Use of Advance Care Planning Billing Codes for Hospitalized Older Adults at High Risk of Dying: A National Observational Study.

We analyzed advance care planning (ACP) billing for adults aged 65 years or above and who were managed by a large national physician practice that employs acute care providers in hospital medicine, emergency medicine and critical care between January 1, 2017 and March 31, 2017. Prompting hospitalists to answer the validated "surprise question" (SQ; "Would you be surprised if the patient died in the next year?") for inpatient admissions served to prime hospitalists and triggered an icon next to the patient's name. Among 113,621 hospital-based encounters, only 6,146 (5.4%) involved a billed ACP conversation: 8.3% among SQ-prompted who answered "no" and 4.1% SQ-prompted who answered "yes" (for non-SQ prompted cases, the fraction was 3.5%; P < .0001). ACP conversations were associated with a comfort-focused care trajectory. Low ACP rates among even those with high hospitalist-predicted mortality risk underscore the need for quality improvement interventions to increase hospital-based ACP.

Readmission Rates and Skilled Nursing Facility Utilization After Major Inpatient Surgery.

BACKGROUND: There is widespread interest in reducing use of postacute care (ie, care after hospital discharge) following major surgery, provided that such reductions do not worsen quality outcomes such as readmission rates. OBJECTIVES: To describe the association between changes in skilled nursing facility (SNF) use and changes in readmission rates after surgery. RESEARCH DESIGN: This was a observational study. SUBJECTS: Fee-for-service Medicare beneficiaries undergoing coronary artery bypass grafting (CABG) or total hip replacement (THR) from 2008 to 2013. MEASURES: Primary exposure was risk-adjusted SNF use initiated 0-2 days after hospital discharge, and the primary outcome was risk-adjusted readmission rates from 3 to 30 days after discharge. RESULTS: Among 176,994 patients who underwent CABG at 804 hospitals and 233,955 patients who underwent THR at 1220 hospitals, hospital-level SNF utilization increased after CABG (16.4%-19.0%, P=0.001) and THR (40.8%-45.5%, P<0.001), from 2008 to 2013. Hospital readmission rates decreased for CABG (14.7%-12.7%, P<0.001) but did not change for THR (4.9%-4.8%, P=0.55), from 2008 to 2013. However, there was wide variation in hospital-level change in readmission rates. After adjusting for hospital characteristics and baseline readmission rates, there was no statistically significant association between change in SNF use and change in readmission rates (0.017 and 0.011 percentage point increase in SNF use for every one percentage point increase in readmission rates for CABG and THR respectively, P=0.58 and 0.32). CONCLUSIONS: Changes in use of postacute care after THR and CABG have not been associated with changes in readmission rates.

Costs and Consequences of Early Hospital Discharge After Major Inpatient Surgery in Older Adults.

