A Comparison of Open and Minimally Invasive Surgery for Hepatic and Pancreatic Resections Among the Medicare Population

Introduction: Minimally invasive surgery (MIS) has become standard of care for many gastrointestinal surgical procedures. Despite possible clinical benefits, MIS may be underutilized in some populations. The aim of this study was to access the utilization of MIS among Medicare patients undergoing hepatopancreatic procedures and define clinical outcomes, as well as costs, of minimally invasive techniques compared with the conventional open approach. Methods: The Medicare Provider Analysis and Review (MEDPAR) Inpatient Files were reviewed to identify Medicare patients who underwent pancreatic and liver procedures between 2013 and 2015. Primary outcomes of the analysis included perioperative clinical outcomes such as rates of complications, index hospitalization length-of-stay (LOS), failure-to-rescue, rates, and causes of 90-day readmission, as well as 90-day mortality. Secondary outcomes were Medicare payments for index hospitalization and readmission. Multivariable logistic regression was used to investigate the impact of MIS on clinical outcomes and health expenditures. Results: A total of 13,716 (90.6%) patients underwent open resection, while MIS was performed in 1424 (9.4%) patients. LOS was shorter among patients undergoing MIS (mean 7.3 \ub1 SD 7.3) versus open (mean 9.3 \ub1 SD 9.1) surgery (p 0.05). Mean total payments for open pancreatic surgery were on average $1421 higher in the open versus MIS pancreatic group (p = 0.01); in contrast, there was no difference in the overall payment for hepatic resection (p > 0.05). Conclusion: The MIS approach was underutilized among patients undergoing liver and pancreatic procedures. MIS was associated with lower complication and readmission and shorter LOS, as well as comparable/slightly lower Medicare payments, compared with the open approach. The MIS approach should strongly be considered among older patients undergoing liver and pancreatic procedures

Readmission after pancreatic resection: causes, costs and cost-effectiveness analysis of high versus low quality hospitals using the Nationwide Readmission Database

Background: Objectives were to determine the causes of readmission and assess the cost-effectiveness of high (HQ) and low quality (LQ) hospitals in performing pancreatic resection, by using readmission rates as the measure of quality. Methods: We identified 53,572 pancreatic resection cases from National Readmission Database from 2010 through 2014. Hospitals were risk adjusted and ranked based on readmission. Top 20% HQ hospitals having the lowest readmission rates were compared to the bottom 20% LQ hospitals with the highest readmission rates. Results: The 90-day readmission rate was 27.2% (HQ: 25.7%, LQ: 30.9%, p < 0.001). Compared to LQ, HQ hospitals had lower mortality (2.1% vs 10.2%, p < 0.001) and major complication (10.5% vs 53%, p < 0.001). Major complication during index operation was a major predictor of readmission (RR: 1.6, 95% CI: 1.6\u20131.7, p < 0.001). The optimal cut point of hospital volume associated with low mortality was 70 or more cases/year. Per year of survival benefit at HQ hospitals, the costs were lower by $9,293 with cost-savings of$6.98 million/year. Conclusion: HQ hospitals were cost-effective at performing pancreatic resection and achieved substantial cost-savings by avoiding major complications during index operation and having lower rates of readmissions. Hospital readmission rate is a strong marker of quality of care

Variation in Medicare Payments and Reimbursement Rates for Hepatopancreatic Surgery Based on Quality: Is There a Financial Incentive\ua0for High-Quality Hospitals?

Background: To better define the financial impact of high-quality care for payers and hospitals, we compared outcomes and Medicare payments between high-quality (HQ) and low-quality (LQ) hospitals after hepatopancreatic surgery. Study Design: Between 2013 through 2015, a total of 15,874 Medicare beneficiaries underwent hepatopancreatic surgery. Using the entire cohort, multivariable logistic regression was performed to categorize hospitals into quintiles based on the probability of experiencing a major complication; HQ (bottom 20%) and LQ (top 20%) hospitals were identified. Only HQ and LQ hospitals were included in the final propensity matching to compare payments. Major complication was defined as a complication associated with a length of stay of &gt;75th percentile. Incremental payment and cost of complication were estimated using multivariable linear regression. Results: Major complications occurred in 9.7% (n = 309 of 3,182) at HQ hospitals compared with 20% (n = 625 of 3,130) at LQ hospitals (p &lt; 0.001). The incremental increased payment associated with major complication was $29,640, which was lower than the incremental hospital cost of$42,935. The Medicare reimbursement rate was also 6% lower at both HQ and LQ hospitals when a major complication occurred vs not; however, HQ hospitals had a 3% higher reimbursement rate compared with LQ hospitals when a major complication did not occur (p = 0.002). Mean unadjusted Medicare payment was lower at HQ hospitals by 5,165 per patient vs LQ hospitals (p < 0.001), largely because HQ hospitals had a lower overall incidence of major complications (n = 315 vs n = 625). By having 310 fewer patients with a major complication, HQ hospitals collectively achieved 3.1 million/year in Medicare savings. Conclusions: High-quality hospitals are able to achieve substantial Medicare savings by avoiding major complications. Occurrence of major complications was associated with lower Medicare reimbursement rates at both HQ and LQ hospitals vs when no complications occurred

