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Ethical Considerations Surrounding Surgeon Ownership of Ambulatory Surgery Centers. J Am Coll Surg 2022; 235:539-543. [PMID: 35972176 DOI: 10.1097/xcs.0000000000000271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
As surgical care continues to transition to an outpatient setting, ambulatory surgery centers (ASCs) present favorable options for physician investment. As of 2017, more than 90% of ASCs have at least some physician ownership, with 64% solely physician-owned. Yet, physician ownership creates an inherent conflict of interest known as dual agency, where clinicians have a personal financial stake in addition to their obligation towards patient well-being. Here, we assess the ethical considerations surrounding dual agency in the setting of ASCs through the lens of beneficence, nonmaleficence, autonomy, and justice. We further propose strategies for appropriate navigation of such situations, including disclosure of ownership status, instruction on unfamiliar techniques, and adherence to accepted clinical practice guidelines for materials selection and surgical indications.
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Yayac M, Goswami K, Liss FE, Abboud JA, Arnold WV, Parvizi J, Courtney PM. Orthopedic Specialty Hospitals Are Associated With Lower Rates of Deep Surgical Site Infection Compared With Tertiary Medical Centers. Orthopedics 2021; 44:e521-e526. [PMID: 34292822 DOI: 10.3928/01477447-20210618-11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Orthopedic specialty hospitals may allow for more streamlined and efficient care, resulting in shorter lengths of stay, lower costs, and fewer complications. Surgical site infection can be a devastating complication of orthopedic procedures and is difficult to treat successfully, requiring substantial cost and resources. The goal of this study was to determine whether specialty hospitals had lower rates of infection than tertiary care institutions. Records were reviewed for patients undergoing primary total hip, knee, or shoulder arthroplasty and single-level lumbar fusion from 2010 to 2017 at 2 academic tertiary hospitals and 2 specialty hospitals. Patient demographic information, comorbidities, and the development of deep surgical site infection within 1 year of the index procedure were recorded and compared between the groups. Multivariate analysis identified variables that significantly correlated with infection rates. A total of 20,264 patients (73.9%) underwent surgery at a tertiary hospital, and 7169 (26.1%) underwent a procedure at a specialty hospital. Patients treated at orthopedic specialty hospitals had lower rates of infection at 1 year (0.6% vs 0.2%, P<.0001). Of the infections, 42 (32.3%) occurred in the knee, 50 (38.5%) in the hip, 24 (18.5%) in the spine, and 12 (10.8%) in the shoulder. When controlling for a healthier patient population, procedures performed at specialty hospitals were an independent predictor of infection within 1 year (odds ratio, 0.3693; P=.0012). Although tertiary hospitals care for older patients with more medical comorbidities, patients undergoing orthopedic procedures at a specialty hospital may be at lower risk for infection. Further study is needed to identify the processes associated with reduced infection rates and to determine whether they can be adopted at tertiary centers. [Orthopedics. 2021;44(4):e521-e526.].
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Defined Daily Dose and Appropriateness of Clinical Application: The Coxibs and Traditional Nonsteroidal Anti-Inflammatory Drugs for Postoperative Orthopaedics Pain Control in a Private Hospital in Malaysia. PHARMACY 2020; 8:pharmacy8040235. [PMID: 33302438 PMCID: PMC7768540 DOI: 10.3390/pharmacy8040235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction: Drug utilization of analgesics in a private healthcare setting is useful to examine their prescribing patterns, especially the newer injectable cyclooxygenase (COX)-2 inhibitors (coxibs). Objectives: To evaluate the utilization of coxibs and traditional nonsteroidal anti-inflammatory drugs (tNSAIDs) indicated for postoperative orthopaedic pain control using defined daily dose (DDD) and ratio of use density to use rate (UD/UR). Method: A retrospective drug utilization review (DUR) of nonsteroidal anti-inflammatory drugs (NSAIDs) at an inpatient department of a private teaching hospital