High-volume Providers Research Articles

Higher volume providers are associated with improved outcomes following ERCP for the palliation of malignant biliary obstruction

BackgroundRelieving malignant biliary obstruction improves quality of life and permits chemotherapy. Outcomes of endoscopic retrograde cholangio-pancratography(ERCP) in inoperable malignant biliary obstruction have been examined in a national cohort to establish factors associated with poor outcomes. MethodsHospital Episode Statistics include diagnostic and procedural data for all NHS hospital attendances in England. Patients from 2006 to 2017 with a Hepaticopancreaticobiliary (HPB) malignancy who had undergone ERCP were studied. Patients undergoing a potentially curative operation were excluded. Associations between demographics, co-morbidities, unit ERCP volume and mortality were examined by logistic regression. Findings39,702 patients were included; 49.4% were male; median age was 75 (IQR 66–88)years. Pancreatic cancer was the most common tumour (63.9%). Mortality was 4.1%, 9.7% and 19.1% for 7-day, in hospital and 30-day respectively. On multivariable analysis: men (OR 1.20(95%CI 1.14–1.26), p < 0.001); increasing age quintile 78–83(1.73(1.59–1.89), p < 0.001), >83(2.70(2.48–2.94),p < 0.001); most deprived quintile (1.21(1.11–1.32), p < 0.001); increasing co-morbidity score >20(3.36(2.94–3.84),p < 0.001); small bowel malignancy (1.45(1.22–1.72), p < 0.001), intrahepatic biliary malignancy(1.10(1.03–1.17), p = 0.005) and year of ERCP 2006/07 (1.37(1.22–1.55), p < 0.001) were associated with increased 30-day mortality. Extrahepatic biliary tree cancers (0.67(0.61–0.73), p<0.001), high volume providers of ERCP (>318 annually, 0.91(0.84–0.98), p = 0.01) and high volume of ERCP for malignant obstruction (>40 annually (0.91(0.85–0.98), p = 0.014) were negatively associated with 30-day mortality. Patients were less likely to require a second ERCP in high volume providers (>318, 8.0%) compared to low volume ((<204, 13.4%), p<0.001). InterpretationShort term mortality in patients with malignant biliary obstruction following ERCP was high. 30-day mortality was positively associated with increasing age and co-morbidity, men, deprivation, and earlier year of ERCP and negatively with extrahepatic biliary tree cancer and high volume ERCP providers. FundingInternal funding only

Economic impacts of care by high-volume providers for non-curative esophagogastric cancer: a population-based analysis.

Esophagogastric cancer (EGC) is one of the deadliest and costliest malignancies to treat. Care by high-volume providers can provide better outcomes for patients with EGC. Cost implications of volume-based cancer care are unclear. We examined the cost-effectiveness of care by high-volume medical oncology providers for non-curative management of EGC. We conducted a population-based cohort study of non-curative EGC over 2005-2017 by linking administrative datasets. High-volume was defined as ≥ 11 patients/provider/year. Healthcare costs ($USD/patient/month-survived) were computed from diagnosis to death or end of follow-up from the perspective of the healthcare system. Multivariable quantile regression examined the association between care by high-volume providers and costs. Sensitivity analyses were conducted by varying costing horizons and high-volume definitions. Among 7011 non-curative EGC patients, median overall survival was superior with care by high-volume providers with 7.0 (IQR 3.3-13.3) compared to 5.9 (IQR 2.6-12.1) months (p < 0.001) for low-volume providers. Median costs/patient/month-lived were lower for high-volume providers ($5518 vs. $5911; p < 0.001), owing to lower inpatient acute care costs, despite higher medication-associated and radiotherapy costs. Care by high-volume providers was independently associated with a reduction of $599 per patient/month-lived (95% confidence interval - 966 to - 331) compared to low-volume providers. The incremental cost-effectiveness ratio was - 393. Care by high-volume providers remained the dominant strategy when varying the costing horizon and the high-volume definition. Care by high-volume providers for non-curative EGC is associated with superior survival and lower healthcare costs, indicating a dominant strategy that may provide an opportunity to improve cost-effectiveness of care delivery.

