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Explaining the Volume-Cost Relationship for Cancer SurgeryVivian
Ho PhDa Meei-Hsiang Ku-Goto MAaand Thomas Aloia MDb
aRice University and Baylor College of MedicinebMD Anderson
Cancer Center*This research was supported by grant number 1R01 CA
138640-01 A2 from the NationalCancer Institute.
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Are there determinants of high quality, low cost cancer
surgery?*
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Background*
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BackgroundHigher surgeon volume lowered hospital costs for 6
cancer operations. (Ho and Aloia, Medical Care 2008)Higher hospital
volume lowered costs only for colectomy.
Do high volume hospitals spend more to improve outcomes?Broader
range of specialists?Advanced ICUs and technology-based
services?
*
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This study*
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DataSEER-Medicare filesPatients diagnosed 2001-2005, Medicare
claims through 2007.
MedPAR files linked to Carrier claims.Patients who received
cancer surgery for 2005-2009.
*
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*Methods
Dependent VariablesRegressorsHospital characteristicsSurgeon
characteristicsPatient characteristics
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Methods*
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Methods*
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MethodsRegressions include year and hospital fixed effects.
Coefficient on volume measures effects of within-hospital
changes in volume. Cant specify volume in categories.
Standard errors adjusted for clustering of unobservables across
patients within hospitals.*
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Methods*
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Methods*
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Methods*
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AHRQ Hospital-level Patient Safety Indicators Complications of
anesthesia (PSI 1)Death in low mortality DRGs (PSI 2)Decubitus
ulcer (PSI 3)Failure to rescue (PSI 4)Foreign body left in during
procedure (PSI 5)Iatrogenic pneumothorax (PSI 6)Selected infections
due to medical care (PSI 7)Postoperative hip fracture (PSI
8)Postoperative hemorrhage or hematoma (PSI 9)Postoperative
physiologic and metabolic derangements (PSI 10)Postoperative
respiratory failure (PSI 11)Postoperative pulmonary embolism or
deep vein thrombosis (PSI 12)Postoperative sepsis (PSI
13)Postoperative wound dehiscence in abdominopelvic surgical
patients (PSI 14)Accidental puncture and laceration (PSI
15)Transfusion reaction (PSI 16)
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Costly Hospital ServicesNurse-to-patient ratiosHospital has CT
ScannerHospital has Electron beam computed tomography
(EBCT)Hospital has Magnetic resonance imaging (MRI)Hospital has
Multi-slice spiral computed tomographyHospital has Positron
emission tomography
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Processes of CareArterial Line Transfusion packed red blood
cells or auto-transfusion Critical Care Consultations Central
Venous Catheter Daily Epidural Management Epidural Anesthesia
Frozen Section Incidental Appendectomy Inpatient Consultations
Pulmonary Artery Catheter Re-intubation Total Parenteral Nutrition
Total claimed hours for anesthesia
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*Figure 1: Hospital Costs by Hospital and Surgeon Volume
(SEER)
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Figure 2: PhysicianReimbursements byHospital and SurgeonVolume
(SEER)
- *Determinants of ln(Hospital Costs + Physician Payments)Colon
Resection (SEER Medicare data)All regressions include patient and
hospital characteristics, mean nurse wages, and the
nurse-to-patient ratio.t-statistics in parentheses*p
- *Determinants of ln(Hospital Costs + Physician
Payments)Pancreatic Resection (SEER Medicare data)All regressions
include patient and hospital characteristics, mean nurse wages, and
the nurse-to-patient ratio.t-statistics in parentheses*p
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Summary of SEER Results*
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Summary of SEER Results*
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Summary of SEER Results*
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Caveats*
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Pancreatic Resection Volume, CMS
HospitalSurgeonMinMedMaxMinMedMax20051314912722006131191254200713138126720081512712542009151381259
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Pancreatic Resection Volume, SEER
HospitalSurgeonMinMedMaxMinMedMax200113131110200214151213200314141210200416161314200515191313
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Top 5 Hospitals by Pancreatic Resection Volume, CMS 2005
Hospital NameVolumeCityStateSEERJohns Hopkins
Hospital149BaltimoreMDNoClarian Health
Partners108IndianapolisINNoMemorial Sloan-Kettering Cancer
Center94New YorkNYYesMassachusetts General
Hospital80BostonMANoSaint Marys Hospital77RochesterMNNo
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Within Provider Change in VolumePancreatic Resection,
2005-2009
HospitalSurgeonMinMedMaxMinMedMax-73-222-35027
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Average Cost per Pancreatic Resection Patient
Chart1
39304.96
38526.125
39182.859
37285.536
35566.749
Cost per Patient
Sheet1
YearCost per Patient
200539304.96
200638526.125
200739182.859
200837285.536
200935566.749
To resize chart data range, drag lower right corner of
range.
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Pancreatic Resection Total Cost Regression, FE*All regressions
include year dummies.
