Marcelo Cerullo

Association of Hospital Market Concentration With Costs of Complex Hepatopancreaticobiliary Surgery

Importance Trade-offs involved with market competition, overall costs to payers and consumers, and quality of care have not been well defined. Less competition within any given market may enable provider-driven increases in charges. Objective To examine the association between regional hospital market concentration and hospital charges for hepatopancreaticobiliary surgical procedures. Design, Setting, and Participants This study included all patients undergoing hepatic or pancreatic resection in the Nationwide Inpatient Sample from January 1, 2003, through December 31, 2011. Hospital market concentration was assessed using a variable-radius Herfindahl-Hirschman Index (HHI) in the 2003, 2006, and 2009 Hospital Market Structure files. Data were analyzed from November 19, 2016, through March 2, 2017. Interventions Hepatic or pancreatic resection. Main Outcomes and Measures Multivariable mixed-effects log-linear models were constructed to determine the association between HHI and total costs and charges for hepatic or pancreatic resection. Results Weighted totals of 38 711 patients undergoing pancreatic resection (50.8% men and 49.2% women; median age, 65 years [interquartile range, 55-73 years]) and 52 284 patients undergoing hepatic resection (46.8% men and 53.2% women; median age, 59 years [interquartile range, 49-69 years]) were identified. Higher institutional volume was associated with lower cost of pancreatic resection (−5.4%; 95% CI, −10.0% to −0.5%; P = .03) and higher cost of hepatic resection (13.4%; 95% CI, 8.2% to 18.8%; P < .001). For pancreatic resections, costs were 5.5% higher (95% CI, 0.1% to 11.1%; P = .047) in unconcentrated hospital markets relative to moderately concentrated markets, although overall charges were 8.3% lower (95% CI, −14.0% to −2.3%; P = .008) in highly concentrated markets. For hepatic resections, hospitals in highly concentrated markets had 8.4% lower costs (95% CI, −13.0% to −3.6%; P = .001) compared with those in unconcentrated markets and charges that were 13.4% lower (95% CI, −19.3% to −7.1%; P < .001) compared with moderately concentrated markets and 10.5% lower (95% CI, −16.2% to −4.4%; P = .001) compared with unconcentrated markets. Conclusions and Relevance Higher market concentration was associated with lower overall charges and lower costs of pancreatic and hepatic surgery. For complex, highly specialized procedures, hospital market consolidation may represent the best value proposition: better quality of care with lower costs.

Assessing the Financial Burden Associated with Treatment Options for Resectable Pancreatic Cancer

Objective: The aim of this study is to assess the financial burden associated with treatment options for resectable pancreatic cancer. Background: As the volume of cancer care increases in the United States, there is growing interest among both clinicians and policy-makers to reduce its financial impact on the healthcare system. However, costs relative to the survival benefit for differing treatment modalities used in practice have not been described. Methods: Patients undergoing resection for pancreatic cancer were identified in the Truven Health MarketScan database. Associations between chemoradiation therapies and survival were performed using parameterized multivariable accelerated failure time models. Median payments over time were calculated for surgery, chemoradiation, and subsequent hospitalizations. Results: A total of 2408 patients were included. Median survival among all patients was 21.1 months [95% confidence interval (CI): 19.8–22.5 months], whereas median follow-up time was 25.1 months (95% CI: 23.5–26.5 months). After controlling for comorbidity, receipt of neoadjuvant therapy, and nodal involvement, a longer survival was associated with undergoing combination gemcitabine and nab-paclitaxel [time ratio (TR) = 1.26, 95% CI: 1.02–1.57, P = 0.035) or capecitabine and radiation (TR = 1.25, 95% CI: 1.04–1.51, P = 0.018). However, median cumulative payments for gemcitabine with nab-paclitaxel were highest overall [median

Effect of surgeon “experience” with laparoscopy on postoperative outcomes after colorectal surgery

74,051, interquartile range (IQR):

Reliability of Glasgow Coma Score in pediatric trauma patients

38,929–

The relationship of hospital market concentration, costs, and quality for major surgical procedures

133,603). Conclusions: Total payments for an episode of care relative to improvement in survival vary significantly by treatment modality. These data can be used to inform management decisions about pursuing further care for pancreatic cancer. Future investigations should seek to refine estimates of the cost-effectiveness of different treatments.