Does Very High Surgeon or Hospital Volume Improve Outcomes for Hemiarthroplasty Following Femoral Neck Fractures?

BackgroundThis study evaluates whether very high-volume hip arthroplasty providers have lower complication rates than other relatively high-volume providers. MethodsHemiarthroplasty patients ≥60 years old were identified in the New York Statewide Planning and Research Cooperative System 2001-2015 dataset. Low-volume hospitals (<50 hip arthroplasty cases/y) and surgeons (<10 cases/y) were excluded. The upper and lower quintiles were compared for the remaining “high-volume” hospitals (50-70 vs >245) and surgeons (10-15 vs ≥60) using multivariable Cox proportional hazards regression. Multiple sensitivity analyses were performed treating volume as a continuous variable. ResultsIn total, 48,809 patients were included. Very high-volume hospitals demonstrated slightly less pneumonia (6% vs 7%, hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.68-0.88, P < .0001). Very high-volume surgeons experienced slightly higher rates of inpatient morality (3% vs 2%, HR 1.30, 95% CI 1.06-1.60, P = .01), revision surgery (3% vs 3%, HR 1.24, 95% CI 1.02-1.52, P = .03), and implant failure (1% vs <1%, HR 1.80, 95% CI 1.10-2.96, P = .02). Sensitivity analyses did not significantly alter these findings but suggested that inpatient mortality may decline as surgeon volume approaches 30 cases/y before gradually increasing at higher volumes. ConclusionA clinically meaningful volume-outcome relationship was not identified among very high-volume hemiarthroplasty surgeons or hospitals. Although prior evidence indicates that outcomes can be improved by avoiding very low-volume providers, these results suggest that complications would not be further reduced by directing all hemiarthroplasty patients to very high-volume surgeons or facilities. Future research investigating whether inpatient mortality changes with surgeon volume (particularly around 30 cases/y) in a different dataset would be valuable. Level of EvidencePrognostic Level III.

Variation in receipt of therapy and survival with provider volume for medical oncology in non-curative esophago-gastric cancer: a population-based analysis.

While surgical care by high-volume providers for esophago-gastric cancer (EGC) yields better outcomes, volume-outcome relationships are unknown for systemic therapy. We examined receipt of therapy and outcomes in the non-curative management of EGC based on medical oncology provider volume. We conducted a population based retrospective cohort study of non-curative EGC over 2005-2017 by linking administrative healthcare datasets. The volume of new EGC consultations per medical oncology provider per year was calculated and divided into quintiles. High-volume (HV) medical oncologists were defined as the 4-5th quintiles. Outcomes were receipt of chemotherapy and overall survival (OS). Multivariate logistic and Cox-proportional hazards regressions examined the association between management by HV medical oncologist, receipt of systemic therapy, and OS. 7011 EGC patients with non-curative management consulted with medical oncology. 1-year OS was superior for HV medical oncologists (> 11 patients/year), with 28.4% (95% CI 26.7-30.2%) compared to 25.1% (95% CI 23.8-26.3%) for low volume (p < 0.001). After adjusting for age, sex, comorbidity burden, rurality, income quintile, and diagnosis year, HV medical oncologist was independently associated with higher odds of receiving chemotherapy (OR 1.13, 95% CI 1.01-1.26), and independently associated with superior OS (HR 0.89, 95% CI 0.84-0.93). Medical oncology provider volume was associated with variation in non-curative management and outcomes of EGC. Care by an HV medical oncologist was independently associated with higher odds of receiving chemotherapy and superior OS, after adjusting for case mix. This information is important to inform disease care pathways and care organization; an increase in the number of HV medical oncologists may reduce variation and improve outcomes.

Volume-outcome relationships in spine surgery – does increasing caseload co-relate with reduced complications?

With the advent of value-based models of healthcare and introduction of alternative payment models, there has been a renewed interest towards the consideration of regionalization policies revolving around ‘concentrating’ spine surgeries to high volume providers in an attempt to reduce complication rates and promote delivery of quality care. The current paper reviews pertinent evidence on the surgeon volume-outcome relationship in spine surgeries, with particular reference to complication rates. The review also provides valuable information on the unintended ramifications of regionalization of care on the healthcare system.

