Hospital-based Outpatient Departments Research Articles

Medicare Restriction of Telehealth Speech Services Negatively Impacts Patient Care.

Ample literature shows voice and swallowing therapy, in-person or virtual, to be essential for Otolaryngology and Speech-Language Pathology care. In March 2023, Medicare announced discontinuing teletherapy reimbursement in hospital-based outpatient departments, effective May 2023. This decision was subsequently reversed; however, the uncertain interval period provided the opportunity to study the impact of eliminating teletherapy. Prospective cohort. Tertiary laryngology center. Affected Medicare patients were contacted via mailed letter, phone, and secure patient portal and offered to change appointments to in-person, teletherapy with cash self-payment ($165-282/session) or cancellation. Demographics and responses were collected. Statistical analyses conducted using Student's t test. Fifty-three patients (28 female; mean age 66.8 ± 14.2 years) were impacted. 64% (n = 34) changed to in-person appointment, 28% (n = 15) canceled, 8% (n = 4) did not respond. No patients opted to self-pay. 67% of patients that canceled telehealth care cited distance from in-person care location. The mean distance for canceled versus rescheduled patients was 92.3 ± 93.0 versus 32.8 ± 57.4 miles, P = .034. Mean age, gender, and number of sessions were not different between groups. Mean time to third next available therapy appointment was 96 ± 46 versus 46 ± 12 days before and after rule change, P = .007. Upon Medicare's reversal, this trend rebounded to nearly baseline (mean 77 ± 12 days, P = .12). Medicare's discontinuation of reimbursement for teletherapy services caused nearly 30% of patients to cancel voice and swallowing therapy, primarily due to distance. These cancellations led to decreased access to care for Medicare patients with voice/swallowing diagnoses, which affect function, quality of life, and potentially even mortality risk.

How Have Patient Out-of-pocket Costs for Common Outpatient Orthopaedic Foot and Ankle Surgical Procedures Changed Over Time? A Retrospective Study From 2010 to 2020.

Out-of-pocket (OOP) costs can be substantial financial burdens for patients and may even cause patients to delay or forgo necessary medical procedures. Although overall healthcare costs are rising in the United States, recent trends in patient OOP costs for foot and ankle orthopaedic surgical procedures have not been reported. Fully understanding patient OOP costs for common orthopaedic surgical procedures, such as those performed on the foot and ankle, might help patients and professionals make informed decisions regarding treatment options and demonstrate to policymakers the growing unaffordability of these procedures. (1) How do OOP costs for common outpatient foot and ankle surgical procedures for commercially insured patients compare between elective and trauma surgical procedures? (2) How do these OOP costs compare between patients enrolled in various insurance plan types? (3) How do these OOP costs compare between surgical procedures performed in hospital-based outpatient departments and ambulatory surgical centers (ASCs)? (4) How have these OOP costs changed over time? This was a retrospective, comparative study drawn from a large, longitudinally maintained database. Data on adult patients who underwent elective or trauma outpatient foot or ankle surgical procedures between 2010 and 2020 were extracted using the MarketScan Database, which contains well-delineated cost variables for all patient claims, which are particularly advantageous for assessing OOP costs. Of the 1,031,279 patient encounters initially identified, 41% (427,879) met the inclusion criteria. Demographic, procedural, and financial data were recorded. The median patient age was 50 years (IQR 39 to 57); 65% were women, and more than half of patients were enrolled in preferred provider organization insurance plans. Approximately 75% of surgical procedures were classified as elective (rather than trauma), and 69% of procedures were performed in hospital-based outpatient departments (rather than ASCs). The primary outcome was OOP costs incurred by the patient, which were defined as the sum of the deductible, coinsurance, and copayment paid for each episode of care. Monetary data were adjusted to 2020 USD. A general linear regression, the Kruskal-Wallis test, and the Wilcoxon-Mann-Whitney test were used for analysis, as appropriate. Alpha was set at 0.05. For foot and ankle indications, trauma surgical procedures generated higher median OOP costs than elective procedures (USD 942 [IQR USD 150 to 2052] versus USD 568 [IQR USD 51 to 1426], difference of medians USD 374; p < 0.001). Of the insurance plans studied, high-deductible health plans had the highest median OOP costs. OOP costs were lower for procedures performed in ASCs than in hospital-based outpatient departments (USD 645 [IQR USD 114 to 1447] versus USD 681 [IQR USD 64 to 1683], difference of medians USD 36; p < 0.001). This trend was driven by higher coinsurance for hospital-based outpatient departments than for ASCs (USD 391 [IQR USD 0 to 1136] versus USD 337 [IQR USD 0 to 797], difference of medians USD 54; p < 0.001). The median OOP costs for common outpatient foot and ankle surgical procedures increased by 102%, from USD 450 in 2010 to USD 907 in 2020. Rapidly increasing OOP costs of common foot and ankle orthopaedic surgical procedures warrant a thorough investigation of potential cost-saving strategies and initiatives to enhance healthcare affordability for patients. In particular, measures should be taken to reduce underuse of necessary care for patients enrolled in high-deductible health plans, such as shorter-term deductible timespans and placing additional regulations on the implementation of these plans. Moreover, policymakers and physicians could consider finding ways to increase the proportion of procedures performed at ASCs for procedure types that have been shown to be equally safe and effective as in hospital-based outpatient departments. Future studies should extend this analysis to publicly insured patients and further investigate the health and financial effects of high-deductible health plans and ASCs, respectively. Level III, economic and decision analysis.

