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Offodile AC, Lin YL, Melamed A, Rauh-Hain JA, Kinzer D, Keating NL. Association of Maryland Global Budget Revenue With Spending and Outcomes Related to Surgical Care for Medicare Beneficiaries With Cancer. JAMA Surg 2022; 157:e220135. [PMID: 35385085 PMCID: PMC8988019 DOI: 10.1001/jamasurg.2022.0135] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance In 2014, Maryland initiated the global budget revenue (GBR) model, placing caps on total hospital expenditures across all care sites. The GBR program aims to reduce unnecessary utilization while maintaining or improving care quality. To date, there has been limited examination of program effects on cancer care. Objective To compare changes in spending, clinical outcomes, and acute care utilization through 4 years of the GBR program among Medicare beneficiaries who undergo cancer-directed surgery in Maryland vs matched control states. Design, Setting, and Participants Drawing from a matched pool of hospitals in Maryland (n = 35) and 24 control states with a similar timing of Medicaid expansion (n = 101), we identified Medicare beneficiaries from Maryland and control states who underwent any cancer-directed surgery from 2011 through 2018. Using difference-in-differences analysis, we compared changes in outcomes from before (2011-2013) to after (2015-2018) GBR implementation between patients treated in Maryland and control states. We also performed a subgroup analysis among patients who underwent major surgical procedures that are usually performed in the inpatient setting (cystectomy, esophagectomy, gastrectomy, colorectal resection, nephrectomy, pancreatectomy, and lung resection). Main Outcomes and Measures Thirty-day episode spending, mortality, readmissions, and emergency department (ED) visits. Results Relative to Medicare beneficiaries undergoing cancer surgery in control states (n = 4737; 3323 [70.1%] female; 571 [12.1%] dual-eligible; mean [SD] age 74.9 [6.5] years), patients in Maryland (n = 20 320; 14 068 [69.2%] female; 1705 [8.4%] dual-eligible; mean [SD] age 74.9 [6.5] years) had a statistically significant reduction of 2.2 percentage points (95% CI, -4.3 to -0.1) in the 30-day readmission rate. We found no statistically significant changes in 30-day spending, mortality, or ED visits. We report no significant results in the subgroup analysis of patients undergoing major surgical procedures. Conclusions and Relevance Global budget revenue was not associated with changes in expenditures, ED utilization, or clinical outcomes after cancer-directed surgery through 4 years. There was a modest decline in 30-day readmissions. Specialty-specific definitions of care quality and better alignment across the entire care delivery value chain (ie, physician incentives) may be strategies that could improve delivery of high-value care for beneficiaries undergoing cancer surgery.
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Affiliation(s)
- Anaeze C Offodile
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston.,Baker Institute for Public Policy, Rice University, Houston, Texas.,Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston
| | - Yu-Li Lin
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston
| | - Alexander Melamed
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - J Alejandro Rauh-Hain
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston.,Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston
| | | | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Fitzgerald TL, Seymore NM, Kachare SD, Zervos EE, Wong JH. Measuring the Impact of Multidisciplinary Care on Quality for Pancreatic Surgery: Transition to a Focused, Very High-volume Program. Am Surg 2020. [DOI: 10.1177/000313481307900817] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Outcomes are superior for pancreatic resection at high-volume centers. To assess the impact of focused high-volume multidisciplinary care, a quality index (QI) was used to review our experience. Data from 1996 to July 2012 were analyzed in three groups: 1) early (1996 to 2007); 2) transition (2008 to 2009); and 3) mature (2010 to July 2012). A total of 239 patients were included with a mean age of 63.4 years and the majority were white (65.7%). The number of patients with Charlson comorbidity index greater than 2 and age older than 80 years increased comparing Group 1 with latter groups. Volume increased over time: Group 1 (n = 93) 7.75/year, Group 2 (n = 51) 25.5/year, and Group 3 (n = 95) 39/year. Overall mortality was 5.9 per cent: Group 1, 4.3 per cent; Group 2, 11.5 per cent; and Group 3, 3.9 per cent ( P = 0.0454). The QI score incorporates documentation, chemotherapy, resection for Stage I/II, time to treatment, margins, lymph nodes, mortality, and surgical volume with a maximum possible score 10. The QI increased over time: 3 in Group 1; 4 in Group 2; and 6 in Group 3. An improvement was noted for the quality indicators: surgical resection ( P = 0.0125) and use of palliative and adjuvant therapy ( P = 0.0144 and < 0.0001). Implementation of a focused multidisciplinary pancreatic surgery program increases quality.