286 Colonoscopy Outcome Similarities and Differences Between GI Providers and Non-GI Providers in Patients Who Undergo Colonoscopy Following a Positive Stool DNA Test

INTRODUCTION: Previous stool DNA studies published aggregated results of colonoscopy outcome in patients who had a positive stool DNA test. In this study, we compare the outcome of colonoscopy based on the specialty of the provider who performed the procedure. METHODS: Review of charts of 1413 patients who had a positive stool DNA followed by documented colonoscopy was done. At total of 4 patients were excluded. Two patients were excluded because of finding of “other carcinoma” aside from adenocarcinoma while the other 2 were excluded because the provider type was unknown. Attention was given to the specialty of the provider performing the procedure. Patients were divided in 2 groups. Group 1 included patients who had their colonoscopy done by a GI provider while group 2 included patients who had their colonoscopy done but a Non-GI provider. Only the index lesion was recorded. Advanced adenoma was defined as an adenoma that is larger than 10 mm or had high risk features such as villous transformation or high grade dysplasia. Nonadvanced adenoma was defined as an adenoma that is smaller than 10 mm and had no high risk features. Statistical analysis with Chi-square and Fisher exact was done to compare the proportions. A P-value &lt; 0.05 was considered to be statistically significant. RESULTS: Out of the 1409 patients included in the study, colonoscopy was performed by a gastroenterologist in 1180 (83.75%) of the patients, by a general surgeon in 198 (14.05%) of the patients, and by a primary care provider (internal medicine or family medicine) in 31 (2.2%) of the patients. The findings in group 1 and group 2 were compared. “adenocarcinoma” was found in 2.03% vs. 0% respectively (P = 0.02). “Advanced adenoma” was found in 23.98% vs. 22.27% respectively (P = 0.58). “10 mm adenoma” was found in 7.71% vs. 4.37% respectively (P = 0.07). Non advanced adenoma was found in 30% vs. 26.64% respectively (P = 0.31). Finally, no adenomas were found in 36.27% vs. 46.72% respectively (P = 0.003). CONCLUSION: This study shows similarities and differences in outcomes of colonoscopies in patients who have positive stool DNA test between high volume and low volume providers. GI providers and non GI providers had a difference in their findings of non advanced adenoma and adenocarcinoma. Further prospective studies are needed to validate these results.

Variability between individual surgeons in route of hysterectomy for patients with endometrial cancer in Florida

ObjectivesMinimally invasive surgery (MIS) was designated as a quality measure for endometrial cancer in 2014. However, national database analyses demonstrate that laparotomy is still performed for this indication. This study aims to assess the route of hysterectomy performed by gynecologic surgeons who manage endometrial cancer in the state of Florida. Materials and methodsAll patients in Florida who were diagnosed with endometrial cancer (both ICD-9 Code 182.0 and ICD-10 Code C54.10), and who received a related surgical procedure from 2014 to 2016 were included. Eligible patients were identified using the Florida Inpatient Discharge Dataset, the Florida Ambulatory and Emergency Discharge Dataset, the Hospital Compare dataset, and the Healthcare Cost Report Information System. The primary surgeon was identified using their national provider identifier (NPI) number. Each surgeon's overall operative volume, MIS volume, and percentage of MIS procedures were collected. ResultsHysterectomy for endometrial cancer was performed in 6086 patients; 4959 (81.5%) underwent MIS and 1127 (18.5%) had an abdominal approach. Hysterectomy for endometrial cancer was performed by 368 providers in Florida (range of 2–244 surgeries). The percentage of MIS to total hysterectomies for providers who performed 1–10 cases was 72.1%; 11–25 cases was 40.9%; 26–100 cases was 80.1%; and more than 100 cases was 86.1%. Variation in operative route exists amongst low- and high-volume providers. ConclusionsStatewide databases can be used to identify surgical trends for policy purposes. These findings support the referral of patients with endometrial cancer to surgeons with high MIS volumes.

Effect of centralization on complex surgical care: A population-based case study of radical cystectomy.