in Seremban, Malaysia was conducted. Patients’ demographic characteristics, medications prescribed, clinical lab results, visual analogue scale (VAS) pain scores and length of hospital stay were documented. Orthopaedic surgeries, namely arthroscopy, reconstructive, and fracture fixation, were included. Stratified random sampling was used to select patients. Data were collected through patients’ medical records. The DDD per 100 admissions and the indicator UD/UR were calculated with the World Health Organization’s DDD as a benchmark. The inclusion criteria were patients undergoing orthopaedic surgery prescribed with coxibs (celecoxib capsules, etoricoxib tablets, parecoxib injections) and tNSAIDs (dexketoprofen injections, diclofenac sodium tablets). Data were analysed descriptively. This research was approved by the academic institution and the hospital research ethics committee. Result: A total of 195 records of patients who received NSAIDs were randomly selected among 1169 cases. In term of the types of orthopaedic surgery, the ratio of included records for arthroscopy:fracture fixation:reconstructive surgery was 55.4:35.9:8.7. Most of the inpatients had low rates of common comorbidities such as cardiovascular disease as supported by their baseline parameters. The majority were not prescribed with other concomitant prescriptions that could cause drug interaction (74.9%), or gastroprotective agents (77.4%). Overall, DDDs per 100 admissions for all NSAIDs were less than 100, except for parecoxib injections (389.23). The UD/UR for all NSAIDs were less than 100, except for etoricoxib tablets (105.75) and parecoxib injections (108.00). Discussion: As per guidelines, the majority (96.9%) received other analgesics to ensure a multimodal approach was carried out to control pain. From the UD/UR results, the arthroscopy surgery was probably the most appropriate in terms of NSAID utilization. Conclusion: The prescribing pattern of NSAIDs except parecoxib was appropriate based on adverse effect and concurrent medication profile. The findings of this DUR provide insight for a low-risk patient population at a private specialized teaching hospital on the recommended use of NSAIDs for postoperative orthopaedic pain control.
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Understanding the Value of Total Shoulder Arthroplasties at Physician-Owned Hospitals. J Am Acad Orthop Surg 2020; 28:e1066-e1072. [PMID: 33962445 DOI: 10.5435/jaaos-d-19-00750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 03/09/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Owing to concerns regarding higher cost, low quality of care and cherry-picking in physician-owned hospitals (POHs), the Affordable Care Act imposed sanctions that prevented the formation of new POHs. With an increasing utilization of total shoulder arthroplasties (TSAs), there is a need for re-evaluation and assessment of quality and cost of TSAs performed at these POHs. METHODS The 2011 to 2014 Medicare 100% Standard Analytical Files was used to identify patients undergoing a reverse TSA or anatomic TSA at POHs and non-POHs. Multivariate regression analyses were used to assess differences in 90-day and 1-year outcomes between the two groups. RESULTS A total of 1,626 (2.2%) patients received a TSA at a POH (N = 50). No notable differences were noted between POH versus non-POHs regarding 90-day surgical site infections (P = 0.645), dislocation (P = 0.068), periprosthetic fractures (P = 0.556), revision arthroplasty (P = 0.114), pulmonary embolism (P = 0.155), deep vein thrombosis (P = 0.208), acute myocardial infarction (P = 0.219), sepsis (P = 0.288), urinary tract infections (P = 0.186), all-cause readmissions (P = 0.427), 1-year dislocations (P = 0.475), 1-year periprosthetic fractures (P = 0.697), and 1-year revision arthroplasties (P = 0.225). TSAs performed at POHs had higher odds of postoperative stiffness at 90-day (odds ratio 1.39; P < 0.001) and 1-year follow-up points (odds ratio 1.51; P < 0.001). TSAs at POHs had markedly lower risk-adjusted 90-day charges (-$8,904) and 90-day costs (-$1,659). CONCLUSION Apart from slightly higher rates of stiffness and renal complications, patients undergoing TSAs at POHs seem to have similar outcomes as compared to non-POHs, while having lower costs of care. The findings suggest a need for further research, evaluating the value of care at POHs. LEVEL OF EVIDENCE Level III.