Prognosis and Adherence with the National Comprehensive Cancer Network Guidelines of Patients with Biliary Tract Cancers: an Analysis of the National Cancer Database

Background: The National Comprehensive Cancer Network (NCCN) guidelines recommend chemotherapy for patients with inoperable biliary tract cancers (BTC), as well as patients following resection of BTC with lymph node metastasis (N1)/positive margins (R1). We sought to define overall adherence, as well as long-term outcomes, with the NCCN guidelines for BTC using the National Cancer Database (NCDB). Methods: A total of 176,536 patients diagnosed with BTC at a hospital participating in the NCDB between 2004 and 2015 were identified. Results: Among all patients, 63% of patients received medical therapy (chemotherapy or best supportive care), 11% underwent surgical palliation, and 26% underwent curative-intent surgery. According to the NCCN guidelines, 86% (n = 152,245) of patients were eligible for chemotherapy, yet, only 42.2% (n = 64,615) received chemotherapy. Factors associated with a lower adherence with NCCN guidelines included patient age (&gt; 65&nbsp;years: OR = 1.02), ethnicity (Black: OR = 1.14, Hispanic: OR = 1.21, Asian: OR = 1.24), and insurance status (non-private: OR = 1.45, all p &lt; 0.001). A smaller subset of patients was either recommended chemotherapy but refused (n = 9269, 10.6%) or had medical factors that contraindicated chemotherapy (n = 8275, 9.4%). On multivariable analysis, adjusting for clinical and tumor-specific factors, adherence with NCCN guidelines was associated with a survival benefit for patients receiving medical therapies (HR = 0.74) or undergoing curative-intent surgery (HR = 0.73, both p &lt; 0.001). Conclusion: Less than half of patients with BTC received systemic chemotherapy in adherence with NCCN guidelines. While a subset of patients had contraindications or refused chemotherapy, other factors such as insurance status and ethnicity were associated with adherence. Adherence with chemotherapy guidelines may influence long-term outcomes

Synergistic Effects of Perioperative Complications on 30-Day Mortality Following Hepatopancreatic Surgery

Background: Data on the interaction effect of multiple concurrent postoperative complications relative to the risk of short-term mortality following hepatopancreatic surgery have not been reported. The objective of the current study was to define the interaction effect of postoperative complications among patients undergoing HP surgery on 30-day mortality. Methods: Using the ACS-NSQIP Procedure Targeted Participant Use Data File, patients who underwent HP surgery between 2014 and 2016 were identified. Hazard ratios (HRs) for 30-day mortality were estimated using Cox proportional hazard models. Two-way interaction effects assessing combinations of complications relative to 30-day mortality were calculated using the relative excess risk due to interaction (RERI) in separate adjusted Cox models. Results: Among 26,824 patients, 10,886 (40.5%) experienced at least one complication. Mortality was higher among patients who experienced at least one complication versus patients who did not experience a complication (3.0 vs 0.1%, p&nbsp;&lt; 0.001). The most common complications were blood transfusion (16.9%, n = 4519), organ space infection (12.2%, n = 3273), and sepsis/septic shock (8.2%, n = 2205). Combinations associated with additive effect on mortality included transfusion + renal dysfunction (RERI 12.3, 95% CI 5.2\u201319.4), pulmonary dysfunction + renal dysfunction (RERI 60.9, 95% CI 38.6\u201383.3), pulmonary dysfunction + cardiovascular complication (RERI 144.1, 95% CI 89.3\u2013199.0), and sepsis/septic shock + renal dysfunction (RERI 11.5, 95% CI 4.4\u201318.7). Conclusion: Both the number and specific type of complication impacted the incidence of postoperative mortality among patients undergoing HP surgery. Certain complications interacted in a synergistic manner, leading to a greater than expected increase in the risk of short-term mortality

Population level outcomes and costs of single stage colon and liver resection versus conventional two-stage approach for the resection of metastatic colorectal cancer