We sought to determine whether non-mandated or passive centralization of radical cystectomy (RC) to higher-volume centers leads to enhanced processes of care and outcomes. This is a population-based, retrospective, cohort study that used the Ontario Cancer Registry (OCR) to identify all incident patients who underwent RC from 1994-2013. Electronic records of treatment were linked to OCR; pathology records were obtained for all cases and reviewed by a team of trained data abstractors. The primary objective was to describe annual provider RC volumes. Secondary objectives included investigating process and outcome measures. For the 5574 patients identified, the mean annual surgeon volume and hospital volume of RC from 1994-2008 was 4.5 (95% confidence interval [CI] 4.4-4.7) and 12.2 (95% CI 11.8-12.5), respectively. From 2009-2013, these volumes significantly increased to 6.8 (95% CI 6.5-7. 1) and 16.4 (95% CI 15.8-16.9). Process variables improved over time, including the use of neoadjuvant chemotherapy. Over the study period, there was a substantial improvement in cancer-specific survival (CSS): hazard ratio (HR) 0.60 (95% CI 0.53-0.67) for 2009-2013. During the most recent era, there was still evidence of a provider volume effect on both process measures and CSS. There has been recent passive centralization of RC to higher-volume providers in the province of Ontario, with measurable improvements in processes of quality care. Although centralization was also associated with improvement in CSS, in the most recent era, there continues to be low-volume providers with a residual volume-outcome effect.

Provider-volume associated with variable receipt of therapy and outcomes for noncurative pancreas adenocarcinoma: A population-based analysis.

352 Background: While high-volume providers for pancreatic adenocarcinoma (PA) surgery yield better outcomes, variation in practice and the role of provider-volume has not been investigated for systemic therapy. We examined variation in practice and outcomes in the management of non-curative PA, based on medical oncology provider-volume. Methods: We conducted a population based retrospective cohort study of non-resected PA over 2005-2016 by linking administrative healthcare datasets. High-volume (HV) medical-oncology providers were defined as the 5th quintile of number of PA seen per provider per year. Outcomes were receipt of chemotherapy and overall survival (OS). Brown Forsythe Levene (BFL) test for equality of variances assessed outcomes variability between provider-volume quintiles (Q1 to 5). Multivariate regressions examined the association between management by HV provider and receipt of systemic therapy and OS. Results: Of 10,881 non-curative PA patients, 7,062 consulted with medical oncology. Among 341 medical oncology providers, 3% were HV, defined as &gt; 16 patients/year. There was variability in receipt of chemotherapy based on provider-volume, with 44% (IQR: 25-54) for Q1 and 47% (IQR: 43-54) for Q5, and in median survival, with 4.1 months (IQR: 2.7-6.2) for Q1 and 7.5 months (IQR: 6.6-8.0) for Q5. Variability between provider-volume quintiles was significant for receipt of chemotherapy and median survival (both BFL p &lt; 0.001). After adjusting for age, sex, comorbidity burden, rurality, income quintile, and diagnosis year, HV provider was independently associated with higher odds of receiving chemotherapy (OR 1.19 [1.05-1.34]), and superior OS (HR 0.79 [0.74-0.84]). Conclusions: There was significant variation in non-curative management and outcomes of PA based on provider-volume. Management by a HV provider was independently associated with higher odds of receiving chemotherapy and superior OS, after adjusting for case-mix. This information is important to inform disease care pathways and care organization. Cancer care systems could consider initiatives to increase the number of HV providers to reduce variation and improve outcomes.

Impact of provider characteristics on use of endovenous ablation procedures in Medicare beneficiaries