Importance: As prospective payment transitions to bundled reimbursement, many US hospitals are implementing protocols to shorten hospitalization after major surgery. These efforts could have unintended consequences and increase overall surgical episode spending if they induce more frequent postdischarge care use or readmissions. Objective: To evaluate the association between early postoperative discharge practices and overall surgical episode spending and expenditures for postdischarge care use and readmissions. Design, Setting, and Participants: This investigation was a cross-sectional cohort study of Medicare beneficiaries undergoing colectomy (189 229 patients at 1876 hospitals), coronary artery bypass grafting (CABG) (218 940 patients at 1056 hospitals), or total hip replacement (THR) (231 774 patients at 1831 hospitals) between January 1, 2009, and June 30, 2012. The dates of the analysis were September 1, 2015, to May 31, 2016. Associations between surgical episode payments and hospitals' length of stay (LOS) mode were evaluated among a risk and postoperative complication-matched cohort of patients without major postoperative complications. To further control for potential differences between hospitals, a within-hospital comparison was also performed evaluating the change in hospitals' mean surgical episode payments according to their change in LOS mode during the study period. Exposure: Undergoing surgery in a hospital with short vs long postoperative hospitalization practices, characterized according to LOS mode, a measure least sensitive to postoperative outliers. Main Outcomes and Measures: Risk-adjusted, price-standardized, 90-day overall surgical episode payments and their components, including index, outlier, readmission, physician services, and postdischarge care. Results: A total of 639 943 Medicare beneficiaries were included in the study. Total surgical episode payments for risk and postoperative complication-matched patients were significantly lower among hospitals with lowest vs highest LOS mode ($26 482 vs $29 250 for colectomy, $44 777 vs $47 675 for CABG, and $24 553 vs $27 927 for THR; P < .001 for all). Shortest LOS hospitals did not exhibit a compensatory increase in payments for postdischarge care use ($4011 vs $5083 for colectomy, P < .001; $6015 vs $6355 for CABG, P = .14; and $7132 vs $9552 for THR, P < .001) or readmissions ($2606 vs $2887 for colectomy, P = .16; $3175 vs $3064 for CABG, P = .67; and $1373 vs $1514 for THR, P = .93). Hospitals that exhibited the greatest decreases in LOS mode had the highest reductions in surgical episode payments during the study period. Conclusions and Relevance: Early routine postoperative discharge after major inpatient surgery is associated with lower total surgical episode payments. There is no evidence that savings from shorter postsurgical hospitalization are offset by higher postdischarge care spending. Therefore, accelerated postoperative care protocols appear well aligned with the goals of bundled payment initiatives for surgical episodes.

Spending On Care After Surgery Driven By Choice Of Care Settings Instead Of Intensity Of Services.

The rising popularity of episode-based payment models for surgery underscores the need to better understand the drivers of variability in spending on postacute care. Examining postacute care spending for fee-for-service Medicare beneficiaries after three common surgical procedures in the period 2009-12, we found that it varied widely between hospitals in the lowest versus highest spending quintiles for postacute care, with differences of 129 percent for total hip replacement, 103 percent for coronary artery bypass grafting (CABG), and 82 percent for colectomy. Wide variation persisted after we adjusted for the intensity of postacute care. However, the variation diminished considerably after we adjusted instead for postacute care setting (home health care, outpatient rehabilitation, skilled nursing facility, or inpatient rehabilitation facility): It decreased to 16 percent for hip replacement, 4 percent for CABG, and 21 percent for colectomy. Health systems seeking to improve surgical episode efficiency should collaborate with patients to choose the highest-value postacute care setting.

Surgeon specialization and operative mortality in United States: retrospective analysis.

OBJECTIVE:  To measure the association between a surgeon's degree of specialization in a specific procedure and patient mortality. DESIGN:  Retrospective analysis of Medicare data. SETTING:  US patients aged 66 or older enrolled in traditional fee for service Medicare. PARTICIPANTS:  25 152 US surgeons who performed one of eight procedures (carotid endarterectomy, coronary artery bypass grafting, valve replacement, abdominal aortic aneurysm repair, lung resection, cystectomy, pancreatic resection, or esophagectomy) on 695 987 patients in 2008-13. MAIN OUTCOME MEASURE:  Relative risk reduction in risk adjusted and volume adjusted 30 day operative mortality between surgeons in the bottom quarter and top quarter of surgeon specialization (defined as the number of times the surgeon performed the specific procedure divided by his/her total operative volume across all procedures). RESULTS:  For all four cardiovascular procedures and two out of four cancer resections, a surgeon's degree of specialization was a significant predictor of operative mortality independent of the number of times he or she performed that procedure: carotid endarterectomy (relative risk reduction between bottom and top quarter of surgeons 28%, 95% confidence interval 0% to 48%); coronary artery bypass grafting (15%, 4% to 25%); valve replacement (46%, 37% to 53%); abdominal aortic aneurysm repair (42%, 29% to 53%); lung resection (28%, 5% to 46%); and cystectomy (41%, 8% to 63%). In five procedures (carotid endarterectomy, valve replacement, lung resection, cystectomy, and esophagectomy), the relative risk reduction from surgeon specialization was greater than that from surgeon volume for that specific procedure. Furthermore, surgeon specialization accounted for 9% (coronary artery bypass grafting) to 100% (cystectomy) of the relative risk reduction otherwise attributable to volume in that specific procedure. CONCLUSION:  For several common procedures, surgeon specialization was an important predictor of operative mortality independent of volume in that specific procedure. When selecting a surgeon, patients, referring physicians, and administrators assigning operative workload may want to consider a surgeon's procedure specific volume as well as the degree to which a surgeon specializes in that procedure.

