Data resources for evaluating the economic and financial consequences of surgical care in the United States.

ABSTRACT: Evaluating the relationship between health care costs and quality is paramount in the current health care economic climate, as an understanding of value is needed to drive policy decisions. While many policy analyses are focused on the larger health care system, there is a pressing need for surgically focused economic analyses. Surgical care is costly, and innovative technology is constantly introduced into the operating room, and surgical care impacts patients' short- and long-term physical and economic well-being. Unfortunately, significant knowledge gaps exist regarding the relationship between cost, value, and economic impact of surgical interventions. Despite the plethora of health care data available in the forms of claims databases, discharge databases, and national surveys, no single source of data contains all the information needed for every policy-relevant analysis of surgical care. For this reason, it is important to understand which data are available and what can be accomplished with each of the data sets. In this article, we provide an overview of databases commonly used in surgical health services research. We focus our review on the following five categories of data: governmental claims databases, commercial claims databases, hospital-based clinical databases, state and national discharge databases, and national surveys. For each, we present a summary of the database sampling frame, clinically relevant variables, variables relevant to economic analyses, strengths, weaknesses, and examples of surgically relevant analyses. This review is intended to improve understanding of the current landscape of data available, as well as stimulate novel analyses among surgical populations. Ongoing debates over national health policy reforms may shape the delivery of surgical care for decades to come. Appropriate use of available data resources can improve our understanding of the economic impact of surgical care on our health care system and our patients. LEVEL OF EVIDENCE: Regular Review, Level V.

Value in acute care surgery, Part 1: Methods of quantifying cost.

BACKGROUND: With health care expenditures continuing to increase rapidly, the need to understand and provide value has become more important than ever. In order to determine the value of care, the ability to accurately measure cost is essential. The acute care surgeon leader is an integral part of driving improvement by engaging in value increasing discussions. Different approaches to quantifying cost exist depending on the purpose of the analysis and available resources. Cost analysis methods range from detailed microcosting and time-driven activity-based costing to less complex gross and expenditure-based approaches. An overview of these methods and a practical approach to costing based on the needs of the acute care surgeon leader is presented.

Benchmarking the value of care: Variability in hospital costs for common operations and its association with procedure volume.

BACKGROUND: Efforts to improve health care value (quality/cost) have become a priority in the United States. Although many seek to increase quality by reducing variability in adverse outcomes, less is known about variability in costs. In conjunction with the American Association for the Surgery of Trauma Healthcare Economics Committee, the objective of this study was to examine the extent of variability in total hospital costs for two common procedures: laparoscopic appendectomy (LA) and laparoscopic cholecystectomy (LC). METHODS: Nationally weighted data for adults 18 years and older was obtained for patients undergoing each operation in the 2014 and 2016 National Inpatient Sample. Data were aggregated at the hospital-level to attain hospital-specific median index hospital costs in 2019 US dollars and corresponding annual procedure volumes. Cost variation was assessed using caterpillar plots and risk-standardized observed/expected cost ratios. Correlation analysis, variance decomposition, and regression analysis explored costs' association with volume. RESULTS: In 2016, 1,563 hospitals representing 86,170 LA and 2,276 hospitals representing 230,120 LC met the inclusion criteria. In 2014, the numbers were similar (1,602 and 2,259 hospitals). Compared with a mean of US $10,202, LA median costs ranged from US $2,850 to US $33,381. Laparoscopic cholecystectomy median costs ranged from US $4,406 to US $40,585 with a mean of US $12,567. Differences in cost strongly associated with procedure volume. Volume accounted for 9.9% (LA) and 12.4% (LC) of variation between hospitals, after controlling for the influence of other hospital (8.2% and 5.0%) and patient (6.3% and 3.7%) characteristics and in-hospital complications (0.8% and 0.4%). Counterfactual modeling suggests that were all hospitals to have performed at or below their expected median cost, one would see a national cost savings of greater than US $301.9 million per year (95% confidence interval, US $280.6-325.5 million). CONCLUSION: Marked variability of median hospital costs for common operations exists. Differences remained consistent across changing coding structures and database years and were strongly associated with volume. Taken together, the findings suggest room for improvement in emergency general surgery and a need to address large discrepancies in an often-overlooked aspect of value. LEVEL OF EVIDENCE: Epidemiological, level III.

Macroeconomic trends and practice models impacting acute care surgery.

