Department of Radiation Oncology (MAASTRO Clinic), Doctor Tanslaan 12, 6229 ET Maastricht, the Netherlands.
| | - Henk Struikmans
- Leiden University Medical Centre, Department of Radiation Oncology, Albinusdreef 2, 2333 ZA Leiden, the Netherlands.
| | - Mieke J Aarts
- Netherlands Comprehensive Cancer Organisation (IKNL), Department of Research and Development, Godebaldkwartier 419, 3511 DT Utrecht, the Netherlands.
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