Adding A Spending Metric To Medicare's Value-Based Purchasing Program Rewarded Low-Quality Hospitals.

In fiscal year 2015 the Centers for Medicare and Medicaid Services expanded its Hospital Value-Based Purchasing program by rewarding or penalizing hospitals for their performance on both spending and quality. This represented a sharp departure from the program's original efforts to incentivize hospitals for quality alone. How this change redistributed hospital bonuses and penalties was unknown. Using data from 2,679 US hospitals that participated in the program in fiscal years 2014 and 2015, we found that the new emphasis on spending rewarded not only low-spending hospitals but some low-quality hospitals as well. Thirty-eight percent of low-spending hospitals received bonuses in fiscal year 2014, compared to 100 percent in fiscal year 2015. However, low-quality hospitals also began to receive bonuses (0 percent in fiscal year 2014 compared to 17 percent in 2015). All high-quality hospitals received bonuses in both years. The Centers for Medicare and Medicaid Services should consider incorporating a minimum quality threshold into the Hospital Value-Based Purchasing program to avoid rewarding low-quality, low-spending hospitals.

Medicare's Bundled Payments for Care Improvement initiative: expanding enrollment suggests potential for large impact.

OBJECTIVES: Aiming to encourage care coordination and cost efficiency, the Center for Medicare and Medicaid Innovation (CMMI) launched the Bundled Payments for Care Improvement (BPCI) initiative in 2013. To help gauge the program's potential impact and generalizability, we describe early and current participants. STUDY DESIGN: We examined the cross-sectional association between BPCI participation and providers' structural and cost characteristics. METHODS: Using data from October 2013 and June 2014, we quantified changes in BPCI participation. We described structural differences between participating and nonparticipating hospitals using t tests and χ2 tests, and we used the Cochrane-Armitage test to assess whether participants were more likely be in higher 90-day episode cost quintiles than their peers at baseline (2009-2010). RESULTS: Overall (risk-bearing and non-risk-bearing) participation in BPCI increased from about 400 in October 2013 to more than 2000 in June 2014-attributable, in part, to Model 2, the most comprehensive of the 4 models offered by CMMI for provider participation. Model 2 hospitals increasingly resemble eligible but nonparticipating hospitals. For the most commonly chosen condition of hip replacement, Model 2 hospitals were not costlier than their peers. Hospitals used to make up 97% of Model 2 participants, but physician practices now comprise a substantial number of Model 2 participants. However, most BPCI participants have not yet begun to bear financial risk. Risk-bearing Model 2 hospitals are a smaller and less representative group, with higher baseline costs for hip replacement than their peers. CONCLUSIONS: Growing participation in BPCI suggests strong interest in bundled payments. The long-term impact of BPCI will depend on CMMI's ability to persuade interested but non-risk-bearing participants to bear risk.

Variation in Medicare Payments for Colorectal Cancer Surgery.