(1) No Controls(2) + Patient Variables(3) + Hospital
VariablesHospital
volume0.000663(0.97)-0.000182(-0.31)-0.0000263(-0.07)Surgeon
volume= ln(surgeon
volume/10)-0.0503***(-6.13)-0.0407***(-5.22)-0.0429***(-5.88)Patient
VariablesXXNurse-to-patient ratio0.0267***(3.96)Hospital
VariablesX
N135721237712348
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Pancreatic Resection Total Cost Regression, FE*Regression
includes year dummies and patient and hospital characteristics.
(4)+ Safety IndicatorsHospital volume-0.000193(-0.40)Postop
hemorrhage or hematoma0.444***(9.14)Surgeon volume= ln(surgeon
volume/10)-0.0357***(-4.76)Postop physio metabol
derangement0.280(1.35)Complications of
anesthesia-0.0346(-0.27)Postop respiratory
failure0.537***(15.84)Decubitus ulcer0.338***(6.19)Postoperative pe
or dvt0.303***(10.75)Death among
surgical0.275***(5.19)Postoperative wound
dehiscence0.503***(5.33)Foreign body left in during
proc-0.408***(-5.99)Accidental
puncture/laceration0.143***(5.17)Iatrogenic
pneumothorax0.152(1.64)
N12348
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Pancreatic Resection Total Cost Regression, FE*Regression
includes year dummies, patient and hospital characteristics, and
PSIs.
(5)+ Birkmeyer Processes of CareHospital
volume-0.000661(-1.41)Daily Epidural
Management-0.00869(-0.65)Surgeon volume= ln(surgeon
volume/10)-0.0193**(-3.07)Re-intubation0.253***(8.36)Incidental
Appendectomy0.0131(0.27)Transfusion/auto-transfusion-0.0217*
(-2.08)Arterial Line0.0660***(6.84)Critical Care
Consultations0.285***(18.83)Central Venous
Catheter0.0150(0.26)Total Parenteral
Nutrition0.148***(6.94)Epidural Anesthesia-0.00500(-0.39)Inpatient
Consultations0.216***(17.66)Frozen Section-0.00557(-0.52)Operating
Room Time0.0383***(18.34)Pulmonary Artery
Catheter0.190***(8.15)
N11877
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Lobectomy Volume, CMS
HospitalSurgeonMinMedMaxMinMedMax20051625513822006162301382200717219138620081822313932009192361377
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Lobectomy Volume, SEER
HospitalSurgeonMinMedMaxMinMedMax20011106316642002110701673200311170176220041126317662005112611865
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Top 5 Hospitals by Lobectomy Volume, CMS 2005
Hospital NameVolumeCityStateSEERMemorial Sloan-Kettering Cancer
Center255New YorkNYYesH Lee Moffitt Cancer Center151TampaFLNoSaint
Marys Hospital151RochesterMNNoNew York-Presbyterian Hospital129New
YorkNYNoUniversity of Texas MD Anderson Cancer
Center111HoustonTXNo
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Within Provider Change in VolumeLobectomy, 2005-2009
HospitalSurgeonMinMedMaxMinMedMax-58036-37153
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Average Cost per Lobectomy Patient
Chart1
23292.178
23285.009
22926.612
22245.323
21858.237
Cost per Patient
Sheet1
YearCost per Patient
200523292.178
200623285.009
200722926.612
200822245.323
200921858.237
To resize chart data range, drag lower right corner of
range.
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Lobectomy Total Cost Regression, FE*All regressions include year
dummies.
(1) No Controls(2) + Patient Variables(3) + Hospital
VariablesHospital volume=(hospital
volume/100)^3-0.0149**(-2.78)0.00845(0.63)0.00760(0.58)Surgeon
volume=(surgeon
volume/10)^.5-0.0487***(-4.16)-0.0403***(-4.32)-0.0403***(-4.31)Patient
VariablesXXNurse-to-patient ratio0.00938*(2.36)Hospital
VariablesX
N570205283552675
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Lobectomy Total Cost Regression, FE*Regression includes year
dummies and patient and hospital characteristics.
(4) + Safety IndicatorsHospital volume=(hospital
volume/100)^30.00990(0.67)Postoperative hip
fracture0.404**(2.72)Surgeon volume=(surgeon
volume/10)^.5-0.0391***(-4.58)Postop hemorrhage or
hematoma0.360***(5.29)Complications of anesthesia0.0611(0.82)Postop
physio metabol derangement0.385***(5.65)Decubitus
ulcer0.494***(10.74)Postop respiratory failure0.770***(37.43)Death
among surgical0.537***(19.57)Postoperative pe or
dvt0.349***(14.91)Foreign body left in during
proc0.200(1.41)Accidental
puncture/laceration0.191***(10.20)Iatrogenic
pneumothorax0.0336***(3.32)
N52675
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Lobectomy Total Cost Regression, FE*Regression includes year
dummies, patient and hospital characteristics, and PSIs.