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Ahn J, Blumenthal S, Derman PB. Physician-owned hospitals in orthopedic and spine surgery. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S162. [PMID: 31624728 DOI: 10.21037/atm.2019.06.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Junyoung Ahn
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Are Patients Undergoing an Anterior Cervical Discectomy and Fusion Treated Differently at a Physician-owned Hospital? Clin Spine Surg 2018; 31:211-215. [PMID: 29851892 DOI: 10.1097/bsd.0000000000000577] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective case-control study. BACKGROUND Physician-owned specialty hospitals focus on taking care of patients with a select group of conditions. In some instances, they may also create a potential conflict of interest for the surgeon. The effect this has on the surgical algorithm for patients with degenerative cervical spine conditions has not been determined. METHODS A retrospective review of all patients who underwent a 1- or 2-level anterior cervical discectomy and fusion between October 2009 and December 2014 at either a physician-owned specialty hospital or an independently owned community hospital were identified. Demographic information, the time course for treatment and the nonoperative treatment regimen were evaluated. RESULTS In total, 115 patients undergoing surgery at a physician-owned specialty hospital and 149 patients undergoing surgery at an independent community hospital were identified. Demographic data between the groups including the presence of 12 medical comorbidities and insurance status was similar between the groups. The only difference that was identified was that patients at the surgeon-owned hospital were marginally younger than patients who had surgery at the independent hospital (49.7 vs. 50.0, P=0.048). No difference in the median number of months from the onset of symptoms to surgery (6.51 vs. 7.53 mo, respectively; P=0.55), from the onset of symptoms to the preoperative visit (6.02 vs. 6.02, P=0.64), or from the initial surgical consultation to surgery (0.99 vs. 1.02, P=0.31) was identified. No difference in the number of patients who underwent formal physical therapy (72.2% vs. 67.1%, P=0.42) or who had a cervical steroid injection (55.6% vs. 50.3%, P=0.25%) was identified between patients who had surgery at a physician-owned or independent hospital; however, patients who underwent surgery at the physician-owned hospital were more likely to have taken oral anti-inflammatories (93.0% vs. 83.9%, P=0.04). CONCLUSIONS When comparing hospitals with similar resources, surgeons do not preferentially select younger, healthier patients with higher paying insurance to be treated at the physician-owned hospital. Furthermore, both the time from the onset of symptoms to surgery and the nonoperative treatment regimen were similar between patients treated at the 2 facilities.
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Abstract
INTRODUCTION We examined practice patterns and surgical indications in the management of common shoulder procedures by surgeons practicing at physician-owned facilities. METHODS This study was a retrospective analysis of 501 patients who underwent arthroscopic shoulder procedures performed by five surgeons in our practice at one of five facilities during an 18-month period. Two of the facilities were physician-owned, and three of the five surgeons were shareholders. Demographics, insurance status, symptom duration, time from injury/symptom onset to the decision to perform surgery (at which time surgical consent is obtained), and time to schedule surgery were studied to determine the influence of facility type and physician shareholder status. RESULTS Median duration of symptoms before surgery was significantly shorter in workers' compensation patients than in non-workers' compensation patients (47% less; P < 0.0001) and in men than in women (31% less; P < 0.001), but was not influenced by shareholder status or facility ownership (P > 0.05). Time between presentation and surgical consent was not influenced by facility ownership (P = 0.39) or shareholder status (P = 0.50). Time from consent to procedure was 13% faster in physician-owned facilities than in non-physician-owned facilities (P = 0.03) and 35% slower with shareholder physicians than with nonshareholder physicians (P < 0.0001). DISCUSSION The role of physician investment in private healthcare facilities has caused considerable debate in the orthopaedic surgery field. To our knowledge, this study is the first to examine the effects of shareholder status and facility ownership on surgeons' practice patterns, surgical timing, and measures of nonsurgical treatment before shoulder surgery. CONCLUSIONS Neither shareholder status nor facility ownership characteristics influenced the speed with which surgeons determined that shoulder surgery was indicated or surgeons' use of preoperative nonsurgical treatment. After the need for surgery was determined, patients underwent surgery sooner at physician-owned facilities than at non-physician-owned facilities and with nonshareholder physicians than with shareholder physicians. LEVEL OF EVIDENCE Level III.