PURPOSE: Colorectal cancer (CRC) is the second most expensive cancer in the United States. Episode-based bundled payments may be a strategy to decrease costs. However, it is unknown how payments are distributed across hospitals and different perioperative services. METHODS: We extracted actual Medicare payments for patients in the fee-for-service Medicare population who underwent CRC surgery between January 2004 and December 2006 (N = 105,016 patients). Payments included all service types from the date of hospitalization up to 1 year later. Hospitals were ranked from least to most expensive and grouped into quintiles. Results were case-mix adjusted and price standardized using empirical Bayes methods. We assessed the contributions of index hospitalization, physician services, readmissions, and postacute care to the overall variation in payment. RESULTS: There is wide variation in total payments for CRC care within the first year after CRC surgery. Actual Medicare payments were $51,345 per patient in the highest quintile and $26,441 per patient in the lowest quintile, representing a difference of Δ = $24,902. Differences were persistent after price standardization (Δ = $17,184 per patient) and case-mix adjustment (Δ = $4,790 per patient). Payments for the index surgical hospitalization accounted for the largest share (65%) of payments but only minimally varied (11.6%) across quintiles. However, readmissions and postacute care services accounted for substantial variations in total payments. CONCLUSION: Medicare spending in the first year after CRC surgery varies across hospitals even after case-mix adjustment and price standardization. Variation is largely driven by postacute care and not the index surgical hospitalization. This has significant implications for policy decisions on how to bundle payments and define episodes of surgical CRC care.

Hospitals In 'Magnet' Program Show Better Patient Outcomes On Mortality Measures Compared To Non-'Magnet' Hospitals.

Hospital executives pursue external recognition to improve market share and demonstrate institutional commitment to quality of care. The Magnet Recognition Program of the American Nurses Credentialing Center identifies hospitals that epitomize nursing excellence, but it is not clear that receiving Magnet recognition improves patient outcomes. Using Medicare data on patients hospitalized for coronary artery bypass graft surgery, colectomy, or lower extremity bypass in 1998-2010, we compared rates of risk-adjusted thirty-day mortality and failure to rescue (death after a postoperative complication) between Magnet and non-Magnet hospitals matched on hospital characteristics. Surgical patients treated in Magnet hospitals, compared to those treated in non-Magnet hospitals, were 7.7 percent less likely to die within thirty days and 8.6 percent less likely to die after a postoperative complication. Across the thirteen-year study period, patient outcomes were significantly better in Magnet hospitals than in non-Magnet hospitals. However, outcomes did not improve for hospitals after they received Magnet recognition, which suggests that the Magnet program recognizes existing excellence and does not lead to additional improvements in surgical outcomes.

Time-to-readmission and Mortality After High-risk Surgery.

OBJECTIVES: To determine if mortality varies by time-to-readmission (TTR). BACKGROUND: Although readmissions reduction is a national health care priority, little progress has been made toward understanding why only some readmissions lead to adverse outcomes. METHODS: In this retrospective cross-sectional cohort analysis, we used 2005-2009 Medicare data on beneficiaries undergoing colectomy, lung resection, or coronary artery bypass grafting (n = 1,033,255) to created 5 TTR groups: no 30-day readmission (n = 897,510), less than 6 days (n = 44,361), 6 to 10 days (n = 31,018), 11 to 15 days (n = 20,797), 16 to 20 days (n = 15,483), or more than 21 days (n = 24,086). Our analyses evaluated TTR groups for differences in risk-adjusted mortality (30, 60, and 90 days) and complications during the index admission. RESULTS: Increasing TTR was associated with a stepwise decline in mortality. For example, 90-day mortality rates in patients readmitted between 1 and 5 days, 6 and 10 days, and 11 and 15 days were 12.6%, 11.4%, and 10.4%, respectively (P < 0.001). Compared to nonreadmitted patients, the adjusted odds ratios (and 95% confidence intervals) were 4.88 (4.72-5.05), 4.20 (4.03-4.37), and 3.81 (3.63-3.99), respectively. Similar patterns were observed for 30- and 60-day mortality. There were no sizable differences in complication rates for patients readmitted within 5 days versus after 21 days (24.8% vs 26.2%, P < 0.001). CONCLUSIONS: Surgical readmissions within 10 days of discharge are disproportionately common and associated with increased mortality independent of index complications. These findings suggest 10-day readmissions should be specially targeted by quality improvement efforts.

Assessing the reach of health reform to outpatient surgery with social network analysis.