ObjectiveThe objective of this study was to assess the association between provider characteristics and intensity of endovenous therapy (EVT) utilization in the Medicare population. MethodsThe Medicare Provider Utilization and Payment Data Public Use Files (2012-2014) were queried to construct a database of providers performing EVT using laser or radiofrequency ablation techniques for treatment of lower extremity venous reflux. A utilization index (UI; EVT procedure per patient treated per year) was calculated for each provider, and median services per county were determined. Provider specialty, geographic region, and site of service (facility vs outpatient) were determined for each patient. Multivariate regression analysis was used to identify provider characteristics associated with a UI above the 75th percentile. ResultsThere were 6599 providers who performed EVT in 405,232 Medicare beneficiaries during the study period. Intensity of EVT use by providers was assessed by the calculated UI, the average number of EVT procedures performed in treated patients per year (range, 1-4). Vascular surgeons had the lowest UI among all provider specialties (1.32). By multivariate analysis, the likelihood of a provider's UI being >1.8 (top 25%) was associated with provider training in a field other than surgery, cardiology, or radiology (odds ratio [OR], 3.35; 2.74-4.09); services performed in an outpatient setting (OR, 2.62; 1.97-3.47); and providers who perform high annual volume of EVT (OR, 8.68; 7.59-9.91). A high annual volume provider was defined as one whose EVT volume was ≥75th percentile nationally. ConclusionsThere is great variation in intensity of vein ablation procedures performed on Medicare beneficiaries by geographic location and provider specialty. High-volume providers and those with a specialty not traditionally associated with the management of lower extremity chronic venous disease are more likely to perform more EVT procedures per patient.

The association between facility case volume and overall survival in patients with metastatic renal cell carcinoma in the targeted therapy era

BackgroundImproved overall survival of cancer patients treated by high-volume providers has been reported in surgical oncology and radiation oncology literature. Whether this volume-outcome association exists in medical oncology-managed metastatic solid tumors is uncertain. This study aimed to investigate the effect of facility case volume (FCV) on overall survival in patients with metastatic renal cell carcinoma (mRCC) diagnosed in the targeted therapy era. Materials and methodsAdult patients diagnosed with mRCC between 2006 and 2015 were identified in the National Cancer Database. The primary exposure was FCV, which was defined by mRCC case volume of each treating facility. The association between FCV and all-cause mortality in mRCC was investigated in multivariable Cox regression model and validated with inverse propensity-score weighting method. Logistic regression was used to identify independent predictors for treatment at high-volume facilities. Covariates adjusted for were sociodemographics, tumor characteristics and treatment modalities. ResultsThere were 31,329 mRCC patients identified. The mean follow-up time was 14.3 months. When FCV was coded as a continuous variable, each increment of 10 mRCC cases/y was associated with reduced all-cause mortality after baseline covariates adjustment [adjusted hazard ratio: 0.93, 95% confidence interval: 0.90–0.96, P value:<0.0001]. In dichotomized models, improved all-cause mortality was observed at cutoffs of 85th (4.3 cases/y), 90th (5.4 cases/y) and 95th (7.4 cases/y) but not at 50th (2.2 cases/y) and 75th (3.4 cases/y) percentiles. For illustrative purpose, 95th percentile was chosen and inverse propensity-score weighting-adjusted Kaplan–Meier curve demonstrated improved overall survival for mRCC patients treated at high-volume facilities (adjusted hazard ratio: 0.90, 95% confidence interval: 0.88–0.94, P value <0.0001; the 1-, 2-, 3-year survival rates were 41%, 26%, and 19% vs. 36%, 22%, and 16% for patients treated at high and low-volume facilities, respectively). Patients without insurance or with Medicaid status, with shorter travel distance, living in nonmetropolitan area or in area with lower averaged education level were less likely to be treated at high-volume facilities. ConclusionsPatients diagnosed with mRCC in the targeted therapy era have improved overall survival when treated at high mRCC-volume facilities, suggesting a volume-outcome association in medical oncology-managed metastatic solid tumors.

High-volume providers and brachytherapy practice: A Medicare provider utilization and payment analysis

PurposeBrachytherapy is an important component of the treatment of gynecologic and prostate cancers, with data supporting its impact on clinical outcomes. Prior data have suggested that brachytherapy tends to be focused at high-volume centers. Medicare reimbursement data can provide an understanding of the distribution of brachytherapy cases among billing providers. The objective of this study is to quantify the distribution of brachytherapy cases and high volume providers. Methods and MaterialsThe Medicare Physician and Other Supplier Public Use File was queried for individual physicians who had performed brachytherapy for more than 10 patients with gynecologic or prostate cancer in the years 2012–2015. Aggregate data were also queried. Trends were identified, and basic summary statistics were tabulated. ResultsDuring the study period, there was an increase in vaginal brachytherapy (3328 unique cases in 2012–4308 in 2015) but a decrease in intrauterine implants, such as tandem placements (1522 in 2012–1307 in 2015) and prostate brachytherapy (8860 in 2012–6527 in 2015). High-volume providers treating more than 10 patients represented a disproportionate number of patients treated, particularly with intra-uterine brachytherapy, representing no more than 1.2% of the active providers in a given year but up to 11.1% of intra-uterine brachytherapy cases. ConclusionsAmong Medicare claims, a small number of providers accounted for a significant proportion of gynecologic and prostate brachytherapy cases, particularly in the case of intrauterine implants. The vast majority of brachytherapy providers perform limited cases in this population. Efforts toward improving access to intrauterine implants in Medicare patients should be a national priority.

