Tyler R. Grenda

Variation in Hospital Episode Costs With Bariatric Surgery

IMPORTANCE Under bundled payment programs, hospitals receive a single payment for all services provided surrounding an episode of care. Because health care providers, such as hospitals and physicians, accept more financial risk under these programs, they will need a better understanding of episode costs to identify areas to target improvements in quality and cost-efficiency. OBJECTIVE To examine hospital variation in episode costs for a common high-risk procedure that is a prime candidate for bundled payment programs (ie, bariatric surgery). DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, we used national Medicare claims data and identified patients undergoing bariatric procedures in 2011-2012 (N = 24 647 patients; 463 hospitals). We calculated risk-adjusted Medicare payments from the date of admission for the index procedure to 30 days following discharge. We then divided hospitals into equally sized quartiles and examined variation in payments for services around episodes of care. Medicare payments were examined by service payment type (ie, payments to hospitals, payments to physicians, and payments for postacute care services) across hospital quartiles. MAIN OUTCOMES AND MEASURES Hospital variation in episode costs for services around an episode of bariatric surgery. RESULTS Mean total payments for bariatric procedures varied from

Using Surgical Video to Improve Technique and Skill.

11 086 to

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13 073 per episode of care, resulting in a mean difference of

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1987 (16.5% difference) per episode of care between the lowest and highest hospital quartiles. The index hospitalization was responsible for the largest portion of total payments (75%), followed by physician services (21%) and postacute care services (2.8%). Payments for index hospitalization accounted for the greatest variation in payments. CONCLUSIONS AND RELEVANCE There are variations in hospital episode payments among Medicare patients undergoing bariatric surgery procedures. As hospitals enter bundled payment programs, they will need to target areas with the largest variation in costs for quality- and efficiency-improvement activities.

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A lthough the recent quality improvement efforts have made considerable gains in improving perioperative care, these approaches largely ignore the details of what occurs during the operation itself. It is generally accepted that what occurs at the hands of the surgeon during a procedure has significant influence on patient outcomes. However, objectively assessing surgeon performance in the operating room has been difficult. As a result, surrogate measures, such as procedural volume, have served as proxies for operative proficiency. Recently, enthusiasm has been growing to tackle the challenges of directly evaluating and improving surgeon performance using intraoperative video. This work with practicing surgeons builds on the previous experience of using video to assess laparoscopic skills among residents. Illustrating this strategy, a recent high-profile study in bariatric surgery demonstrated that higher peer ratings of surgical skill— assessed by video analysis of performance during laparoscopic gastric bypass—were associated with lower rates of postoperative adverse events. Although it may seem obvious that greater skill would be associated with improved outcomes, this was the first study to demonstrate that variations in technical skill could be reliably measured by peer evaluation of practicing surgeons. Perhaps most importantly, this study was the first to definitively link peer ratings of skill directly with patient outcomes. This study has only scratched the surface of using video analysis to improve intraoperative performance. Video analysis affords the opportunity to study both surgical technique (ie, the details of how an operation is conducted) and surgical skill (ie, how well a surgeon performs a procedure). This strategy may be particularly applicable for technically complex procedures that already have the capability to capture video (eg, advanced laparoscopy, robotic surgery, video-assisted thoracoscopic surgery). Furthermore, this work could also be extended to open procedures using other video-recording modalities.

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Regionally advanced squamous cell carcinoma (SCC) of the esophagus portends a poor prognosis even when esophageal resection can be accomplished. In an effort to improve patient survival, multimodal approaches to this disease have evolved that prompt re-evaluation whether esophageal resection remains a key part of treatment. In review of the available literature, multimodality approaches that include chemoradiation (CRT) may offer the best survival benefit, whereas the exact role of surgery remains unclear and continues to evolve. Further prospective studies are needed to solidify the role of surgery in regionally advanced SCC of the esophagus.