OBJECTIVE: To assess the proportion of outpatient surgery currently delivered in ambulatory surgery centers (ASCs) unconnected to nearby hospitals. BACKGROUND: The ASC as a site for outpatient surgery represents one of the fastest growing sectors in health care. Because most are freestanding, ASCs may have little connection to local health systems, possibly placing them outside health reform's reach. METHODS: Using all-payer data from Florida (2005-2009), we identified all ASCs and hospitals active in the state. Using the tools of social network analysis, we then measured each ASC's strength of connection to nearby hospitals on the basis of the number of surgeons shared between facilities. Finally, we determined the proportion of all procedures and charges accounted for by (1) ASCs that are strongly connected to their local health system, (2) those that are weakly connected, and (3) those that are unconnected. RESULTS: Of the 1.4 million procedures performed in Florida ASCs each year, fewer than 250,000 occur at unconnected and weakly connected ASCs. Put differently, 83% of the $4.3 billion in charges for ASC-based care originate from facilities that have substantial integration with their local health system. Although weakly and strongly connected ASCs are similar from an organizational perspective, unconnected ones tend to focus on a single specialty (P = 0.026) and are staffed by fewer physicians (P = 0.013). Furthermore, there is a trend toward fewer unconnected ASCs over time (P = 0.080). CONCLUSIONS: Most ASCs are strongly connected to their local health system. Thus, efforts to constrain spending should target population-based rates of surgery, not unconnected ASCs.

Impact of Surgical Quality Improvement on Payments in Medicare Patients.

OBJECTIVE: To examine the financial impact of quality improvement using Medicare payment data. BACKGROUND: Demonstrating a business case for quality improvement--that is, that fewer complications translates into lower costs--is essential to justify investment in quality improvement. Prior research is limited to cross-sectional studies showing that patients with complications have higher costs. We designed a study to better evaluate the relationship between payments and complications by using quality improvement itself as a measured outcome. METHODS: We used national Medicare data for patients undergoing general (n = 1,485,667) and vascular (n = 531,951) procedures. We calculated hospitals' rates of serious complications in 2 time periods: 2003-2004 and 2009-2010. We sorted hospitals into quintiles by the change in complication rates across these time periods. Costs were assessed using price-standardized Medicare payments, and regression analyses used to determine the average change in payments over time. RESULTS: There was significant change in serious complication rates across the 2 time periods. The top 20% of hospitals demonstrated a 38% decrease (14.3% vs 11.6%, P < 0.001) in complications; in contrast the bottom 20% demonstrated a 25% increase (11.1% vs 16.5%, P < 0.001). There was a strong relationship between quality improvement and payments. The top hospitals reduced their payments by $1544 per patient (95% confidence interval: $1334-1755), whereas the bottom of hospitals had no significant change (average $67 increase, 95% confidence interval: -$123 to $258). CONCLUSIONS: Hospitals that reduced their complications over time had significant reductions in Medicare payments. This demonstrates that payers are clearly incentivized to invest in quality improvement.

Differences between physician social networks for cardiac surgery serving communities with high versus low proportions of black residents.

BACKGROUND: Compared with white patients, black patients are more likely to undergo cardiac surgery at low-quality hospitals, even when they live closer to high-quality ones. Opportunities for organizational interventions to alleviate this problem remain elusive. OBJECTIVES: To explore physician isolation in communities with high proportions of black residents as a factor contributing to racial disparities in access to high-quality hospitals for cardiac surgery. RESEARCH DESIGN: Using national Medicare data (2008-2011), we mapped physician social networks at hospitals where coronary artery bypass grafting procedures were performed, measuring their degree of connectedness. We then fitted a series of multivariate regression models to examine for associations between physician connectedness and the proportion of black residents in the hospital service area (HSA) served by each network. MEASURES: Measures of physician connectedness (ie, repeat-tie fraction, clustering, and number of external ties). RESULTS: After accounting for regional differences in healthcare capacity, the social networks of physicians practicing in areas with more black residents varied in many important respects from those of HSAs with fewer black residents. Physicians serving HSAs with many black residents had a smaller number of repeated interactions with each other than those in other HSAs (P<0.001). When these physicians did interact, they tended to assemble in smaller groups of highly interconnected colleagues (P<0.001). They also had fewer interactions with physicians outside their immediate geographic area (P=0.048). CONCLUSIONS: Physicians in HSAs with many black residents are more isolated than those in HSAs with fewer black residents. This isolation may negatively impact on care coordination and information sharing. As such, planned delivery system reforms that encourage minorities to seek care within their established local networks may further exacerbate existing surgical disparities.