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Affiliation(s)
- Timothy L. Fitzgerald
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina; and
- Lineberger Comprehensive Cancer Center, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Noah M. Seymore
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina; and
| | - Swapnil D. Kachare
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina; and
| | - Emmanuel E. Zervos
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina; and
- Lineberger Comprehensive Cancer Center, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Jan H. Wong
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina; and
- Lineberger Comprehensive Cancer Center, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
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Baack Kukreja JE, Kiernan M, Schempp B, Siebert A, Hontar A, Nelson B, Dolan J, Noyes K, Dozier A, Ghazi A, Rashid HH, Wu G, Messing EM. Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study. BJU Int 2016; 119:38-49. [PMID: 27128851 DOI: 10.1111/bju.13521] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine if patients managed with a cystectomy enhanced recovery pathway (CERP) have improved quality of care after radical cystectomy (RC), as defined by a decrease in length of hospital stay (LOS) without an increase in complications or readmissions compared with those not managed with CERP. SUBJECTS AND METHODS The Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study was a non-randomized quasi-experimental study. Data were collected between June 2011 and April 2015. The CERP was implemented in July 2013. The primary endpoint was LOS. Secondary endpoints were quality scores, complications and readmissions. Multivariable regression was performed. Propensity score matching was carried out to further simulate randomized clinical trial conditions. A CERP quality composite score was created and evaluated with regard to adherence to CERP elements. RESULTS The study included 79 patients managed with CERP and 121 who were not managed with CERP. After matching, there were 75 patients in the non-CERP group. The LOS was significantly different between the groups: the median LOS was 5 and 8 days for the CERP and non-CERP group, respectively (P < 0.001). Multivariable linear regression showed that any complication was the most significant predictor of total LOS at 90 days after RC. The higher the quality composite score the shorter the LOS (P < 0.001). There was no association between CERP and a greater number of complications or readmissions. CONCLUSIONS Audited quality measures in the CERP are associated with a reduction in LOS with no increase in readmissions or complications. The CERP is important for the future improvement of peri-operative care for RC and provides an opportunity to improve the quality of care provided.
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Affiliation(s)
- Janet E Baack Kukreja
- Department of Urology, Strong Memorial Hospital University of Rochester Medical Center, Rochester, NY, USA
| | - Maureen Kiernan
- Department of Urology, Strong Memorial Hospital University of Rochester Medical Center, Rochester, NY, USA
| | - Bethany Schempp
- School of Nursing, University of Rochester Medical Center, Rochester, NY, USA
| | - Aisha Siebert
- School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY, USA
| | - Adriana Hontar
- Department of Urology, Strong Memorial Hospital University of Rochester Medical Center, Rochester, NY, USA
| | - Benjamin Nelson
- Department of Urology, Strong Memorial Hospital University of Rochester Medical Center, Rochester, NY, USA
| | - James Dolan
- Department of Public Health Sciences, Strong Memorial Hospital University of Rochester Medical Center, Rochester, NY, USA
| | - Katia Noyes
- Department of Surgery, Strong Memorial Hospital University of Rochester Medical Center, Rochester, NY, USA
| | - Ann Dozier
- Department of Public Health Sciences, Strong Memorial Hospital University of Rochester Medical Center, Rochester, NY, USA
| | - Ahmed Ghazi
- Department of Urology, Strong Memorial Hospital University of Rochester Medical Center, Rochester, NY, USA
| | - Hani H Rashid
- Department of Urology, Strong Memorial Hospital University of Rochester Medical Center, Rochester, NY, USA
| | - Guan Wu
- Department of Urology, Strong Memorial Hospital University of Rochester Medical Center, Rochester, NY, USA
| | - Edward M Messing
- Department of Urology, Strong Memorial Hospital University of Rochester Medical Center, Rochester, NY, USA
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Billmire DF, Rescorla FJ, Ross JH, Schlatter MG, Dicken BJ, Krailo MD, Rodriguez-Galindo C, Olson TA, Cullen JW, Frazier AL. Impact of central surgical review in a study of malignant germ cell tumors. J Pediatr Surg 2015; 50:1502-5. [PMID: 25783295 PMCID: PMC5149399 DOI: 10.1016/j.jpedsurg.2014.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 12/07/2014] [Accepted: 12/13/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Verification of surgical staging has received little attention in clinical oncology trials. Central surgical review was undertaken during a study of malignant pediatric germ cell tumors. METHODS Children's Oncology Group study AGCT0132 included central surgical review during the study. Completeness of submitted data and confirmation of assigned stage were assessed. Review responses were: assigned status confirmed, assignment withheld pending review of additional information requested, or institutional assignment of stage disputed with explanation given. Changes in stage assignment were at the discretion of the enrolling institution. RESULTS A total of 206 patients underwent central review. Failure to submit required data elements or need for clarification was noted in 40%. Disagreement with stage assignment occurred in 10% with 17/21 discordant patients reassigned to stage recommended by central review. Four ovarian tumor patients not meeting review criteria for Stage I remained in that stratum by institutional decision. Two-year event free survival in Stage I ovarian patients was 25% for discordant patients compared to 57% for those meeting Stage I criteria by central review. CONCLUSIONS Central review of stage assignment improved complete data collection and assignment of correct tumor stage at study entry, and allowed for prompt initiation of chemotherapy in patients determined not to have Stage I disease.