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Schroeder GD, Kurd MF, Kepler CK, Radcliff KE, Rihn JA, Anderson DG, Hilibrand AS, Vaccaro AR. Comparing the Treatment Algorithm and Complications for Patients Undergoing an Anterior Cervical Discectomy and Fusion at a Physician-Owned Specialty Hospital and a University-Owned Tertiary Care Hospital. Am J Med Qual 2016; 32:208-214. [PMID: 26721252 DOI: 10.1177/1062860615619691] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this case-control study is to compare the treatment algorithm and complication rate for patients who undergo an anterior cervical discectomy and fusion at a physician-owned specialty hospital to those who undergo surgery at a university-owned tertiary care hospital. Two controls were identified for 77 patients, and no differences in demographic data were identified. The median time between the onset of symptoms and surgery was shorter for patients who had surgery at the tertiary care center than for patients who had surgery at the specialty hospital (26.7 weeks vs 32.7 weeks, P = .0004). Furthermore, a higher percentage of patients who had surgery at the specialty hospital attempted nonoperative treatments than patients who underwent surgery at the tertiary care hospital.
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Affiliation(s)
| | - Mark F Kurd
- 1 The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | | | - Kris E Radcliff
- 1 The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Jeffery A Rihn
- 1 The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - D Greg Anderson
- 1 The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Alan S Hilibrand
- 1 The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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Chakravarty S. Much ado about nothing? The financial impact of physician-owned specialty hospitals. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2016; 16:103-131. [PMID: 27878712 DOI: 10.1007/s10754-015-9181-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 11/04/2015] [Indexed: 06/06/2023]
Abstract
The U.S. hospital industry has recently witnessed a number of policy changes aimed at aligning hospital payments to costs and these can be traced to significant concerns regarding selection of profitable patients and procedures by physician-owned specialty hospitals. The policy responses to specialty hospitals have alternated between payment system reforms and outright moratoriums on hospital operations including one in the recently enacted Affordable Care Act. A key issue is whether physician-owned specialty hospitals pose financial strain on the larger group of general hospitals through cream-skimming of profitable patients, yet there is no study that conducts a systematic analysis relating such selection behavior by physician-owners to financial impacts within hospital markets. The current paper takes into account heterogeneity in specialty hospital behavior and finds some evidence of their adverse impact on profit margins of competitor hospitals, especially for-profit hospitals. There is also some evidence of hospital consolidation in response to competitive pressures by specialty hospitals. Overall, these findings underline the importance of the payment reforms aimed at correcting distortions in the reimbursement system that generate incentives for risk-selection among providers groups. The identification techniques will also inform empirical analysis on future data testing the efficacy of these payment reforms.
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Affiliation(s)
- Sujoy Chakravarty
- Center for State Health Policy, Rutgers University, 112 Paterson Street, Room 548, New Brunswick, NJ, 08901, USA.
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Malik A, Bell CM, Stukel TA, Urbach DR. Recurrence of inguinal hernias repaired in a large hernia surgical specialty hospital and general hospitals in Ontario, Canada. Can J Surg 2016; 59:19-25. [PMID: 26574701 DOI: 10.1503/cjs.003915] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The effect of hospital specialization on the risk of hernia recurrence after inguinal hernia repair is not well described. METHODS We studied Ontario residents who had primary elective inguinal hernia repair at an Ontario hospital between 1993 and 2007 using population-based, administrative health data. We compared patients from a large hernia specialty hospital (Shouldice Hospital) with those from general hospitals to determine the risk of recurrence. RESULTS We studied 235 192 patients, 27.7% of whom had surgery at Shouldice hospital. The age-standardized proportion of patients who had a recurrence ranged from 5.21% (95% confidence interval [CI] 4.94%-5.49%) among patients who had surgery at the lowest volume general hospitals to 4.79% (95% CI 4.54%-5.04%) who had surgery at the highest volume general hospitals. In contrast, patients who had surgery at the Shouldice Hospital had an age-standardized recurrence risk of 1.15% (95% CI 1.05%-1.25%). Compared with patients who had surgery at the lowest volume hospitals, hernia recurrence among those treated at the Shouldice Hospital was significantly lower after adjustment for the effects of age, sex, comorbidity and income level (adjusted hazard ratio 0.21, 95% CI 0.19-0.23, p < 0.001). CONCLUSION Inguinal hernia repair at Shouldice Hospital was associated with a significantly lower risk of subsequent surgery for recurrence than repair at a general hospital. While specialty hospitals may have better outcomes for treatment of common surgical conditions than general hospitals, these benefits must be weighed against potential negative impacts on clinical care and the financial sustainability of general hospitals.