Ambulatory surgery centers and outpatient procedure use among Medicare beneficiaries.

BACKGROUND: There has been a strong push to move outpatient surgery from hospital settings to ambulatory surgery centers (ASCs). Despite the efficiency advantages of ASCs, many are concerned that these facilities could increase overall utilization. OBJECTIVE: To assess the impact of ASC opening on rates of outpatient surgery. DESIGN: This was a retrospective cohort study of Medicare beneficiaries undergoing outpatient surgery between 2001 and 2010. We compared population-based rates of outpatient surgery in Hospital Service Areas (HSAs) with freestanding ASCs to those without. After adjusting for differences using multiple propensity score methods, we assessed the impact of ASC opening in an HSA previously without one on rates of outpatient surgery. SUBJECTS: Patients included were Medicare beneficiaries with Part B eligibility. MAIN OUTCOME MEASURE: Adjusted HSA-level rates of outpatient surgery. RESULTS: Adjusted outpatient surgery rates increased from 2806 to 3940 per 10,000 and the number of ASC operating rooms grew from 7036 to 11,223 (both P<0.001 for trend). By the fourth year after opening, rates of outpatient surgery increased by 10.9% (from 3338 to 3701 per 10,000) in HSAs adding an ASC for the first time. In contrast, outpatient surgery rates grew by only 2.4% and 0.6% in HSAs where an ASC was always or never present, respectively (P<0.001 for test between 3 slopes). CONCLUSIONS: Rather than redistributing patients from one setting to another, the opening of ASCs increases outpatient surgery use. However, the 10.9% increase is more modest than previously suggested by state-level data.

Use of medical consultants for hospitalized surgical patients: an observational cohort study.

IMPORTANCE: Payments around episodes of inpatient surgery vary widely among hospitals. As payers move toward bundled payments, understanding sources of variation, including use of medical consultants, is important. OBJECTIVE: To describe the use of medical consultations for hospitalized surgical patients, factors associated with use, and practice variation across hospitals. DESIGN, SETTING, AND PARTICIPANTS: Observational retrospective cohort study of fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) between January 1, 2007, and December 31, 2010, at US acute care hospitals. MAIN OUTCOMES AND MEASURES: Number of inpatient medical consultations. RESULTS: More than half of patients undergoing colectomy (91,684) or THR (339,319) received at least 1 medical consultation while hospitalized (69% and 63%, respectively). Median consultant visits from a medicine physician were 9 (interquartile range [IQR], 4-19) for colectomy and 3 for THR (IQR, 2-5). The likelihood of having at least 1 medical consultation varied widely among hospitals (interquartile range [IQR], 50%-91% for colectomy and 36%-90% for THR). For colectomy, settings associated with greater use included nonteaching (adjusted risk ratio [ARR], 1.14 [95% CI, 1.04-1.26]) and for-profit (ARR, 1.10 [95% CI, 1.01-1.20]). Variation in use of medical consultations was greater for colectomy patients without complications (IQR, 47%-79%) compared with those with complications (IQR, 90%-95%). Results stratified by complications were similar for THR. CONCLUSIONS AND RELEVANCE: The use of medical consultations varied widely across hospitals, particularly for surgical patients without complications. Understanding the value of medical consultations will be important as hospitals prepare for bundled payments and strive to enhance efficiency.

Variations in Medicare payments for episodes of spine surgery.

