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Nationwide variation in outcomes and cost of laparoscopic procedures

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Abstract

Introduction

Healthcare systems and surgeons are under increasing pressure to provide high-quality care for the lowest possible cost . This study utilizes national data to examine the outcomes and costs of common laparoscopic procedures based on hospital type and location.

Methods

The National Inpatient Sample was queried from 2008 to 2011 for five laparoscopic procedures: colectomy (LC), inguinal hernia repair, ventral hernia repair (LVHR), Nissen fundoplication (NF), and cholecystectomy (LCh). Outcomes, including complication rate and inpatient mortality, were stratified by region and hospital type. Both univariate and multivariate regression analyses were performed using regression-based survey methods; risk-adjusted mean costs for hospital were calculated after adjusting for patient characteristics.

Results

In univariate analysis, the rates of minor complications varied significantly between geographic regions for LCh, LC, NF, and LVHR (p < 0.05). Though LCh and LVHR had statistical variation between regions for rates of major complications (p < 0.05), all regions were equivalent in rates of inpatient mortality for the procedures (p > 0.05). Rural and urban centers had similar rates of complications (p > 0.05), except for higher rates of major complications following IHR and LC in rural centers (p < 0.02) and following Nissen fundoplication in urban facilities(p < 0.0003). Though urban centers were more expensive for all procedures (p < 0.0001), mortality was similar between groups (p > 0.05). For hospital ownership, private investor-owned facilities were substantially more expensive (p < 0.0001), but had no significant differences in complications compared to other hospital types (p > 0.05). In multivariate analysis, while patient factors helped explain differences between outcome differences in different hospital types and locations, in general, the difference in cost remained statistically significant between hospitals.

Conclusion

Though patient demographics and characteristics accounted for some differences in postoperative outcomes after common laparoscopic procedures, higher cost of care was not associated with better outcomes or more complex patients.

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References

  1. Reames BN, Sheetz KH, Waits SA, Dimick JB, Regenbogen SE (2014) Geographic variation in use of laparoscopic colectomy for colon cancer. J Clin Oncol off J Am Soc Clin Oncol 32(32):3667–3672. doi:10.1200/JCO.2014.57.1588

    Article  Google Scholar 

  2. Ricketts TC, Belsky DW (2012) Medicare costs and surgeon supply in hospital service areas. Ann Surg 255(3):474–477. doi:10.1097/SLA.0b013e31822f2021

    Article  PubMed  Google Scholar 

  3. Robinson BR, Pritts TA, Hanseman DJ, Wilson GC, Abbott DE (2014) Cost discrepancies for common acute care surgery diagnoses in Ohio: influences of hospital characteristics on charge and payment differences. Surgery 156(4):814–822. doi:10.1016/j.surg.2014.06.071

    Article  PubMed  Google Scholar 

  4. The Dartmouth Atlas of Health Care (2014) The Dartmouth Institute. http://www.dartmouthatlas.org/. Accessed Jan 2015

  5. Sheiner L (2014) Why the geographic variation in health care spending can’t tell us much about the efficiency or quality of our health care system. Paper presented at the fall 2014 brookings panel on economic activity, Washington DC

  6. Interim Report of the Institute of Medicine Committee on Geographic Variation in Health Care Spending and Promotion of High-Value Health Care: Preliminary Committee Observations (2013) The National Academies Press, Washington, DC

  7. Haider DSA (2014) Success in academic surgery: health services research. Springer, New York

    Google Scholar 

  8. Aboagye JK, Kaiser HE, Hayanga AJ (2014) Rural–urban differences in access to specialist providers of colorectal cancer care in the United States: a physician workforce issue. JAMA Surg. doi:10.1001/jamasurg.2013.5062

    PubMed  Google Scholar 

  9. Alnasser M, Schneider EB, Gearhart SL, Wick EC, Fang SH, Haider AH, Efron JE (2014) National disparities in laparoscopic colorectal procedures for colon cancer. Surg Endosc 28(1):49–57. doi:10.1007/s00464-013-3160-8

    Article  PubMed  Google Scholar 

  10. Ancona C, Agabiti N, Forastiere F, Arca M, Fusco D, Ferro S, Perucci CA (2000) Coronary artery bypass graft surgery: socioeconomic inequalities in access and in 30 day mortality. A population-based study in Rome, Italy. J Epidemiol Community Health 54(12):930–935

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  11. Martin M, Beekley A, Kjorstad R, Sebesta J (2010) Socioeconomic disparities in eligibility and access to bariatric surgery: a national population-based analysis. Surg Obes Relat Dis Off J Am Soc Bariatric Surg 6(1):8–15. doi:10.1016/j.soard.2009.07.003