Abstract No. 253 Financial impact of case allocation for a health system-owned office-based lab

Outpatient interventional radiology (IR) procedures may be performed at a variety of sites with variable reimbursement, including hospital-based outpatient departments (HOPD) or office-based labs (OBL). OBL reimbursement is uniquely structured with a global fee that includes all equipment costs for procedures. Understanding reimbursement differences between sites is important for health systems considering expansion OBLs to increase overall outpatient IR capacity and optimize workflows.

How Outpatient Diabetes Education Programs Can Support Local Hospitals to Reduce Emergency Department Visits for Adults With Diabetes

ObjectivesOur aim in this study was to assess the level of collaboration between a hospital-based outpatient diabetes education program (DEP) and emergency departments (EDs) for reducing number of ED revisits and hospital admissions by implementing intervention strategies to promote education services and streamlining referral and appointment intake processes. MethodsPatients (≥18 years of age) with an ED visit for hyper- or hypoglycemia were analyzed in 2 cohorts based on their intervention exposure. We conducted a single-cohort analysis of the exposed cohort (exposure to the intervention strategies) and compared 2-year outcomes with those of the unexposed cohort. Primary outcomes were hyper- or hypoglycemia-related ED revisit and hospitalization rates. Process outcomes included DEP referrals and DEP attendance. ResultsThere were no significant differences in ED revisits and hospital admissions between the exposed and unexposed cohorts. However, patients were more likely to be referred to a DEP by ED physicians (odds ratio [OR], 1.76; p=0.02) and to attend a DEP appointment (OR, 1.96; p<0.01) after intervention exposure. DEP attendees from both cohorts became less likely to revisit an ED (exposed: OR, 0.41; 95% confidence interval [CI], 0.23 to 0.71; unexposed: OR, 0.4; 95% CI, 0.15 to 1.15) at 12-month follow up; however, this reduction was sustained only among the exposed cohort (OR, 0.5; 95% CI, 0.31 to 0.81) and not the unexposed cohort (OR, 1.32; 95% CI, 0.60 to 2.91) at 24 months (p=0.04 when comparing the 2 cohorts). ConclusionsCollaboration between outpatient DEPs with local EDs could effectively reduce diabetes-related ED revisits by increasing diabetes program utilization.

Effect of the Million Hearts Cardiovascular Disease Risk Reduction Model on Initiating and Intensifying Medications