BACKGROUND CONTEXT: Although the high cost of spine surgery is generally recognized, there is little information on the extent to which payments vary across hospitals. PURPOSE: To examine the variation in episode payments for spine surgery in the national Medicare population. We also sought to determine the root causes for observed variations in payment at high cost hospitals. STUDY DESIGN: All patients in the national fee for service Medicare population undergoing surgery for three conditions (spinal stenosis, spondylolisthesis, and lumbar disc herniation) between 2005 and 2007 were included. PATIENT SAMPLE: Included 185,954 episodes of spine surgery performed between 2005 and 2007. OUTCOME MEASURES: Payments per episode of spine surgery. METHODS: All patients in the national fee for service Medicare population undergoing surgery for three conditions (spinal stenosis, spondylolisthesis, and lumbar disc herniation) between 2005 and 2007 were identified (n=185,954 episodes of spine surgery). Hospitals were ranked on least to most expensive and grouped into quintiles. Results were risk- and price-adjusted using the empirical Bayes method. We then assessed the contributions of index hospitalization, physician services, readmissions, and postacute care to the overall variations in payment. RESULTS: Episode payments for hospitals in the highest quintile were more than twice as high as those made to hospitals in the lowest quintile ($34,171 vs. $15,997). After risk- and price-adjustment, total episode payments to hospitals in the highest quintile remained $9,210 (47%) higher. Procedure choice, including the use of fusion, was a major determinant of the total episode payment. After adjusting for procedure choice, however, hospitals in the highest quintile continued to be 28% more expensive than those in the lowest. Differences in the use of postacute care accounted for most of this residual variation in payments across hospitals. Hospital episode payments varied to a similar degree after subgroup analyses for disc herniation, spinal stenosis, and spondylolisthesis. Hospitals expensive for one condition were also found to be expensive for services provided for other spinal diagnoses. CONCLUSIONS: Medicare payments for episodes of spine surgery vary widely across hospitals. As they respond to the new financial incentives inherent in health care reform, high cost hospitals should focus on the use of spinal fusion and postacute care.

Relationship between regional spending on vascular care and amputation rate.

IMPORTANCE: Although lower extremity revascularization is effective in preventing amputation, the relationship between spending on vascular care and regional amputation rates remains unclear. OBJECTIVE: To test the hypothesis that higher regional spending on vascular care is associated with lower amputation rates for patients with severe peripheral arterial disease. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 18,463 US Medicare patients who underwent a major peripheral arterial disease-related amputation during the period between 2003 and 2010. EXPOSURE: Price-adjusted Medicare spending on revascularization procedures and related vascular care in the year before lower extremity amputation, across hospital referral regions. MAIN OUTCOMES AND MEASURES: Correlation coefficient between regional spending on vascular care and regional rates of peripheral arterial disease-related amputation. RESULTS: Among patients who ultimately underwent an amputation, 64% were admitted to the hospital in the year prior to the amputation for revascularization, wound-related care, or both; 36% were admitted only for their amputation. The mean cost of inpatient care in the year before amputation, including costs related to the amputation procedure itself, was $22,405, but it varied from $11,077 (Bismarck, North Dakota) to $42,613 (Salinas, California) (P < .001). Patients in high-spending regions were more likely to undergo vascular procedures as determined by crude analyses (12.0 procedures per 10,000 patients in the lowest quintile of spending and 20.4 procedures per 10,000 patients in the highest quintile of spending; P < .001) and by risk-adjusted analyses (adjusted odds ratio for receiving a vascular procedure in highest quintile of spending, 3.5 [95% CI, 3.2-3.8]; P < .001). Although revascularization was associated with higher spending (R = 0.38, P < .001), higher spending was not associated with lower regional amputation rates (R = 0.10, P = .06). The regions that were most aggressive in the use of endovascular interventions were the regions that were most likely to have high spending (R = 0.42, P = .002) and high amputation rates (R = 0.40, P = .004). CONCLUSIONS AND RELEVANCE: Regions that spend the most on vascular care perform the most procedures, especially endovascular interventions, in the year before amputation. However, there is little evidence that higher regional spending is associated with lower amputation rates. This suggests an opportunity to limit costs in vascular care without compromising quality.

Hospital volume and operative mortality in the modern era.

