Post on 13-Dec-2015
Trends in Regionalization of Inpatient Care for Urological Malignancies
Trends in Regionalization of Inpatient Care for Urological Malignancies
Matthew R. CooperbergSanjukta ModakBadrinath R. Konety
Department of UrologyUniversity of California,San Franicsco
AHRQ Annual ConferenceBethesda, MD
September 10, 2008
Matthew R. CooperbergSanjukta ModakBadrinath R. Konety
Department of UrologyUniversity of California,San Franicsco
AHRQ Annual ConferenceBethesda, MD
September 10, 2008
A Heath Care Utilization Project Nationwide Inpatient Sample Study
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Hospital surgical volume associated with better outcomes, first noted 1979 [Luft et al. NEJM 1979; 301:1364]
Major cancer surgery [Begg et al. JAMA 1998; 280:1747]
Urologic oncologic surgery [Joudi et al. J Urol 2005; 174:432]
• HCUP NIS cystectomy studies: postop mortality 2.9% vs 6.4% in highest vs lowest quintile volume hospitals [Birkmeyer et al. NEJM 2002; 346:1128]
• Higher volume assoc with shorter LOS, lower charges, lower complication rates [Konety et al. J Urol 2005;
175:1695. Konety et al. Urology 2006; 68:58]
• HVH status for other urologic or non-urologic surgery not assoc with outcomes [Konety et al. J Clin Oncol
2006; 24:2006]
Associating volume and outcomes
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Is hospital volume or surgeon volume more important?
• Medicare analysis: surgeon volume accounts for 39% of the effect of hospital volume [Birkmeyer et al. NEJM 2004; 349:2117]
What else drives the association?• Hospital size (beds / capacity)
• Urban location
• Teaching mission
• Staffing ratios
• Patient age, LOS, other procedures
“Getting under the hood”
Hollenbeck et al. J Urol 2007; 177:2095 Konety et al. J Urol 2004; 172:1056
Konety et al. J Urol 2005; 173:1695
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Volume-outcomes continued…
IOM systemic review 2002: 135 studies across 27 diagnoses / procedures [Halm et al. Ann Intern Med 2002; 137:511]
• In general higher volumes associate with better outcomes, but magnitude of association varies widely, as does methodological quality of studies
Provider variables may be outweighed by patient variables, perhaps insufficiently reflected in claims-based data (NSQIP investigators) [Khuri et al. World J Surg 2005; 29:1222, Best et al. J Am Coll Surg 2002; 194:257]
Secular / temporal trends• e.g., NIS analysis CABG: during period of declining
volume, 50% decline in proportion of HVH, mortality declined consistently with greatest decline among LVHs [Ricciardi et al. Arch Surg 2008; 143:338]
Regionalization already supported by policy (public and private, mostly reimbursement-driven) in some cases
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
15-year Trends in Regionalization
HCUP NIS data 1988-2002: accessible source of population-based data on health services trends
• Bladder cancer
• Renal cancer
• Prostate cancer
Hospitals ranked to tertiles in each year by numbers of discharges (excluding those with no discharges)
Separate analyses of surgical and non-surgical admissions
Subset analyses by geographic region and primary payer
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Surgical volume thresholds
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Trends in Admissions
Hospital Type 1988-1992 1993-1997 1998-2002
Bladder cancer
Surgical volume p < 0.0001
High 67.0 67.2 70.0
Moderate / Low 33.0 32.8 30.0
Non-surgical volume p < 0.0001
High 70.3 72.4 71.8
Moderate / Low 29.7 27.6 28.2
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Trends in Admissions
Hospital Type 1988-1992 1993-1997 1998-2002
Renal cancer
Surgical volume p < 0.0001
High 67.4 71.7 73.2
Moderate / Low 32.6 28.3 26.8
Non-surgical volume p < 0.0001
High 62.5 69.1 68.3
Moderate / Low 37.5 31.0 31.7
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Trends in Admissions
Hospital Type 1988-1992 1993-1997 1998-2002
Prostate cancer
Surgical volume p = 0.029
High 76.1 75.7 76.5