High-volume general practitioners in Alberta: a descriptive analysis.

Alberta is considering capping daily fee-for-service physician billings, but little is known about high-volume practice in the province and its impact on patient health outcomes. In this initial study, we conducted a descriptive analysis of general practitioners' patient volumes and billing practices in relation to associated practitioner demographic characteristics. We conducted a retrospective descriptive analysis of the associations of practitioner characteristics, including full-time versus non-full-time practice, provider sex, years in practice, geographic location and international medical graduate status, with high-volume (> 50 visits/d) practice using general practice billing data from 2011 to 2016. Use of general practitioner service codes was described and compared by general practitioner volume status, with adjustment for physician demographic characteristics and geographic parameters. We included 3465 general practitioners practising fee-for-service in Alberta between 2011 and 2016, of whom 233 (6.7%) were identified as high-volume providers. Physicians who had been in practice longer (odds ratio [OR] 1.04 per year, 95% confidence interval [CI] 1.02-1.05) and international medical graduates (OR 1.89, 95% CI 1.40-2.54) were more likely to exceed 50 patient visits/day. Female physicians were less likely to exceed 50 patient visits/day (OR 0.14, 95% CI 0.07-0.28). Rural practice location was negatively associated with high-volume practice (OR 0.87, 95% CI 0.79-0.95) when we controlled for zone within the province. Zone 5 (North) was associated with high-volume practice (OR 1.95, 95% CI 1.06-3.58). Less than full-time practice was prevalent (1836 providers [53.0%]). High-volume general practitioners billed fewer service codes requiring longer visits, except for the most highly remunerated code (patients with complex health issues). These results can inform policy-makers when considering payment system changes. Our next step is to examine the association of high-volume practice with outcomes important to patients, such as evidence of treatment failure (emergency department visits and hospital admissions) for conditions sensitive to primary care management.

High Volume Providers and Brachytherapy Practice: An Analysis of the Medicare Provider Utilization and Payment Data Set

Brachytherapy is an important component of the treatment of gynecologic cancers, with data supporting its impact on clinical outcomes in cervical and uterine cancer. Correspondingly, prior studies have suggested an increase in the use of high dose rate (HDR) brachytherapy in the early 2000s, and brachytherapy practice at nonacademic facilities were typically of low volume. Medicare reimbursement data can provide an understanding of the distribution of brachytherapy cases among billing providers.

Long-Term Outcomes After Carotid Endarterectomy: The Experience of an Average-Volume Surgeon

Long-term outcome data for patients undergoing carotid endarterectomy (CEA) are lacking. As most of the published literature on CEA outcomes has been from high-volume providers, we wanted to investigate theoutcomes of an average-volume cerebrovascular neurosurgeon. We reviewed a single neurosurgeon's experience with CEA focusing on long-term outcomes. Most procedures (99.0%) were performed with primary closure of the arteriotomy. We studied 192 CEAs performed between 1998 and 2017, 77% for symptomatic disease. Two patients (1%) experienced immediate postoperative stroke. During an average follow-up of 53 months (range, 0-205 months), 2 more patients (1%) experienced ipsilateral carotid circulation stroke, and 5 patients (2.6%) experienced ipsilateral transient ischemic attacks. Five patients (2.6%) experienced contralateral transient ischemic attacks, and 6 (3.1%) experienced contralateral stroke. There were also 3 cases of (1.6%) hemorrhagic stroke and 6 cases (3.1%) of vertebrobasilar circulation stroke. The rate of ipsilateral stroke-free survival was 98.4% at 5 years post-CEA, 97.9% at 10 years post-CEA, and 97.9% at 15 years post-CEA. The rate of ipsilateral restenosis-free survival was 97.9% at 5years post-CEA, 96.8% at 10 years post-CEA, and 96.8% at 15 years post-CEA. Six patients (3.1%) experienced restenosis >70% during follow-up. Two of these patients underwent carotid artery stenting. Almost all patients (>95%) were maintained on an antiplatelet medication and statin. In the hands of an average-volume cerebrovascular neurosurgeon, CEA can provide durable protection from recurrent stroke in the ipsilateral carotid distribution that extends beyond 15 years. Thus, this procedure should be considered the gold standard against which other revascularization modalities should be evaluated.