Acute care surgery (ACS) diagnoses are responsible for approximately a quarter of the costs of inpatient care in the US government, and individuals will be responsible for a larger share of the costs of this healthcare as the population ages. ACS as a specialty thus has the opportunity to meet a significant healthcare need, and by optimizing care delivery models do so in a way that improves both quality and value. ACS practice models that have maintained or added emergency general surgery (EGS) and even elective surgery have realized more operative case volume and surgeon satisfaction. However, vulnerabilities exist in the ACS model. Payer mix in a practice varies by geography and distribution of EGS, trauma, critical care, and elective surgery. Critical care codes constitute approximately 25% of all billing by acute care surgeons, so even small changes in reimbursement in critical care can have significant impact on professional revenue. Staffing an ACS practice can be challenging depending on reimbursement and due to uneven geographic distribution of available surgeons. Empowered by an understanding of economics, using team-oriented leadership inherent to trauma surgeons, and in partnership with healthcare organizations and regulatory bodies, ACS surgeons are positioned to significantly influence the future of healthcare in the USA.

Trauma in the neighborhood: a geospatial analysis and assessment of social determinants of major injury in North America.

OBJECTIVES: We sought to identify and characterize areas with high rates of major trauma events in 9 diverse cities and counties in the United States and Canada. METHODS: We analyzed a prospective, population-based cohort of injured individuals evaluated by 163 emergency medical service agencies transporting patients to 177 hospitals across the study sites between December 2005 and April 2007. Locations of injuries were geocoded, aggregated by census tract, assessed for geospatial clustering, and matched to sociodemographic measures. Negative binomial models were used to evaluate population measures. RESULTS: Emergency personnel evaluated 8786 major trauma patients, and data on 7326 of these patients were available for analysis. We identified 529 (13.7%) census tracts with a higher than expected incidence of major trauma events. In multivariable models, trauma events were associated with higher unemployment rates, larger percentages of non-White residents, smaller percentages of foreign-born residents, lower educational levels, smaller household sizes, younger age, and lower income levels. CONCLUSIONS: Major trauma events tend to cluster in census tracts with distinct population characteristics, suggesting that social and contextual factors may play a role in the occurrence of significant injury events.

A critical assessment of the out-of-hospital trauma triage guidelines for physiologic abnormality.

BACKGROUND: It remains unclear whether the American College of Surgeons Committee on Trauma (ACSCOT) "step 1" field physiologic criteria could be further restricted without substantially sacrificing sensitivity. We assessed whether more restrictive physiologic criteria would improve the specificity of this triage step without missing high-risk patients. METHODS: We analyzed an out-of-hospital, consecutive patient, prospective cohort of injured adults >or=15 years collected from December 1, 2005, to February 28, 2007, by 237 emergency medical service agencies transporting to 207 acute care hospitals in 11 sites across the United States and Canada. Patients were included based on ACSCOT field decision scheme physiologic criteria systolic blood pressure 29 breaths/min, Glasgow Coma Scale score 2 days. RESULTS: Of 7,127 injured persons, 6,259 had complete outcome information and were included in the analysis. There were 3,631 (58.0%) persons with death or LOS >2 days. Using only physiologic measures, the derived rule included advanced airway intervention, shock index >1.4, Glasgow Coma Scale <11, and pulse oximetry <93%. Rule validation demonstrated sensitivity 72% (95% confidence interval: 70%-74%) and specificity 69% (95% confidence interval: 67%-72%). Inclusion of demographic and mechanism variables did not significantly improve performance measures. CONCLUSIONS: We were unable to omit or further restrict any ACSCOT step 1 physiologic measures in a decision rule practical for field use without missing high-risk trauma patients.

Emergency medical services intervals and survival in trauma: assessment of the "golden hour" in a North American prospective cohort.

STUDY OBJECTIVE: The first hour after the onset of out-of-hospital traumatic injury is referred to as the "golden hour," yet the relationship between time and outcome remains unclear. We evaluate the association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality. METHODS: This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged > or =15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was in-hospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders. RESULTS: There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings. CONCLUSION: In this North American sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.

Alternate site surge capacity in times of public health disaster maintains trauma center and emergency department integrity: Hurricane Katrina.