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Affiliation(s)
- Deborah F. Billmire
- Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Frederick J. Rescorla
- Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Jonathan H. Ross
- Division of Urology, Case Western Reserve University, Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Marc G. Schlatter
- Helen DeVos Children’s Hospital at Spectrum Health, Grand Rapids, MI
| | - Bryan J. Dicken
- Department of Surgery, University of Alberta, Stollery Childrens Hospital, Edmunton, Alberta
| | - Mark D. Krailo
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Thomas A. Olson
- Aflac Cancer and Blood Disorders Center, Childrens Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - John W. Cullen
- Rocky Mountain Hospital for Children, Presbyterian St Luke’s Medical, Denver, CO
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Greene FL. Cancer staging in outcomes assessment. J Surg Oncol 2014; 110:616-20. [PMID: 25043160 DOI: 10.1002/jso.23704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 05/24/2014] [Indexed: 02/06/2023]
Abstract
The T N M staging system created by a surgeon in the 1950s continues to be a major benchmark for assessing long-term outcomes in adult solid tumors. Although several major changes have occurred in this anatomical staging system, the tenets of TNM staging remain constant. Recently molecular markers and biologic modifiers have been added to this anatomical staging system to create a more robust outcomes tool.
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Affiliation(s)
- Frederick L Greene
- Medical Director of Data Registry, Levine Cancer Institute, Charlotte, North Carolina, 28204
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6
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Albert JM, Das P. Quality assessment in oncology. Int J Radiat Oncol Biol Phys 2012; 83:773-81. [PMID: 22445001 DOI: 10.1016/j.ijrobp.2011.12.079] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 12/23/2011] [Indexed: 01/05/2023]
Abstract
The movement to improve healthcare quality has led to a need for carefully designed quality indicators that accurately reflect the quality of care. Many different measures have been proposed and continue to be developed by governmental agencies and accrediting bodies. However, given the inherent differences in the delivery of care among medical specialties, the same indicators will not be valid across all of them. Specifically, oncology is a field in which it can be difficult to develop quality indicators, because the effectiveness of an oncologic intervention is often not immediately apparent, and the multidisciplinary nature of the field necessarily involves many different specialties. Existing and emerging comparative effectiveness data are helping to guide evidence-based practice, and the increasing availability of these data provides the opportunity to identify key structure and process measures that predict for quality outcomes. The increasing emphasis on quality and efficiency will continue to compel the medical profession to identify appropriate quality measures to facilitate quality improvement efforts and to guide accreditation, credentialing, and reimbursement. Given the wide-reaching implications of quality metrics, it is essential that they be developed and implemented with scientific rigor. The aims of the present report were to review the current state of quality assessment in oncology, identify existing indicators with the best evidence to support their implementation, and propose a framework for identifying and refining measures most indicative of true quality in oncologic care.
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Affiliation(s)
- Jeffrey M Albert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Raising the Bar for Breast Health Care in the United States. Womens Health Issues 2012; 22:e129-33. [DOI: 10.1016/j.whi.2011.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 08/23/2011] [Accepted: 08/23/2011] [Indexed: 11/30/2022]
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Wang TT, Ahmed K, Khan MS, Dasgupta P. Quality-of-care framework in urological cancers: where do we stand? BJU Int 2011; 109:1436-43. [DOI: 10.1111/j.1464-410x.2011.10747.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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