Cancer Among Women Treated in the Veterans Affairs Healthcare System.

The Veterans Affairs (VA) healthcare system is a high-volume provider of cancer care. Women are the fastest growing patient population using VA healthcare services. Quantifying the types of cancers diagnosed among women in the VA is a critical step toward identifying needed healthcare resources for women Veterans with cancer. We obtained data from the VA Central Cancer Registry for cancers newly diagnosed in calendar year 2010. Our analysis was limited to women diagnosed with invasive cancers (e.g., stages I-IV) between January 1, 2010, and December 31, 2010, in the VA healthcare system. We evaluated frequency distributions of incident cancer diagnoses by primary anatomical site, race, and geographic region. For commonly occurring cancers, we reported distribution by stage. We identified 1,330 women diagnosed with invasive cancer in the VA healthcare system in 2010. The most commonly diagnosed cancer among women Veterans was breast (30%), followed by cancers of the respiratory (16%), gastrointestinal (12%), and gynecological systems (12%). The most commonly diagnosed cancers were similar for white and minority women, except white women were significantly more likely to be diagnosed with respiratory cancers (p < 0.01) and minority women were significantly more likely to be diagnosed with gastrointestinal cancers (p = 0.03). Understanding cancer incidence among women Veterans is important for healthcare resource planning. While cancer incidence among women using the VA healthcare system is similar to U.S civilian women, the geographic dispersion and small incidence relative to male cancers raise challenges for high quality, well-coordinated cancer care within the VA.

Early Management of Infants With Robin Sequence: An International Survey and Algorithm

There is no widely accepted protocol for management of infants with Robin sequence (RS) who present with airway obstruction and feeding impairment. The purposes of this study were to evaluate diagnostic and treatment preferences of clinicians from the United States and non-US countries and to use these data to propose an algorithm for early management of infants with RS. A cross-sectional study was implemented using a survey, which was distributed to craniofacial surgeons and non-surgeon physicians involved in management of infants with RS. Predictor variables were nationality, specialty, and surgical volume. Outcome variables included survey responses regarding preferences for evaluation and early treatment of patients with RS. A diagnostic and early treatment algorithm was proposed based on the most common survey responses. Descriptive and analytic statistics were calculated and a P less than .05 was considered significant. A total of 275 responses were received and 82 were excluded, leaving a final sample of 193 participants: 155 (80%) surgeons and 38 (20%) non-surgeon physicians. Thirty-seven US states were represented by 143 (74%) respondents and 50 (26%) participants were from 19 non-US countries. There were 96 (50%) low-volume and 97 (50%) high-volume respondents. There was general agreement in methods for evaluation and early treatment among respondents; the only significant differences were 1) US surgeons operate earlier to address airway obstruction than those from other countries (P=.001), 2) high-volume providers tend to operate earlier (P=.017) and to choose mandibular distraction more frequently (P=.003) than low-volume respondents, and 3) mandibular distraction is the preferred operation in the United States, but several operations for airway improvement are used equally in non-US countries (P<.001). Despite variation in the evaluation and treatment of infants with RS, this international and multispecialty survey showed trends that could represent best practices. An algorithm based on these findings is proposed.