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Affiliation(s)
- Atiqa Malik
- From the Institute of Medical Science, University of Toronto, Toronto, Ont. (Malik, Urbach); the Toronto General Research Institute, Toronto, Ont. (Malik, Urbach); the Department of Surgery, University Health Network, Toronto, Ont. (Urbach); the Department of Medicine, Mount Sinai Hospital, Toronto, Ont. (Bell); and the Institute for Clinical Evaluative Sciences, Toronto, Ont. (Malik, Stukel, Urbach)
| | - Chaim M Bell
- From the Institute of Medical Science, University of Toronto, Toronto, Ont. (Malik, Urbach); the Toronto General Research Institute, Toronto, Ont. (Malik, Urbach); the Department of Surgery, University Health Network, Toronto, Ont. (Urbach); the Department of Medicine, Mount Sinai Hospital, Toronto, Ont. (Bell); and the Institute for Clinical Evaluative Sciences, Toronto, Ont. (Malik, Stukel, Urbach)
| | - Thérèse A Stukel
- From the Institute of Medical Science, University of Toronto, Toronto, Ont. (Malik, Urbach); the Toronto General Research Institute, Toronto, Ont. (Malik, Urbach); the Department of Surgery, University Health Network, Toronto, Ont. (Urbach); the Department of Medicine, Mount Sinai Hospital, Toronto, Ont. (Bell); and the Institute for Clinical Evaluative Sciences, Toronto, Ont. (Malik, Stukel, Urbach)
| | - David R Urbach
- From the Institute of Medical Science, University of Toronto, Toronto, Ont. (Malik, Urbach); the Toronto General Research Institute, Toronto, Ont. (Malik, Urbach); the Department of Surgery, University Health Network, Toronto, Ont. (Urbach); the Department of Medicine, Mount Sinai Hospital, Toronto, Ont. (Bell); and the Institute for Clinical Evaluative Sciences, Toronto, Ont. (Malik, Stukel, Urbach)
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Abstract
BACKGROUND Despite declines in both the incidence of and mortality following hip fracture, there are racial and socioeconomic disparities in treatment access and outcomes. We evaluated the presence and implications of disparities in delivery of care, hypothesizing that race and community socioeconomic characteristics would influence quality of care for patients with a hip fracture. METHODS We collected data from the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS), which prospectively captures information on all discharges from nonfederal acute-care hospitals in New York State. Records for 197,290 New York State residents who underwent surgery for a hip fracture between 1998 and 2010 in New York State were identified from SPARCS using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Multivariable regression models were used to evaluate the association of patient characteristics, social deprivation, and hospital/surgeon volume with time from admission to surgery, in-hospital complications, readmission, and 1-year mortality. RESULTS After adjusting for patient and surgery characteristics, hospital/surgeon volume, social deprivation, and other variables, black patients were at greater risk for delayed surgery (odds ratio [OR] = 1.49; 95% confidence interval [CI] = 1.42, 1.57), a reoperation (hazard ratio [HR] = 1.21; CI = 1.11, 1.32), readmission (OR = 1.17; CI = 1.11, 1.22), and 1-year mortality (HR = 1.13; CI = 1.07, 1.21) than white patients. Subgroup analyses showed a greater risk for delayed surgery for black and Asian patients compared with white patients, regardless of social deprivation. Additionally, there was a greater risk for readmission for black patients compared with white patients, regardless of social deprivation. Compared with Medicare patients, Medicaid patients were at increased risk for delayed surgery (OR = 1.17; CI = 1.10, 1.24) whereas privately insured patients were at decreased risk for delayed surgery (OR = 0.77; CI = 0.74, 0.81), readmission (OR = 0.77; CI = 0.74, 0.81), complications (OR = 0.80; CI = 0.77, 0.84), and 1-year mortality (HR = 0.80; CI = 0.75, 0.85). CONCLUSIONS There are race and insurance-based disparities in delivery of care for patients with hip fracture, some of which persist after adjusting for social deprivation. In addition to investigation into reasons contributing to disparities, targeted interventions should be developed to mitigate effects of disparities on patients at greatest risk. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christopher J Dy
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Joseph M Lane
- Department of Orthopaedic Surgery (J.M.L. and M.L.P.) and Healthcare Research Institute (J.M.L., T.J.P., M.L.P., and S.L.), Hospital for Special Surgery, New York, NY Weill Cornell Medical College, New York, NY
| | - Ting Jung Pan
- Department of Orthopaedic Surgery (J.M.L. and M.L.P.) and Healthcare Research Institute (J.M.L., T.J.P., M.L.P., and S.L.), Hospital for Special Surgery, New York, NY