Physiologic correlates of intraoperative blood transfusion among patients undergoing major gastrointestinal operations

Background. Although the relationship between laparoscopic surgery and improved clinical outcomes has been well established across a variety of procedures, the effect of operative experience with laparoscopic surgery remains less defined. The present study sought to assess the comparative benefit of laparoscopic colorectal surgery relative to surgeon volume. Methods. Commercially insured patients aged 18 to 64 years undergoing a colorectal resection were identified using the MarketScan Database from 2010–2014. Multivariable logistic regression analysis was used to calculate and compare postoperative mortality/morbidity by operative approach relative to surgeon volume. Results. A total of 21,827 patients were identified who met inclusion criteria. The median age among patients was 53 years (interquartile range: 46–59) with a slight majority of patients being female (n = 11,248, 51.5%). Laparoscopic operations were performed in 49.2% of patients (n = 10,756), whereas 50.7% (n = 11,071) underwent an open colorectal resection. On multivariable analysis, laparoscopic surgery was associated with 64% decreased odds of developing a postoperative complication or mortality (odds ratio = 0.36, 95% confidence interval, 0.32–0.41, P < .001). Patients who underwent colectomy performed by a higher operative volume surgeon (high versus low: odds ratio = 0.68, 95% confidence interval, 0.61–0.77, P < .001) demonstrated decreased odds of developing a postoperative complication/mortality. Interestingly the potential decrease in risk‐adjusted morbidity/mortality between laparoscopic and open surgery was somewhat greater among high‐operative‐volume surgeons (odds ratio = 0.29, 95% confidence interval, 0.25–0.34, P < .001) and intermediate‐operative‐volume surgeons (odds ratio = 0.30, 95% confidence interval, 0.25–0.36, P < .001) compared with low‐operative‐volume surgeons (odds ratio = 0.36, 95% confidence interval, 0.32–0.41, P < .001). Conclusion. Although laparoscopic surgery was associated with improved postoperative clinical outcomes, the effect of laparoscopic surgery varied somewhat according to surgeon volume.

Frailty as a Risk Predictor of Morbidity and Mortality Following Liver Surgery

BACKGROUND Discordant assessments of Glasgow Coma Score (GCS) following trauma can result in inappropriate triage. This study sought to determine the reliability of prehospital GCS compared to emergency department (ED) GCS. METHODS We conducted a retrospective review of traumas from 01/2000 to 12/2015 at a Level-1 pediatric trauma center. We evaluated reliability between field and ED GCS using Pearsons correlation. We ascertained the difference between prehospital and ED GCS (delta-GCS). Associations between patient characteristics and delta-GCS were modeled using Poisson and linear regression, adjusting for demographic and clinical covariates. RESULTS We identified 5306 patients. Pearsons correlation for GCS measurements was 0.57 for ages 0-3, and 0.67-0.77 for other age groups. Mean delta-GCS was highest for age<3years (0.95, SD=2.4). Poisson regression demonstrated that compared to children 0-3years, higher age was associated with lower delta-GCS (RR 0.65 95% CI 0.56-0.74). Linear regression showed that in those with a delta-GCS, more severe injury (higher ISS, worse ED disposition) and older age were associated with a negative change, signifying decline in score. CONCLUSIONS GCS is generally unreliable in pediatric trauma patients aged 0-3years, particularly the verbal score component. This may impact accuracy of triage priority for pediatric trauma patients. LEVEL OF EVIDENCE III, Prognostic.

Metformin Use Is Associated with Improved Survival in Patients Undergoing Resection for Pancreatic Cancer

BACKGROUND Our objective was to determine the association between indicators of surgical quality - incidence of major complications and failure-to-rescue - and hospital market concentration in light of differences in costs of care. METHODS Patients undergoing coronary artery bypass graft (CABG), colon resection, pancreatic resection, or liver resection in the 2008-2011 Nationwide Inpatient Sample were identified. The effect of hospital market concentration on major complications, failure-to-rescue, and inpatient costs was estimated at the lowest and highest mortality hospitals using multivariable regression techniques. RESULTS A weighted total of 527,459 patients were identified. Higher market concentration was associated with between 4% and 6% increased odds of failure-to-rescue across all four procedures. Across procedures, more concentrated markets had decreased inpatient costs (average marginal effect ranging from -

Awareness of racial/ethnic disparities in surgical outcomes and care: factors affecting acknowledgment and action

3064 (95% CI: -

Hospital Volume and the Costs Associated with Surgery for Pancreatic Cancer

5812 - -