Moderate / Low 23.9 24.3 23.5
Non-surgical volume p < 0.0001
High 71.0 70.0 69.2
Moderate / Low 29.0 30.0 30.8
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Trends: Medicare / Medicaid
Hospital Type 1988-1992 1993-1997 1998-2002
Renal cancer
Surgical volume p < 0.0001
High 66.1 69.8 71.1
Moderate / Low 33.9 31.2 28.9
Non-surgical volume p = 0.0004
High 59.5 65.9 64.5
Moderate / Low 40.5 34.1 35.5
Prostate cancer
Surgical volume p <0.0001
High 77.0 73.7 74.4
Moderate / Low 23.0 26.3 25.6
Non-surgical volume p < 0.0001
High 71.0 69.6 68.7
Moderate / Low 29.0 30.4 31.3
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Prostate Cancer HVH Admissions
Prostate Cancer, Northeast0
10
20
30
40
50
60
70
80
90
100
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
% o
f D
isch
arg
es a
t H
VH
s
Surgical
Non-surgical
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Prostate Cancer HVH Admissions
Prostate Cancer, Midwest0
10
20
30
40
50
60
70
80
90
100
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
% o
f D
isch
arg
es a
t H
VH
s
Surgical
Non-surgical
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Prostate Cancer HVH Admissions
Prostate Cancer, South0
10
20
30
40
50
60
70
80
90
100
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
% o
f D
isch
arg
es a
t H
VH
s
Surgical
Non-surgical
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Prostate Cancer HVH Admissions
Prostate Cancer, West0
10
20
30
40
50
60
70
80
90
100
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
% o
f D
isch
arg
es a
t H
VH
s
Surgical
Non-surgical
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Summary of findings
About 2/3 of urologic oncology admissions at HVHs
Relative increase in regionalization
• 4.5% for bladder cancer
• 8.9% for renal cancer
• No increase for prostate cancer but higher baseline
Substantial regional variation
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Is regionalization a good trend?
HCUP study: hospitals meeting Leapfrog Group volume standards had similar in-hospital mortality to others. Volume standards would adversely impact low volume hospitals and increase patient travel time. [Ward et al. J Rural Health 2004; 20:344]
Many rural areas lack the referral base to support even one HVH for some procedures. [Dimick et al. Health Aff 2004; web VAR45]
For invasive bladder cancer a delay of >3 months from diagnosis to cystectomy is associated with increased mortality. [Chang et al. J Urol 2003; 170: 1085. Sanchez-Ortiz et al. J Urol 2003; 169:110]
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Is regionalization a good trend?
Proportion of US hospitals performing cystectomy varied from 45 to 50% between 1988 and 1996, then fell to 39% by 2000. [Taub et al. J Urol 2006; 176:2612]
Nonwhite patients, those with Medicaid / no insurance less likely to receive complex surgical care at HVH (in general and cystectomy) [Liu et al. JAMA 2006; 296:1973. Konety et al. Cancer 2007; 109:542]
Bladder cancer patients tend to be older and low SES; radical cystectomy generally perceived to be under-compensated. Regionalization increases burden of uncompensated care on HVHs [Soloway. Cancer 2005; 104:1559]
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Urologist Distribution
Odisho et al. J Urol, in press
Data from HRSA Area Resource File, 2006
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Urologist Distribution
Odisho et al. J Urol, in press
Data from HRSA Area Resource File, 2006
Urologists <45
UCSFUniversity of CaliforniaSan Francisco
UCSFUniversity of CaliforniaSan Francisco
Conclusions
Regionalization of bladder and renal cancer care has occurred over the past 15 years
Trend is likely to continue given provider demographic trends
Policy decisions must balance (possible) benefit due to regionalization with (likely) harm if access is reduced
Alternative: identify and promulgate HVH processes of care
HCUP/NIS invaluable for descriptive health services research; clinically rich data needed to better define volume-outcomes associations