Association of bundled payments with spending, utilization, and quality for surgical conditions: A scoping review

OBJECTIVES

To assess the body of literature examining episode-based bundled payment models effect on health care spending, utilization, and quality of care for surgical conditions.

BACKGROUND SUMMARY

Episode-based bundled payments were developed as a strategy to lower healthcare spending and improve coordination across phases of healthcare. Surgical conditions may be well-suited targets for bundled payments because they often have defined periods of care and widely variable healthcare spending. In bundled payment models, hospitals receive financial incentives to reduce spending on care provided to patients during a predefined clinical episode. Despite the recent proliferation of bundles for surgical conditions, a collective understanding of their effect is not yet clear.

METHODS

A scoping review was conducted, and four databases were queried from inception through September 27, 2021, with search strings for bundled payments and surgery. All studies were screened independently by two authors for inclusion.

RESULTS

Our search strategy yielded a total of 879 unique articles of which 222 underwent a full-text review and 28 met final inclusion criteria. Of these studies, most (23 of 28) evaluated the impact of voluntary bundled payments in orthopedic surgery and found that bundled payments are associated with reduced spending on total care episodes, attributed primarily to decreases in post-acute care spending. Despite reduced spending, clinical outcomes (e.g., readmissions, complications, and mortality) were not worsened by participation. Evidence supporting the effects of bundled payments on cost and clinical outcomes in other non-orthopedic surgical conditions remains limited.

CONCLUSIONS

Present evaluations of bundled payments primarily focus on orthopedic conditions and demonstrate cost savings without compromising clinical outcomes. Evidence for the effect of bundles on other surgical conditions and implications for quality and access to care remain limited.

Safety of limb lengthening after Roux-en-Y gastric bypass: an analysis of the MBSAQIP database

BACKGROUND

Roux-en-Y gastric bypass (RYGB) effectively treats severe obesity, but some patients may require revisional surgery like limb lengthening (LL) for postoperative weight gain.

OBJECTIVES

This study aims to compare 30-day serious complications and mortality rates between LL and primary RYGB, given limited safety data on LL.

METHODS

Patients who underwent LL and RYGB were identified from the 2020 and 2021 MBSAQIP databases, the only years in which LL data were available. Baseline characteristics and 30-day rates of serious complications and mortality were analyzed.

RESULTS

A total of 86,990 patients underwent RYGB and 455 underwent LL. Patients undergoing RYGB were younger (44.4 versus 49.8 yr, P < .001), had a higher body mass index (BMI) (45.5 versus 41.8 kg/m2, P < .001) and higher rates of comorbidities including diabetes (30.0 versus 13.6%, P < .001). RYGB and LL had similar operative duration (125.3 versus 123.2 min, P = .5). There were no statistical differences between cohorts for length of stay (LOS) (1.6 RYGB versus 1.6 LL d, P = .6). After LL, there were higher 30-day rates of reoperation (3.3 versus 1.9%, P = .03) and deep surgical site infections (1.3 versus .5%, P = .03) compared to RYGB. There were no differences in overall serious complications (5.1 LL versus 5.0% RYGB, P = 1.0) and mortality (.2 LL versus .1% RYGB, P = .5). Multivariable logistic regression adjustment found that previous venous thromboembolism was associated with serious complications after LL.

CONCLUSIONS

When compared to primary RYGB, LL has a favorable safety profile with similar 30-day rates of serious complications and mortality.

Evaluating outcomes among surgeons who changed their technique for gastric bypass: a state-wide analysis from 2011 to 2021

INTRODUCTION

Technical variation exists when performing the gastrojejunostomy during Roux-en-Y gastric bypass (RYGB). However, it is unclear whether changing technique results in improved outcomes or patient harm.

METHODS

Surgeons participating in a state-wide bariatric surgery quality collaborative who completed a survey on how they perform a typical RYGB in 2011 and again in 2021 were included in the analysis (n = 31). Risk-adjusted 30-day complication rates and case characteristics for cases in 2011 were compared to those in 2021 among surgeons who changed their gastrojejunostomy technique from end-to-end anastomosis (EEA) to either a linear staple or handsewn anastomosis (LSA/HSA). In addition, case characteristics and outcomes among surgeons who maintained an EEA technique throughout the study period were assessed.