    Article  Google Scholar 

  12. Coakley M (2010) Office of the Massachusetts Attorney General. Investigation of health care cost trends and cost drivers preliminary report. Massachusetts State Government, online

  13. Schootman M, Lian M, Pruitt SL, Hendren S, Mutch M, Deshpande AD, Jeffe DB, Davidson NO (2014) Hospital and geographic variability in two colorectal cancer surgery outcomes: complications and mortality after complications. Ann Surg Oncol 21(8):2659–2666. doi:10.1245/s10434-013-3472-x

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  14. Association BCBS (2015) A study of cost variations for knee and hip replacement surgeries in the U.S. The Health of America

  15. Hsia RY, Akosa Antwi Y, Nath JP (2014) Variation in charges for 10 common blood tests in California hospitals: a cross-sectional analysis. BMJ Open 4(8):e005482. doi:10.1136/bmjopen-2014-005482

    Article  PubMed Central  PubMed  Google Scholar 

  16. National Health Expenditure Accounts (NHEA) Annual Report (2013). Centers for medicare and medicaid services (CMS), online report

  17. Riskin DJ, Longaker MT, Gertner M, Krummel TM (2006) Innovation in surgery: a historical perspective. Ann Surg 244(5):686–693. doi:10.1097/01.sla.0000242706.91771.ce

    Article  PubMed Central  PubMed  Google Scholar 

  18. Get Well Sooner Program. (2015) Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). http://www.sages.org/get-well-sooner/. Accessed Jan 2015

  19. Cooper MA, Hutfless S, Segev DL, Ibrahim A, Lyu H, Makary MA (2014) Hospital level under-utilization of minimally invasive surgery in the United States: retrospective review. BMJ 349:g4198. doi:10.1136/bmj.g4198

    Article  PubMed Central  PubMed  Google Scholar 

  20. Perissat J, Collet D, Belliard R, Desplantez J, Magne E (1992) Laparoscopic cholecystectomy: the state of the art. A report on 700 consecutive cases. World J Surg 16(6):1074–1082

    Article  CAS  PubMed  Google Scholar 

  21. Soper NJ, Stockmann PT, Dunnegan DL, Ashley SW (1992) Laparoscopic cholecystectomy. The new ‘gold standard’? (Chicago, Ill : 1960). Arch Surg 127(8):917–921

    Article  CAS  PubMed  Google Scholar 

  22. Sauerland S, Jaschinski T, Neugebauer EA (2010) Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev (10):CD001546. doi:10.1002/14651858.CD001546.pub3

  23. Fundamentals of Laparoscopic Surgery (FLS). (2015) Society of American gastrointestinal and endoscopic surgeons. http://www.flsprogram.org. Accessed Jan 2015

  24. ACGME Resident Case Log System. (2015) Accreditation council for graduate medical education. http://www.acgme.org/. Accessed Jan 2015

  25. Fox AM, Pitzul K, Bhojani F, Kaplan M, Moulton CA, Wei AC, McGilvray I, Cleary S, Okrainec A (2012) Comparison of outcomes and costs between laparoscopic distal pancreatectomy and open resection at a single center. Surg Endosc 26(5):1220–1230. doi:10.1007/s00464-011-2061-y

    Article  PubMed  Google Scholar 

  26. Jordan J, Dowson H, Gage H, Jackson D, Rockall T (2014) Laparoscopic versus open colorectal resection for cancer and polyps: a cost-effectiveness study. ClinicoEcon Outcomes Res CEOR 6:415–422. doi:10.2147/ceor.s66247

    Google Scholar 

  27. Keller DS, Champagne BJ, Reynolds HL Jr, Stein SL, Delaney CP (2014) Cost-effectiveness of laparoscopy in rectal cancer. Dis Colon Rectum 57(5):564–569. doi:10.1097/DCR.0b013e3182a73244

    Article  PubMed  Google Scholar 

  28. Quality AfHRa (2006–2009) Healthcare cost and utilization project (HCUP) Net: national inpatient sample (NIS). http://hcupnet.ahrq.gov/

  29. Charlson M, Szatrowski TP, Peterson J, Gold J (1994) Validation of a combined comorbidity index. J Clin Epidemiol 47(11):1245–1251

    Article  CAS  PubMed  Google Scholar 

  30. D’Hoore W, Bouckaert A, Tilquin C (1996) Practical considerations on the use of the Charlson comorbidity index with administrative data bases. J Clin Epidemiol 49(12):1429–1433