The Million Hearts Cardiovascular Disease (CVD) Risk Reduction Model pays provider organizations for measuring and reducing Medicare patients' cardiovascular risk. To assess whether the model increases the initiation or intensification of antihypertensive medications or statins among patients with blood pressure or low-density lipoprotein (LDL) cholesterol levels above guideline thresholds for treatment intensification. This prespecified secondary analysis of a cluster-randomized, pragmatic trial included primary care and cardiology practices, health care centers, and hospital-based outpatient departments across the US. Participants included Medicare patients who were enrolled into the model in 2017 by participating organizations and who were at high risk and at medium risk of a myocardial infarction or stroke in 10 years. Patient outcomes were analyzed for 1 year postenrollment (through December 2018) using an intent-to-treat design. Analysis began November 2019. US Centers for Medicare & Medicaid Services paid organizations for risk stratifying Medicare patients and reducing CVD risk among high-risk patients through discussing risk scores, developing individualized risk reduction plans, and following up with patients twice yearly. Initiating or intensifying statin or antihypertensive therapy within 1 year of enrollment, measured in Medicare Part D claims, and LDL cholesterol and systolic blood pressure levels approximately 1 year after enrollment, measured in usual care and reported to Centers for Medicare & Medicaid Services via a data registry (data complete for 51% of high-risk enrollees). The study's primary outcome (incidence of first-time myocardial infarction and stroke) is not reported because the trial is ongoing. A total of 330 primary care and cardiology practices, health care centers, and hospital-based outpatient departments and 125 436 Medicare patients were included in this analysis. High-risk patients in the intervention group had a mean (SD) age of 74 (4.1), 15 213 (63%) were male, 21 657 (90%) were receiving antihypertensive medication at baseline, and 16 558 (69%) were receiving statins. Almost all (21 791 [91%]) high-risk intervention group patients had above-threshold systolic blood pressure level (>130 mm Hg), LDL cholesterol level (>70 mg/dL), or both. Patients in the intervention group with these risk factors were more likely than control patients (8127 [37.3%] vs 4753 [32.4%]; adjusted difference in percentage points, 4.8; 95% CI, 2.9-6.7; P < .001) to initiate or intensify statins or antihypertensive medication. Centers for Medicare & Medicaid Services did not pay for CVD risk reduction for medium-risk enrollees, but initiation or intensification rates for these enrollees were also higher in the intervention vs control groups (12 668 [27.9%] vs 7544 [24.8%]; adjusted difference in percentage points, 3.1; 95% CI, 1.9-4.3; P < .001). Among high-risk enrollees with clinical data approximately 1 year after enrollment, LDL cholesterol level was slightly lower in the intervention vs control groups (mean [SD], 89 [31.8] vs 91 [32.1] mg/dL; adjusted difference in percentage points, -1.8; 95% CI, -2.9 to -0.6; P = .002), as was systolic blood pressure (mean [SD], 133 [15.7] vs 135 [16.4] mm Hg; adjusted difference in percentage points, -1.7; 95% CI, -2.8 to -0.6; P = .003). In this study, a pay-for-performance model led to modest increases in the use of CVD medications in a range of organizations, despite high medication use at baseline.

Association of Race, Health Insurance Status, and Household Income With Location and Outcomes of Ambulatory Surgery Among Adult Patients in 2 US States

The receipt of surgery in freestanding ambulatory surgery centers (ASCs) is often less costly compared with surgery in hospital-based outpatient departments. Although increasing numbers of surgical procedures are now being performed in freestanding ASCs, questions remain regarding the existence of disparities among patients receiving care at ASCs. To examine the association of patient race, health insurance status, and household income with the location (ASC vs hospital-based outpatient department) of ambulatory surgery. This cohort study used data from the State Ambulatory Surgery and Services Databases of the Healthcare Cost and Utilization Project to perform a secondary analysis of patients who received ambulatory surgery in New York and Florida between 2011 and 2013. Patients aged 18 to 89 years who underwent 12 different types of ambulatory surgical procedures were included. Data were analyzed from December 2018 to June 2019. Receipt of surgery at a freestanding ASC and 30-day unplanned hospital visits after ambulatory surgery. A total of 5.6 million patients in New York (57.4% female; 68.9% aged ≥50 years; and 62.5% White) and 7.5 million patients in Florida (57.3% female; 77.4% aged ≥50 years; 74.3% White) who received ambulatory surgery were included in the analysis. After adjusting for age, comorbidities, health insurance status, household income, location of surgery, and type of surgical procedure, the likelihood of receiving ambulatory surgery at a freestanding ASC was significantly lower among Black patients (adjusted odds ratio [aOR], 0.82; 95% CI, 0.81-0.83; P < .001) and Hispanic patients (aOR, 0.78; 95% CI, 0.77-0.79; P < .001) compared with White patients in New York. This likelihood was also lower among Black patients (aOR, 0.65; 95% CI, 0.65-0.66; P < .001) compared with White patients in Florida. Public health insurance coverage was associated with a significantly lower likelihood of receiving ambulatory surgery at freestanding ASCs in both New York and Florida, particularly among patients with Medicaid (in New York, aOR, 0.22; 95% CI, 0.22-0.22; P < .001; in Florida, aOR, 0.40; 95% CI, 0.40-0.41; P < .001) and Medicare (in New York, aOR, 0.46; 95% CI, 0.46-0.46; P < .001; in Florida, aOR, 0.67; 95% CI, 0.66-0.67; P < .001). Differences in the use of freestanding ASCs were found among Black patients and patients with public health insurance. Further exploration of the factors underlying these differences will be important to ensure that all populations have access to the increasing number of freestanding ASCs.