RESULTS

A total of 15 surgeons (48.3%) changed their technique from EEA to LSA/HSA while 7 surgeons (22.3%) did not. Nine surgeons did LSA or HSA the entire period and therefore were not included. Surgeons who changed their technique had significantly lower rates of surgical complications in 2021 when compared to 2011 (1.9% vs 5.1%, p = 0.0015), including lower rates of wound complications (0.5% vs 2.1%, p = 0.0030) and stricture (0.1% vs 0.5%, p = 0.0533). Likewise, surgeons who did not change their EEA technique, also experienced a decrease in surgical complications (1.8% vs 5.8%, p < 0.0001), wound complications (0.7% vs 2.1%, p < 0.0001) and strictures (0.2% vs 1.2%, p = 0.0006). Surgeons who changed their technique had a significantly higher mean annual robotic bariatric volume in 2021 (30.0 cases vs 4.9 cases, p < 0.0001) when compared to those who did not.

CONCLUSIONS

Surgeons who changed their gastrojejunostomy technique from circular stapled to handsewn demonstrated greater utilization of the robotic platform than those who did not and experienced a similar decrease in adverse events during the study period, despite altering their technique. Surgeons who chose to modify their operative technique may be more likely to adopt newer technologies.

Surfing the clinical trials of ECG teaching to medical students: A systematic review

Interpreting an electrocardiogram (ECG) is crucial for every physician. The physician's competency in ECG interpretation needs to be improved at any stage of medical education. The aim of the present study was to review the currently published clinical trials of ECG teaching to medical students and provide suggestions for future works. On May 1, 2022, PubMed, Scopus, Web of Science, Google Scholar, and ERIC were searched to retrieve relevant articles on clinical trials of ECG teaching to medical students. The quality of the included studies was assessed utilizing the Buckley et al. criteria. The screening, data extraction, and quality appraisal processes were duplicated independently. In case of disagreements, consultation with a third author was put forth. In total, 861 citations were found in the databases. After screening abstracts and full texts, 23 studies were deemed eligible. The majority of the studies were of good quality. Peer teaching (7 studies), self-directed learning (6 studies), web-based learning (10 studies), and various assessment modalities (3 studies) comprised the key themes of the studies. Various methods of ECG teaching were encountered in the reviewed studies. Future studies in ECG training should focus on novel and creative teaching methods, the extent to which self-directed learning can be effective, the utility of peer teaching, and the implications of computer-assisted ECG interpretation (e.g., artificial intelligence) for medical students. Long-term knowledge retention assessment studies based on different approaches integrated with clinical outcomes could be beneficial in determining the most efficient modalities.

Surgeon Perspectives on Determinants of Same-Day Mastectomy: A Roadmap for Implementing Change

BACKGROUND

Same-day discharge after mastectomy without immediate reconstruction (MwoR) has been shown to be safe, with improved patient satisfaction when compared with patients discharged 1 or more days after surgery. Nevertheless, only 16% of patients undergoing MwoR in Michigan are discharged on the day of surgery, with significant variation between facilities (3-88%). Our objective was to explore determinants of same-day discharge and offer strategies for broader implementation of this practice.

METHODS

We conducted semi-structured interviews with surgeons performing MwoR across the state of Michigan. Recruitment utilized purposeful and snowball sampling methods. The Tailored Implementation in Chronic Disease (TICD) framework was used to inform the creation of the interview guide. Interviews were transcribed and then analyzed using directed content analysis guided by the TICD framework. Salient determinants were organized into patient, provider, and system-level factors.

RESULTS

Participants (n = 26) included general surgeons, breast surgeons, and surgical oncologists. Most surgeons (n = 18, 69%) reported that they discharged fewer than 60% of patients the same day after MwoR. The most common barriers included patient knowledge at the patient level; awareness of evidence, surgeon dogma, and peer influence at the provider level; and team processes and operating room logistics at the system level.