    Article  PubMed  Google Scholar 

  31. Ross SW, Oommen B, Wormer BA, Walters AL, Matthews BD, Heniford BT, Augenstein VA (2015) National outcomes of laparoscopic Heller myotomy: operative complications and risk factors for adverse events. Surg Endosc. doi:10.1007/s00464-014-4054-0

    Google Scholar 

  32. Calculating Nationwide (National) Inpatient Sample (NIS) Variance: Report #2003-02 (2014). HCUP methods series. Agency for healthcare research and quality, Rockville, MD

  33. Manning WG, Mullahy J (2001) Estimating log models: to transform or not to transform? Journal of Health Econ 20(4):461–494

    Article  CAS  Google Scholar 

  34. Hierarchical Modeling using HCUP Data, Report #2007-01 (2007). HCUP methods series. Agency for healthcare research and quality, Rockville, MD

  35. Cutler D, Dafny L (2011) Designing transparency systems for medical care prices. N Engl J Med 364(10):894–895. doi:10.1056/NEJMp1100540

    Article  CAS  PubMed  Google Scholar 

  36. Zamosky L (2014) The challenges of healthcare price transparency. Med Econ 91(16):38–40

    PubMed  Google Scholar 

  37. Sinaiko AD, Rosenthal MB (2011) Increased price transparency in health care–challenges and potential effects. N Engl J Med 364(10):891–894. doi:10.1056/NEJMp1100041

    Article  CAS  PubMed  Google Scholar 

  38. Okike K, O’Toole RV, Pollak AN, Bishop JA, McAndrew CM, Mehta S, Cross WW 3rd, Garrigues GE, Harris MB, Lebrun CT (2014) Survey finds few orthopedic surgeons know the costs of the devices they implant. Health Aff 33(1):103–109. doi:10.1377/hlthaff.2013.0453 (Project Hope)

    Article  Google Scholar 

  39. Rock TA, Xiao R, Fieldston E (2013) General pediatric attending physicians’ and residents’ knowledge of inpatient hospital finances. Pediatrics 131(6):1072–1080. doi:10.1542/peds.2012-1753

    Article  PubMed  Google Scholar 

  40. Allan GM, Lexchin J, Wiebe N (2007) Physician awareness of drug cost: a systematic review. PLoS Med 4(9):e283. doi:10.1371/journal.pmed.0040283

    Article  PubMed Central  PubMed  Google Scholar 

  41. Tek Sehgal R, Gorman P (2011) Internal medicine physicians’ knowledge of health care charges. J Grad Med Educ 3(2):182–187. doi:10.4300/jgme-d-10-00186.1

    Article  PubMed Central  PubMed  Google Scholar 

  42. Io Medicine (2003) A shared destiny: community effects of uninsurance. The National Academies Press, Washington, DC

    Google Scholar 

  43. Charles AG, Ortiz-Pujols S, Ricketts T et al (2013) The employed surgeon: A changing professional paradigm. JAMA Surg 148(4):323–328. doi:10.1001/jamasurg.2013.1013

    Article  PubMed  Google Scholar 

  44. Jepson G (2014) Report of the Connecticut Attorney General Concerning Hospital Physician Practice Acquisitions and Hospital-Based Facility Fees. Office of the Connecticut Attorney General, Connecticut. online

  45. Cyr-Taro AE, Kotwall CA, Menon RP, Hamann MS, Nakayama DK (2008) Employment and satisfaction trends among general surgery residents from a community hospital. J Surg Educ 65(1):43–49. doi:10.1016/j.jsurg.2007.07.004

    Article  PubMed  Google Scholar 

  46. Martin Gaynor PhD RTP (2012) Update: the impact of hospital consolidation. the synthesis project. Robert Johnson Wood Foundation, Princeton

    Google Scholar 

  47. Birkmeyer JD, Reames BN, McCulloch P, Carr AJ, Campbell WB, Wennberg JE (2013) Understanding of regional variation in the use of surgery. Lancet 382(9898):1121–1129. doi:10.1016/s0140-6736(13)61215-5

    Article  PubMed Central  PubMed  Google Scholar 

  48. Melotti G, Butturini G, Piccoli M, Casetti L, Bassi C, Mullineris B, Lazzaretti MG, Pederzoli P (2007) Laparoscopic distal pancreatectomy: results on a consecutive series of 58 patients. Ann Surg 246(1):77–82

    Article  PubMed Central  PubMed  Google Scholar 

  49. Cheng D, Downey RJ, Kernstine K, Stanbridge R, Shennib H, Wolf R, Ohtsuka T, Schmid R, Waller D, Fernando H, Yim A, Martin J (2007) Video-assisted thoracic surgery in lung cancer resection: a meta-analysis and systematic review of controlled trials. Innovations 2(6):261–292. doi:10.1097/IMI.0b013e3181662c6a (Philadelphia, Pa)