(5) + Birkmeyer Processes of CareHospital volume=(hospital
volume/100)^30.0116(0.91)Daily Epidural
Management0.0158**(2.92)Surgeon volume=(surgeon
volume/10)^.5-0.0048(-0.66)Re-intubation0.412***(31.60)Incidental
Appendectomy1.250***(4.78)Transfusion/auto-transfusion0.0954***(16.61)Arterial
Line0.0180***(4.01)Critical Care
Consultations0.282***(30.11)Central Venous
Catheter0.122*(2.52)Total Parenteral
Nutrition0.313***(11.20)Epidural Anesthesia-0.00768(-1.62)Inpatient
Consultations0.186***(34.42)Frozen Section0.0426***(10.63)Operating
Room Time0.0742***(33.22)Pulmonary Artery
Catheter0.177***(11.04)
N48689
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Colon Resection Volume, CMS
HospitalSurgeonMinMedMaxMinMedMax2005123368177020061233721784200712434516832008127342168020091252531558
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Colon Resection Volume, SEER
HospitalSurgeonMinMedMaxMinMedMax20051249615362006126127164120071251041636200812510616272009125981637
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Top 5 Hospitals by Colon Resection Volume, CMS 2005
Hospital NameVolumeCityStateSEERFlorida
Hospital368OrlandoFLNoNew York-Presbyterian Hospital291New
YorkNYNoChristiana Care Health System264NewarkDENoMethodist
Hospital262San AntonioTXNoBeaumont Hospital Royal Oak252Royal
OakMIYes
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Within Provider Change in VolumeColon Resection, 2005-2009
HospitalSurgeonMinMedMaxMinMedMax-647147-22356
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Average Cost per Colon Resection Patient
Chart1
19916.529
20385.956
20255.139
19934.386
20606.862
Cost per Patient
Sheet1
YearCost per Patient
200519916.529
200620385.956
200720255.139
200819934.386
200920606.862
To resize chart data range, drag lower right corner of
range.
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Colon Resection Total Cost Regression, FE*All regressions
include year dummies.
(1) No Controls(2) + Patient Variables(3) + Hospital
VariablesHospital
volume0.000149(1.01)-0.0000399(-0.31)-0.0000180(-0.14)Surgeon
volume-0.00532***(-16.35)-0.00201***(-9.07)-0.00202***(-9.08)Patient
VariablesXXNurse-to-patient ratio0.0104***(3.74)Hospital
VariablesX
N160712149803148925
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Colon Resection Total Cost Regression, FE*Regression includes
year dummies and patient and hospital characteristics.
(4) + Safety IndicatorsHospital volume0.0000110(0.09)Postop
hemorrhage or hematoma0.458***(15.73)Surgeon
volume-0.00187***(-8.52)Postop physio metabol
derangement0.525***(8.63)Complications of
anesthesia-0.133*(-2.50)Postop respiratory
failure0.631***(45.37)Decubitus ulcer0.320***(18.70)Postoperative
pe or dvt0.365***(34.24)Death among
surgical0.274***(15.55)Postoperative wound
dehiscence0.677***(27.33)Foreign body left in during
proc0.216*(2.03)Accidental
puncture/laceration0.209***(22.38)Iatrogenic
pneumothorax0.350***(9.11)Transfusion
reaction-0.0720***(-10.43)Postoperative hip
fracture0.614***(5.75)
N148925
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Colon Resection Total Cost Regression, FE*Regression includes
year dummies, patient and hospital characteristics, and PSIs.
(5) + Birkmeyer Processes of CareHospital
volume-0.000101(-0.92)Daily Epidural
Management0.0259***(5.05)Surgeon
volume-0.000370(-1.87)Re-intubation0.260***(27.95)Incidental
Appendectomy0.0303***(4.57)Transfusion/auto-transfusion0.0831***(27.13)Arterial
Line0.157***(36.19)Critical Care
Consultations0.331***(66.48)Central Venous
Catheter0.00459(0.15)Total Parenteral
Nutrition0.238***(42.61)Epidural Anesthesia-0.00146(-0.30)Inpatient
Consultations0.242***(74.07)Frozen Section0.0632***(15.31)Operating
Room Time0.0893***(36.53)Pulmonary Artery
Catheter0.189***(13.15)
N138488
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Policy ImplicationsSurgeon volume is more closely associated
with average costs than hospital volume.Given that higher surgeon
volume lowers mortality, should states report surgeon volumes &
mortality?
Processes of care explain much of the surgeon volume-cost
relationship.
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Conclusions*
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Caveats*
*Note: Real costs per patient fell over time.
**These variables have not been included in the regression
results for SEER data yet.*Natural log scale masks potentially
large differences in mean costs. (inverse ln of 8.9 and 9.0 are
$7,331 and $8.103 respectively). Predicted costs appear lower for
patients in lower tertile of hosp volume (1 to 35/yr) relative to
highest tertile (>65)*Mcare only values***Mcare only values*WANT
TO INCLUDE THOSE NOT IN SAMPLE?*Mcare only values*