Superior 3-Year Value of Open and Endovascular Repair of Abdominal Aortic Aneurysm With High-Volume Providers

This analysis was based on a statewide database between 2000 and 2010. Patients undergoing elective open and endovascular aneurysm repair (EVAR) were identified using the New York Statewide Planning and Research Cooperative System database. Charge data were normalized to 2016 dollars. Emergency room surgeons performed 12,148 open AAA repairs and 615 performed 14,459 EVARs. About two-thirds of providers performing open AAA repairs were vascular surgeons compared to 85% of those providers performing EVARs. The other providers were general or thoracic surgeons but not cardiologists. For both open and endovascular AAA repair, high-volume providers had lower cumulative adjusted charges for all aneurysm-related care and superior calculated 3-year value (patient life years per cumulative charge) than low-volume providers, even though the high-volume providers treated a patient population with more vascular risk factors. High-volume surgeons disproportionately practiced at high-volume hospitals for both repair modalities. Since high-volume providers repair AAAs with lower charges and improved survival, regionalization of care for patients with aortic aneurysms should occur. Surprisingly, high-volume hospitals performing EVAR provided superior value compared to low-volume hospitals, but such a difference did not exist for open AAA repair.

Comparison of 3 Types of Readmission Rates for Measuring Hospital and Surgeon Performance After Primary Total Hip and Knee Arthroplasty

BackgroundAll-cause 30-day hospital readmission is in widespread use for monitoring and incentivizing hospital performance for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, little is known on the extent to which all-cause readmission is influenced by hospital or surgeon performance and whether alternative measures may be more valid. MethodsThis is an observational study using multilevel modeling on English administrative data to determine the interhospital and intersurgeon variation for 3 readmission metrics: all-cause, surgical, and return-to-theater. Power calculations estimated the likelihood of identifying whether the readmission rate for a surgeon or hospital differed from the national average by a factor of 1.25, 1.5, 2, or 3 times, for both average and high-volume providers. Results259,980 THAs and 311,033 TKAs were analyzed. Variations by both surgeons and hospitals were smaller for the all-cause measure than for the surgical or return-to-theater metrics, although statistical power to detect differences was higher. Statistical power to detect surgeon-level rates of 1.25 or 1.5 times the average was consistently low. However, at the hospital level, the surgical readmission measure showed more variation by hospital while maintaining excellent power to detect differences in rates between hospitals performing the average number of THA or TKA cases per year in England. In practice, more outliers than expected from purely random variation were found for all-cause and surgical readmissions, especially at hospital level. ConclusionThe 30-day surgical readmission rate should be considered as an adjunctive measure to 30-day all-cause readmission rate when assessing hospital performance.

Predictors of rectal cancer resection at high-volume hospitals among Medicare patients.

808 Background: Hospitals that perform high volumes of rectal cancer resections achieve superior rates of sphincter preservation and survival compared to those that do not, but many rectal cancer resections are still performed in low-volume centers. We aimed to determine the patient, provider and pathway characteristics associated with receipt of surgery from high-volume hospitals. Methods: Patient and provider characteristics were extracted from the SEER-Medicare database for Medicare beneficiaries (age 66+) with stage II/III rectal adenocarcinoma diagnosed 2007-2011 who received rectal cancer-directed surgery. Hospitals were divided into quartiles by volume of rectal cancer resections, and were also classified by NCI cancer center designation. Results: 2056 patients were included, and 57% received surgery in a high-volume hospital or NCI-designated center. Those residing in census tracts classified as rural and having higher median incomes, lower poverty, and higher levels of education more frequently received surgery in high-volume hospitals; there were no differences by age, gender, stage, or co-morbidity status. 55% of patients received surgery at the same facility where they received the colonoscopy that identified their cancer. In multivariate analyses, the strongest predictor of receiving one’s surgery in a high-volume hospital was receipt of colonoscopy at a high-volume facility (OR = 3.75, 95% CI: 2.93-4.79). Those treated in high-volume hospitals more often had guideline-recommended staging (TRUS/MRI) and treatment (neoadjuvant chemoradiation). Conclusions: Rectal cancer patients tended to stay at the facility where their cancer was diagnosed; and did not typically seek out high-volume providers if their colonoscopy was performed in a low-volume facility. This suggests that colonoscopists may have substantial influence over where patients receive surgery. Given that rurality, income and education appear to more strongly predict receipt of surgery at a high-volume hospital compared to clinical characteristics, further research is needed to understand considerations driving patient decisions and referring providers’ recommendations for care.