    PubMed  Google Scholar 

  50. Clinical Outcomes of Surgical Therapy Study G (2004) A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 350(20):2050–2059. doi:10.1056/NEJMoa032651

    Article  Google Scholar 

  51. Robinson CN, Chen GJ, Balentine CJ, Sansgiry S, Marshall CL, Anaya DA, Artinyan A, Albo D, Berger DH (2011) Minimally invasive surgery is underutilized for colon cancer. Ann Surg Oncol 18(5):1412–1418

    Article  PubMed  Google Scholar 

  52. Rossi A, Rossi D, Rossi M, Rossi P (2011) Continuity of care in a rural critical access hospital: surgeons as primary care providers. Am J Surg 201(3):359–362. doi:10.1016/j.amjsurg.2010.08.026 (discussion 362)

    Article  PubMed  Google Scholar 

  53. Lynge DC, Larson EH, Thompson MJ, Rosenblatt RA, Hart LG (2008) A longitudinal analysis of the general surgery workforce in the United States, 1981–2005 (Chicago, Ill : 1960). Arch Surg 143(4):345–350. doi:10.1001/archsurg.143.4.345 (discussion 351)

    Article  PubMed  Google Scholar 

  54. Miskovic D, Ni M, Wyles SM, Tekkis P, Hanna GB (2012) Learning curve and case selection in laparoscopic colorectal surgery: systematic review and international multicenter analysis of 4852 cases. Dis Colon Rectum 55(12):1300–1310. doi:10.1097/DCR.0b013e31826ab4dd

    Article  PubMed  Google Scholar 

  55. Gorgun E, Benlice C, Corrao E, Hammel J, Isik O, Hull T, Remzi FH (2014) Outcomes associated with resident involvement in laparoscopic colorectal surgery suggest a need for earlier and more intensive resident training. Surgery 156(4):825–832. doi:10.1016/j.surg.2014.06.072

    Article  PubMed  Google Scholar 

  56. Davis SS Jr, Husain FA, Lin E, Nandipati KC, Perez S, Sweeney JF (2013) Resident participation in index laparoscopic general surgical cases: impact of the learning environment on surgical outcomes. J Am Coll Surg 216(1):96–104. doi:10.1016/j.jamcollsurg.2012.08.014

    Article  PubMed  Google Scholar 

  57. Unicare (2012) Physician Tiering FAQ. https://www.unicarestateplan.com/pdf/physicianTieringFAQ.pdf. Nov 2014

  58. Wadgaonkar AD, Schneider EC, Bhattacharyya T (2010) Physician tiering by health plans in Massachusetts. J Bone Joint Surg Am 92(12):2204–2209. doi:10.2106/jbjs.i.01080

    Article  PubMed Central  PubMed  Google Scholar 

  59. Hong CS, Atlas SJ, Chang Y, Subramanian SV, Ashburner JM, Barry MJ, Grant RW (2010) Relationship between patient panel characteristics and primary care physician clinical performance rankings. JAMA 304(10):1107–1113. doi:10.1001/jama.2010.1287

    Article  CAS  PubMed  Google Scholar 

  60. de Leval MR, Francois K, Bull C, Brawn W, Spiegelhalter D (1994) Analysis of a cluster of surgical failures. Application to a series of neonatal arterial switch operations. The Journal of thoracic and cardiovascular surgery 107(3):914–923 (discussion 923–914)

    PubMed  Google Scholar 

  61. Colavita PD, Zemlyak AY, Burton PV, Dacey KT, Walters AL, Lincourt AE, Tsirline VE, Kercher KW, Heniford BT (2013) The expansive cost of wound complications after ventral hernia repair. Presented at the Annual Meeting of the American College of Surgeons, Washington, DC

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Authors and Affiliations

  1. Division of GI and Minimally Invasive Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA

    Ciara R. Huntington, Tiffany C. Cox, Laurel J. Blair, Tanushree Prasad, Amy E. Lincourt, B. Todd Heniford & Vedra A. Augenstein

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  1. Ciara R. Huntington
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  2. Tiffany C. Cox
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  3. Laurel J. Blair
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Correspondence to Vedra A. Augenstein.

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Drs. Huntington, Cox, Blair, Lincourt, Heniford, and Augenstein and Ms. Prasad declare no personal or financial conflicts of interest relevant to this manuscript or its data.

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Huntington, C.R., Cox, T.C., Blair, L.J. et al. Nationwide variation in outcomes and cost of laparoscopic procedures. Surg Endosc 30, 934–946 (2016). https://doi.org/10.1007/s00464-015-4328-1

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