Background: The objective of the current study was to compare outcomes among patients combined colon (CR) and liver resection (LR) for the treatment of simultaneous colorectal liver metastasis (CRLM) versus patients undergoing two-stage CR and LR. Methods: Patients undergoing surgery for CRLM between 2004 and 2014 were identified using the Nationwide Inpatient Sample (NIS). Propensity-score matching was used to compare patients undergoing CR + LR with patients undergoing two-stage CR and LR. Results: Among 83,410 patients, CR + LR was performed in 5659 (6.7%), stage C + LR was performed in 5659 (6.7%), while isolated CR and LR was performed in 70,177 (84.0%) and 7574 (9.3%) patients, respectively. The number of patients undergoing CR + LR increased from 423 in 2004 to 580 in 2014 (\u394 = +37%). Patients undergoing CR + LR had lower postoperative morbidity (CR + LR vs. two-staged CR and LR: 38.5% vs. 61.2%), shorter LOS (median LOS: 8 days [IQR: 7\u201312] vs. 14 days [IQR: 10\u201321]), and lower postoperative mortality (3.1% vs. 5.9%) versus patients undergoing two-stage CR and LR. Compared with patients undergoing two-staged CR and LR, median hospital costs were $13,093 lower for patients undergoing CR + LR (median costs:$36,775 [IQR: 26,416\u201354,245] vs. $23,682 [IQR: 16,299\u201332,996]). Conclusion: CR + LR was increasingly performed for treatment of CRLM. Compared with two-staged CR and LR, CR + LR was associated with improved outcomes and lower costs

Surgical Procedures in Health Professional Shortage Areas: Impact of a Surgical Incentive Payment Plan

Introduction: The Affordable Care Act established a Center for Medicare/Medicaid Services based 10% reimbursement bonus for general surgeons in Health Professional Shortage Areas. We sought to assess the impact of the Affordable Care Act Surgery Incentive Payment on surgical procedures performed in Health Professional Shortage Areas. Methods: Hospital utilization data from the California Office of Statewide Health Planning and Development between January 1, 2006, and December 31, 2015, were used to categorize hospitals according to Health Professional Shortage Area location. A difference-in-differences analysis measured the effect of the Surgery Incentive Payment on year-to-year differences for inpatient and outpatient surgical procedures by hospital type pre- (2006\u20132010) versus post- (2011\u20132015) Surgery Incentive Payment implementation. Results: Among 409 unique hospitals that performed surgical procedures for at least 1 year of the study period, 2 performed surgery in a designated Health Professional Shortage Area. The two Health Professional Shortage Area -designated hospitals were located in a rural area, were non-teaching hospitals, and had 196 and 202 hospital beds, respectively. After the enactment of the Surgery Incentive Payment, while non- Health Professional Shortage Areas had only a modest relative decrease in total inpatient procedures (Pre-Surgery Incentive Payment: 4,666,938 versus Post-Surgery Incentive Payment: 4,451,612; \u394 124.6%), the proportional decrease in inpatient surgical procedures at Health Professional Shortage Area hospitals was more marked (Pre-Surgery Incentive Payment: 25,830 versus Post-Surgery Incentive Payment: 21,503; \u394 1216.7%). In contrast, Health Professional Shortage Area hospitals proportionally had a greater increase in total outpatient procedures (Pre-Surgery Incentive Payment: 17,840 versus Post-Surgery Incentive Payment: 22,375: \u394+25.4%) versus non- Health Professional Shortage Area hospitals (Pre-Surgery Incentive Payment: 5,863,300 versus Post-Surgery Incentive Payment: 6,156,138; \u394+4.9%). Based on the difference-in-differences analysis, the increase in the trend of surgical procedures at Health Professional Shortage Area hospitals was much more notable after Surgery Incentive Payment implementation (\u394+75.2%). Conclusion: The Medicare Surgery Incentive Payment program was associated with an increase in the number of surgical procedures performed at Health Professional Shortage Area hospitals relative to non-Health Professional Shortage Area hospitals during the study period, reversing the trend from negative to positive

Trends in centralization of surgical care and compliance with National Cancer Center Network guidelines for resected cholangiocarcinoma

Background: A retrospective study was performed to characterize trends in centralization of care and compliance with National Comprehensive Cancer Network (NCCN) guidelines for resected cholangiocarcinoma (CCA), and their impact on overall survival (OS). Methods: Using the National Cancer Database (NCDB) 2004–2015 we identified patients undergoing resection for CCA. Receiver Operating Characteristic (ROC) analyses identified time periods and hospital volume groups for comparison. Propensity score matching provided case-mix adjusted patient cohorts. Cox hazard analysis identified risk factors for OS. Results: Among the 40,338 patients undergoing resection for CCA, the proportion of patients undergoing surgery at high volume hospitals increased over time (25%–44%, p &lt; 0.001), while the proportion of patients undergoing surgery at low volume hospitals decreased (30%–15%, p &lt; 0.001). Using ROC analyses, a hospital volume of 14 operations/year was the most sensitive and specific value associated with mortality. Surgery at high volume hospitals [HR] = 0.92, 95% CI: 0.88–0.97, p &lt; 0.001) and receipt of care compliant with NCCN guidelines (HR = 0.87, 95% CI: 0.83–0.91, p &lt; 0.001) were independently associated with improved OS. Conclusions: Both centralization of surgery for CCA to high volume hospitals and increased compliance with NCCN guidelines were associated with significant improvements in overall survival