BACKGROUND: Hospital surge capacity has been advocated to accommodate large increases in demand for healthcare; however, existing urban trauma centers and emergency departments (TC/EDs) face barriers to providing timely care even at baseline patient volumes. The purpose of this study is to describe how alternate-site medical surge capacity absorbed large patient volumes while minimizing impact on routine TC/ED operations immediately after Hurricane Katrina. METHODS: From September 1 to 16, 2005, an alternate site for medical care was established. Using an off-site space, the Dallas Convention Center Medical Unit (DCCMU) was established to meet the increased demand for care. Data were collected and compared with TC/ED patient volumes to assess impact on existing facilities. RESULTS: During the study period, 23,231 persons displaced by Hurricane Katrina were registered to receive evacuee services in the City of Dallas, Texas. From those displaced, 10,367 visits for emergent or urgent healthcare were seen at the DCCMU. The mean number of daily visits (mean +/- SD) to the DCCMU was 619 +/- 301 visits with a peak on day 3 (n = 1,125). No patients died, 3.2% (n = 257) were observed in the DCCMU, and only 2.9% (n = 236) required transport to a TC/ED. During the same period, the mean number of TC/ED visits at the region's primary provider of indigent care (Hospital 1) was 346 +/- 36 visits. Using historical data from Hospital 1 during the same period of time (341 +/- 41), there was no significant difference in the mean number of TC/ED visits from the previous year (p = 0.26). CONCLUSIONS: Alternate-site medical surge capacity provides for safe and effective delivery of care to a large influx of patients seeking urgent and emergent care. This protects the integrity of existing public hospital TC/ED infrastructure and ongoing operations.

Transfusion of blood products and nosocomial infection in surgical patients.

PURPOSE OF REVIEW: Liberal transfusion of blood products may be associated with a worse clinical outcome, including in-hospital mortality. This review focuses on the mechanisms by which transfusions may result in an increased risk of bacterial infection. RECENT FINDINGS: The association between blood transfusion and worse outcome has been attributed to suppression of the recipient's immune function, the so called transfusion-related immunomodulation effect, as well as changes that may occur as blood ages. Despite several attempts to identify the mechanism by which transfusion worsens outcomes, this mechanism, as well as the role of leukoreduction in the mitigation of transfusion-related immunomodulation, have yet to be demonstrated. Bacterial contamination of the blood supply has become a serious problem in the past 20 years, and is currently the second leading cause of transfusion-associated death. Since the implementation of specific platelet transfusion protocols, the incidence of morbidity and mortality caused by infected platelet units appears to be markedly reduced. SUMMARY: Transfusion of blood and blood products can be life-saving interventions. Consequences of transfusion may ultimately result in worse outcomes. More research will be required in order to identify indications and practices that optimize outcomes of surgical patients who require a blood transfusion.

Economic impact of motorcycle helmets: from impact to discharge.

BACKGROUND: The economic impact of helmet use remains controversial. Previous studies of injured motorcyclists suggest a marginal inpatient hospital cost difference between helmeted and unhelmeted riders. The purpose of this study was to expand the economic analysis of motorcycle helmet utilization to the point of injury by including motorcycle crash patients who do not require hospital admission. METHODS: Prehospital motorcycle crash data were collected from the National Highway Transportation Safety Administration (NHTSA) General Estimates System (GES) database from 1994 to 2002 with respect to helmet use, injury severity, and transport to a hospital. A focused literature search yielded the hospital admission rates of helmeted and unhelmeted motorcyclists evaluated in the emergency department. The National Trauma Data Bank (NTDB) was queried from 1994 to 2002 to collect data including helmet use and hospital charges for injured motorcyclists. Cost analysis was performed by linkage of the queried databases and data from the literature. Statistical comparisons between groups were performed using an independent samples t test and chi analysis. RESULTS: The NHTSA GES database yielded 5,328 sample patients. 1,854 patients (34.8%) were unhelmeted and 3,474 (65.2%) were helmeted. Transport to a hospital was required of 78.6% of unhelmeted and 73.3% of helmeted patients (p < 0.01). Of motorcyclists evaluated in the emergency department, 39.9% of unhelmeted and 32.8% of helmeted patients required hospital admission. NTDB analysis of injured motorcyclists from the concomitant interval yielded 9,033 patients in whom helmet use data were available and 5,343 patients for whom associated hospital cost data were available. Unhelmeted motorcyclists incurred charges of 39,390 dollars + 1,436 dollars per injury, whereas helmeted motorcyclists incurred charges of 36,334 dollars + 1,232 dollars per injury. Mathematical extrapolation derived a charge of 12,353 dollars per unhelmeted and 8,735 dollars per helmeted motorcyclist for every crash with a difference of 3,618 dollars between helmeted and unhelmeted riders involved in a motorcycle crash. CONCLUSIONS: With a current estimate of 197,608 motorcycle crashes/year in which 69,163 riders were unhelmeted, the differential healthcare economic burden between unhelmeted and helmeted motorcyclists is approximately $250,231,734 per year and underscores the need for improved legislation to improve motorcycle helmet utilization.