| | - Michael L Parks
- Department of Orthopaedic Surgery (J.M.L. and M.L.P.) and Healthcare Research Institute (J.M.L., T.J.P., M.L.P., and S.L.), Hospital for Special Surgery, New York, NY
| | - Stephen Lyman
- Department of Orthopaedic Surgery (J.M.L. and M.L.P.) and Healthcare Research Institute (J.M.L., T.J.P., M.L.P., and S.L.), Hospital for Special Surgery, New York, NY Weill Cornell Medical College, New York, NY
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Blumenthal DM, Orav EJ, Jena AB, Dudzinski DM, Le ST, Jha AK. Access, quality, and costs of care at physician owned hospitals in the United States: observational study. BMJ 2015; 351:h4466. [PMID: 26333819 PMCID: PMC4558297 DOI: 10.1136/bmj.h4466] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare physician owned hospitals (POHs) with non-POHs on metrics around patient populations, quality of care, costs, and payments. DESIGN Observational study. SETTING Acute care hospitals in 95 hospital referral regions in the United States, 2010. PARTICIPANTS 2186 US acute care hospitals (219 POHs and 1967 non-POHs). MAIN OUTCOME MEASURES Proportions of patients using Medicaid and those from ethnic and racial minority groups; hospital performance on patient experience metrics, care processes, risk adjusted 30 day mortality, and readmission rates; costs of care; care payments; and Medicare market share. RESULTS The 219 POHs were more often small (<100 beds), for profit, and in urban areas. 120 of these POHs were general (non-specialty) hospitals. Compared with patients from non-POHs, those from POHs were younger (77.4 v 78.4 years, P<0.001), less likely to be admitted through an emergency department (23.2% v. 29.0%, P<0.001), equally likely to be black (5.1% v 5.5%, P=0.85) or to use Medicaid (14.9% v 15.4%, P=0.75), and had similar numbers of chronic diseases and predicted mortality scores. POHs and non-POHs performed similarly on patient experience scores, processes of care, risk adjusted 30 day mortality, 30 day readmission rates, costs, and payments for acute myocardial infarction, congestive heart failure, and pneumonia. CONCLUSION Although POHs may treat slightly healthier patients, they do not seem to systematically select more profitable or less disadvantaged patients or to provide lower value care.
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Affiliation(s)
- Daniel M Blumenthal
- Department of Internal Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - E John Orav
- Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - David M Dudzinski
- Department of Internal Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Sidney T Le
- University of California, San Francisco, San Francisco, CA, USA
| | - Ashish K Jha
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
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Trybou J, De Regge M, Gemmel P, Duyck P, Annemans L. Effects of physician-owned specialized facilities in health care: a systematic review. Health Policy 2014; 118:316-40. [PMID: 25305719 DOI: 10.1016/j.healthpol.2014.09.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 09/17/2014] [Accepted: 09/22/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Multiple studies have investigated physician-owned specialized facilities (specialized hospitals and ambulatory surgery centres). However, the evidence is fragmented and the literature lacks cohesion. OBJECTIVES To provide a comprehensive overview of the effects of physician-owned specialized facilities by synthesizing the findings of published empirical studies. METHODS Two reviewers independently researched relevant studies using a standardized search strategy. The Institute of Medicine's quality framework (safe, effective, equitable, efficient, patient-centred, and accessible care) was applied in order to evaluate the performance of such facilities. In addition, the impact on the performance of full-service general hospitals was assessed. RESULTS Forty-six studies were included in the systematic review. Overall, the quality of the included studies was satisfactory. Our results show that little evidence exists to confirm the advantages attributed to physician-owned specialized facilities, and their impact on full-service general hospitals remains limited. CONCLUSION Although data is available on a wide variety of effects, the evidence base is surprisingly thin. There is no compelling evidence available demonstrating the added value of physician-owned specialized facilities in terms of quality or cost of the delivered care. More research is necessary on the relative merits of physician-owned specialized facilities. In addition, their corresponding impact on full-service general hospitals remains unclear. The development of physician-owned specialized facilities should thus be monitored carefully.