OBJECTIVE: To determine whether the relationship between hospital volume and mortality has changed over time. BACKGROUND: It is generally accepted that hospital volume is associated with mortality in high-risk procedures. However, as surgical safety has improved over the last decade, recent evidence has suggested that the inverse relationship has diminished or been eliminated. METHODS: Using national Medicare claims data from 2000 through 2009, we examined mortality among 3,282,127 patients who underwent 1 of 8 gastrointestinal, cardiac, or vascular procedures. Hospitals were stratified into quintiles of operative volume. Using multivariable logistic regression models to adjust for patient characteristics, we examined the relationship between hospital volume and mortality, and assessed for changes over time. We performed sensitivity analyses using hierarchical logistic regression modeling with hospital-level random effects to confirm our results. RESULTS: Throughout the 10-year period, a significant inverse relationship was observed in all procedures. In 5 of the 8 procedures studied, the strength of the volume-outcome relationship increased over time. In esophagectomy, for example, the adjusted odds ratio of mortality in very low volume hospitals compared to very high volume hospitals increased from 2.25 [95% confidence interval (CI): 1.57-3.23] in 2000-2001 to 3.68 (95% CI: 2.66-5.11) in 2008-2009. Only pancreatectomy showed a notable decrease in strength of the relationship over time, from 5.83 (95% CI: 3.64-9.36) in 2000-2001, to 3.08 (95% CI: 2.07-4.57) in 2008-2009. CONCLUSIONS: For all procedures examined, higher volume hospitals had significantly lower mortality rates than lower volume hospitals. Despite recent improvements in surgical safety, the strong inverse relationship between hospital volume and mortality persists in the modern era.

Does pay-for-performance improve surgical outcomes? An evaluation of phase 2 of the Premier Hospital Quality Incentive Demonstration.

OBJECTIVE: We sought to determine whether the changes in incentive design in phase 2 of Medicare's flagship pay-for-performance program, the Premier Hospital Quality Incentive Demonstration (HQID), reduced surgical mortality or complication rates at participating hospitals. BACKGROUND: The Premier HQID was initiated in 2003 to reward high-performing hospitals. The program redesigned its incentive structure in 2006 to also reward hospitals that achieved significant improvement. The impact of the change in incentive structure on outcomes in surgical populations is unknown. METHODS: We examined discharge data for patients who underwent coronary artery bypass (CABG), hip replacement, and knee replacement at Premier hospitals and non-Premier hospitals in Hospital Compare from 2003 to 2009 in 12 states (n = 861,411). We assessed the impact of incentive structural changes in 2006 on serious complications and 30-day mortality. In these analyses, we adjusted for patient characteristics using multiple logistic regression models. To account for improvement in outcomes over time, we used difference-in-difference techniques that compare trends in Premier versus non-Premier hospitals. We repeated our analyses after stratifying hospitals into quintiles according to risk-adjusted mortality and serious complication rates. RESULTS: After restructuring incentives in 2006 in Premier hospitals, there were lower risk-adjusted mortality and complication rates for both cardiac and orthopedic patients. However, after accounting for temporal trends in non-Premier hospitals, there were no significant improvements in mortality for CABG [odds ratio (OR) = 1.09; 95% confidence interval (CI), 0.92-1.28] or joint replacement (OR = 0.81; 95% CI, 0.58-1.12). Similarly, there were no significant improvements in serious complications for CABG (OR = 1.05; 95% CI, 0.97-1.14) or joint replacement (OR = 1.12; 95% CI, 1.01-1.23). Analysis of the "worst" quintile hospitals that were targeted in the incentive structural changes also did not reveal a change in mortality [(OR = 1.01; 95% CI, 0.78-1.32) for CABG and (OR = 0.96; 95% CI, 0.22-4.26) for joint replacement] or serious complication rates [(OR = 1.08; 95% CI, 0.88-1.34) for CABG and (OR = 0.92; 95% CI, 0.67-1.28) for joint replacement]. CONCLUSIONS: Despite recent enhancements to incentive structures, the Premier HQID did not improve surgical outcomes at participating hospitals. Unless significantly redesigned, pay-for-performance may not be a successful strategy to improve outcomes in surgery.