CONCLUSION

We identified surgeon-defined determinants of same-day discharge after MwoR. For the identified barriers, potential implementation strategies could include incorporation of preoperative drain teachings for patients, utilizing consensus statements and opinion leaders to disseminate evidence supporting same-day mastectomies, and conducting workshops with relevant stakeholders to establish consistent facility practice patterns among surgical teams.

Impact of concurrent hiatal hernia repair during laparoscopic sleeve gastrectomy on patient-reported gastroesophageal reflux symptoms: a state-wide analysis

BACKGROUND

Concurrent hiatal hernia repair (HHR) during laparoscopic sleeve gastrectomy (LSG) may improve gastroesophageal reflux disease (GERD) symptoms. However, patient-reported outcomes are limited, and the influence of surgeon technique remains unclear.

OBJECTIVES

To assess patient-reported GERD severity before and after LSG with and without concomitant HHR.

SETTING

Teaching and non-teaching hospitals participating in a state-wide quality improvement collaborative.

METHODS

Using a state-wide bariatric-specific data registry, all patients who underwent a primary LSG between 2015 and 2019 who completed a baseline and 1 year validated GERD health related quality of life (GERD-HRQL) survey were identified (n = 11,742). GERD severity at 1 year as well as 30-day risk-adjusted adverse events was compared between patients who underwent LSG with or without HHR. Results were also stratified by anterior versus posterior HHR.

RESULTS

A total of 4015 patients underwent a LSG-HHR (34%). Compared to patients who underwent LSG without HHR, LSG-HHR patients were older (47.8 yr versus 44.6 yr; P < .0001), had a lower preoperative body mass index (BMI) (45.8 kg/m² versus 48 kg/m²; P < .0001) and more likely to be female (85.2% versus 77.6%, P < .0001). Patients who underwent a posterior HHR (n = 3205) experienced higher rates of symptom improvement (69.5% versus 64.0%, P = .0014) and lower rates of new onset symptoms at 1 year (28.2% versus 30.2%, P = .0500). Patients who underwent an anterior HHR (n = 496) experienced higher rates of hemorrhage and readmissions with no significant difference in symptom improvement.

CONCLUSIONS

Concurrent posterior hiatal HHR at the time of sleeve gastrectomy can improve reflux symptoms. Patients undergoing anterior repair derive no benefit and should be avoided.

Incompleteness of health-related quality of life assessments before left ventricular assist device implant: A novel quality metric

BACKGROUND

Improved health-related quality of life (HRQOL) is an important outcome following durable left ventricular assist device (LVAD) implant. However, half of pre-implant HRQOL data are incomplete in The Society of Thoracic Surgeons' Intermacs registry. Pre-implant HRQOL incompleteness may reflect patient status or hospital resources to capture HRQOL data. We hypothesized that pre-implant HRQOL incompleteness predicts 90 day outcomes and serves as a novel quality metric.

METHODS

Risk factors for pre-implant HRQOL (EQ-5D-5L visual analog scale; 12-item Kansas City Cardiomyopathy Questionnaire "KCCQ") incompleteness were examined by stepwise logistic modeling. Direct standardization method was used to calculate adjusted incompleteness rates using a mixed effects logistic model. Hospitals were dichotomized as low or high based on median adjusted incompleteness rates. Andersen-Gill models were used to associate pre-implant HRQOL adjusted incompleteness rate with adverse events within 90 day post-implant.

RESULTS

The study cohort included 14,063 patients receiving a primary LVAD (4/2012-8/2017). HRQOL incompleteness at high-rate hospitals was more often due to administrative reasons (risk difference, EQ-5D: 10.1%; KCCQ-12: 11.6%) and less likely due to patient reasons (risk difference, EQ-5D: -8.9%; KCCQ-12: -11.4%). A 10% increase in the adjusted pre-implant EQ-5D incompleteness rate was significantly associated with higher risk of infection-related mortality (HR: 1.09), infection (HR: 1.05), and renal dysfunction (HR: 1.03). A 10% increase in the adjusted pre-implant KCCQ-12 incompleteness rate was significantly associated with higher risk of infection (HR: 1.04).

CONCLUSIONS

Hospital adjusted pre-implant HRQOL incompleteness was predictive of 90-day post-implant outcomes and may serve as a novel quality metric.