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Affiliation(s)
- Jeroen Trybou
- Department of Public Health, Ghent University, De Pintelaan 185, B-9000 Gent, Belgium.
| | - Melissa De Regge
- Department of Innovation, Entrepreneurship and Service Management, Ghent University, Tweekerkenstraat 2, B-9000 Gent, Belgium.
| | - Paul Gemmel
- Department of Innovation, Entrepreneurship and Service Management, Ghent University, Tweekerkenstraat 2, B-9000 Gent, Belgium.
| | - Philippe Duyck
- Faculty of Medicine and Health Science, Ghent University, De Pintelaan 185, B-9000 Gent, Belgium.
| | - Lieven Annemans
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Pleinlaan 2, B-1050 Elsene, Brussels, Belgium.
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Dy CJ, Marx RG, Bozic KJ, Pan TJ, Padgett DE, Lyman S. Risk factors for revision within 10 years of total knee arthroplasty. Clin Orthop Relat Res 2014; 472:1198-207. [PMID: 24347046 PMCID: PMC3940740 DOI: 10.1007/s11999-013-3416-6] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 11/27/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND An in-depth understanding of risk factors for revision TKA is needed to minimize the burden of revision surgery. Previous studies indicate that hospital and community characteristics may influence outcomes after TKA, but a detailed investigation in a diverse population is warranted to identify opportunities for quality improvement. QUESTIONS/PURPOSES We asked: (1) What is the frequency of revision TKA within 10 years of primary arthroplasty? (2) Which patient demographic factors are associated with revision within 10 years of TKA? (3) Which community and institutional characteristics are associated with revision within 10 years of TKA? METHODS We identified 301,955 patients who underwent primary TKAs in New York or California from 1997 to 2005 from statewide databases. Identifier codes were used to determine whether they underwent revision TKA. Patient, community, and hospital characteristics were analyzed using multivariable regression modeling to determine predictors for revision. RESULTS The frequency of revision was 4.0% at 5 years after the index arthroplasty and 8.9% at 9-years. Patients between 50 and 75 years old had a lower risk of revision than patients younger than 50 years (hazard ratio [HR], 0.47; 95% CI, 0.44, 0.50). Black patients were at increased risk for needing revision surgery (HR, 1.39; 95% CI, 1.29, 1.49) after adjustment for insurance type, poverty level, and education. Women (HR, 0.82; 95% CI, 0.79, 0.86) and Medicare recipients (HR, 0.82; 95% CI, 0.79, 0.86) were less likely to undergo revision surgery, whereas those from the most educated (HR, 1.09; 95% CI, 1.02, 1.16) and the poorest communities (HR, 1.08; 95% CI, 1.01, 1.15) had modest increases in risk of revision. Mid-volume hospitals (200-400 annual cases) had a reduction of early revision (HR, 0.91; 95% CI, 0.83, 0.99) compared with those performing less than 200 cases annually, whereas higher-volume hospitals (greater than 400 cases) showed little effect compared with low-volume hospitals. CONCLUSIONS Patient, community, and institutional characteristics affect the risk for revision within 10 years of index TKA. These data can be used to develop process improvement and implant surveillance strategies among high-risk patients. LEVEL OF EVIDENCE Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christopher J. Dy
- />Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY USA
- />Epidemiology and Biostatistics Core, Hospital for Special Surgery, 535 E 70th Street, New York, NY 10021 USA
| | - Robert G. Marx
- />Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY USA
| | - Kevin J. Bozic
- />Department of Orthopaedic Surgery and Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA USA
| | - Ting Jung Pan
- />Epidemiology and Biostatistics Core, Hospital for Special Surgery, 535 E 70th Street, New York, NY 10021 USA
| | - Douglas E. Padgett
- />Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY USA
| | - Stephen Lyman
- />Epidemiology and Biostatistics Core, Hospital for Special Surgery, 535 E 70th Street, New York, NY 10021 USA
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15
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Dubois JM, Carroll K, Gibb T, Kraus E, Rubbelke T, Vasher M, Anderson EE. Environmental Factors Contributing to Wrongdoing in Medicine: A Criterion-Based Review of Studies and Cases. ETHICS & BEHAVIOR 2012; 22:163-188. [PMID: 23226933 PMCID: PMC3515073 DOI: 10.1080/10508422.2011.641832] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In this paper we describe our approach to understanding wrongdoing in medical research and practice, which involves the statistical analysis of coded data from a large set of published cases. We focus on understanding the environmental factors that predict the kind and the severity of wrongdoing in medicine. Through review of empirical and theoretical literature, consultation with experts, the application of criminological theory, and ongoing analysis of our first 60 cases, we hypothesize that 10 contextual features of the medical environment (including financial rewards, oversight failures, and patients belonging to vulnerable groups) may contribute to professional wrongdoing. We define each variable, examine data supporting our hypothesis, and present a brief case synopsis from our study that illustrates the potential influence of the variable. Finally, we discuss limitations of the resulting framework and directions for future research.
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Affiliation(s)
- James M Dubois
- Bander Center for Medical Business Ethics, Saint Louis University
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16
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Are African American patients more likely to receive a total knee arthroplasty in a low-quality hospital? Clin Orthop Relat Res 2012; 470:1185-93. [PMID: 21879410 PMCID: PMC3293986 DOI: 10.1007/s11999-011-2032-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Accepted: 08/08/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Total joint arthroplasty is widely performed in patients of all races with severe osteoarthritis. Prior studies have reported that African American patients tend to receive total joint arthroplasties in low-volume hospitals compared with Caucasian patients, suggesting potential racial disparity in the quality of arthroplasty care. QUESTIONS/PURPOSES We asked whether (1) a hospital outcome measure of risk-adjusted mortality or complication rate within 90 days of primary TKA can be directly used to profile hospital quality of care, and (2) African Americans were more likely to receive TKAs at low-quality hospitals (or hospitals with higher risk-adjusted outcome rate) compared with Caucasian patients. PATIENTS AND METHODS We developed a risk-adjusted, 90-day postoperative outcome measure to identify high-, intermediate-, and low-quality hospitals based on patient records in the Medicare Provider Analysis and Review files between July 1, 2002, and June 30, 2005 (the first cohort). We then analyzed a second cohort of African American and Caucasian patients receiving Medicare who underwent primary TKAs between July and December 2005 to determine the independent impact of race on admissions to high-, intermediate-, and low-quality hospitals. RESULTS The risk-adjusted postoperative mortality/complication rate varied substantially across hospitals; hospitals can be meaningfully categorized into quality groups. In the second cohort of admissions, 8% of African American patients (n = 4894) versus 9.2% of Caucasian patients (n = 86,705) were treated in high-quality hospitals whereas 14.7% of African American patients versus 12.7% of Caucasians patients were treated in low-quality hospitals. After controlling for patient demographic, socioeconomic, geographic, and diagnostic characteristics, the odds ratio for admission to low-quality hospitals was 1.28 for African American patients compared with Caucasian patients (95% CI, 1.18-1.41). CONCLUSIONS Among elderly Medicare beneficiaries undergoing TKA, African American patients were more likely than Caucasian patients to be admitted to hospitals with higher risk-adjusted postoperative rates of complications or mortality. Future work is needed to address the residential, social, and referring factors that underlie this disparity and implications for outcomes of care.
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Babu MA, Rosenow JM, Nahed BV. Physician-owned hospitals, neurosurgeons, and disclosure: lessons from law and the literature. Neurosurgery 2011; 68:1724-32; discussion 1732. [PMID: 21336209 DOI: 10.1227/neu.0b013e31821144ff] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Physician ownership of hospitals has been a subject of controversy for years. Opponents claim that physician ownership and the hospital profits that result from imaging, laboratory tests, and procedures create a conflict of interest for physicians in providing impartial patient care. Proponents argue that having an ownership stake in a hospital means that physicians can have control over all facets of the patient experience, which leads potentially to better patient satisfaction and outcomes. With passage of health reform legislation, physician-owned specialty hospitals have been under renewed attack and now face more restrictive limitations on their growth and expansion. The following review explores the history of physician-owned specialty hospitals, the controversy surrounding physician ownership, and the scope of neurosurgeon ownership in specialty hospitals and offers 2 models for disclosure of potential conflicts of interest.
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Affiliation(s)
- Maya A Babu
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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