Use of Optimal Evidence-Based Anticancer Drug Regimens in Physician Offices Versus Hospital Outpatient Facilities.

Cancer care has increasingly shifted from physician offices (MDOs) to hospital-based outpatient departments (HOPDs). This study compared the proportion of patients receiving optimal, evidence-based anticancer drug regimens and the cost of care when administered in these sites. Patients with breast, lung, or colorectal cancer were identified from a large health insurance database. Anticancer drug regimens were considered on pathway when they were on the payer's program list of optimal regimens when administered. Anticancer drug-related costs included all patient- and plan-paid costs on claims for anticancer drugs over the 6-month postindex period; total per-patient costs were summed over all claims in that period. A total of 38,140 patients (MDO, n = 18,998; HOPD, n = 19,142) were included. On-pathway status was similar in HOPDs (59.5%; 95% CI, 58.6% to 60.4%) versus MDOs (60.8%; 95% CI, 59.8% to 61.8%; P = .069). HOPDs had substantially higher costs. Adjusted cancer drug-related costs were $63,763 (95% CI, $62,301 to $65,224) for HOPDs versus $36,500 (95% CI, $35,729 to $37,271) for MDOs (P < .001); adjusted total costs were $115,843 (95% CI, $113,642 to $118,044) for HOPDs versus $77,346 (95% CI, $76,072 to $78,620) for MDOs (P < .001). For Medicare Advantage, adjusted total costs were $61,812 for HOPDs compared with $62,769 for MDOs; adjusted drug-related costs were $31,610 for HOPDs compared with $33,168 for MDOs. For commercial insurance, total costs were $119,288 for HOPDs compared with $77,613 for MDOs; drug-related costs were $65,930 for HOPDs compared with $36,366 for MDOs. Total and cancer drug-related per-patient costs were higher in HOPDs versus MDOs, but on-pathway status was similar. The cost differential between HOPDs and MDOs was driven by commercially insured members rather than Medicare Advantage members.

Complication rates following hip arthroscopy in the ambulatory surgical center

There has been an increase in the number of hip arthroscopy procedures performed in the outpatient setting. The purpose of this study was to query a national database to compare post-operative adverse events between hip arthroscopy procedures performed in hospital based outpatient departments (HOPD) versus ASC's. The Humana Claims Database was queried for all patients undergoing hip arthroscopy performed between 2007 and 2016, using the PearlDiver supercomputer. The study population was divided into two cohorts based on the surgical setting, ASC or HOPD. Complications of interest occurring within 90 days after surgery included Center for Medicare and Medicaid Services (CMS)-reportable complications, readmission, and return to the operating room. Visits to the emergency department after 7 days of surgery was also studied. Univariate comparisons between ASC and HOPD groups were drawn with chi-square tests for categorical variables and t-tests for continuous variables. Logistic regression models were created to determine the association between surgical setting and primary outcomes. Rates of 90-day CMS-reportable complications (2.95% vs 2.17%%; p = 0.193), 90-day readmission (4.95% vs 4.25%; p = 0.370) and return to the operating room within 90 days (0.07% vs 0.2%; p = 0.286) were not significantly different between groups. Rate of visits to the emergency department within 7 days was not statistically different between groups (2.57% vs 3.03%; p = 0.458). With the ASC group as reference, no statistically significant association between an outcome and surgical setting was detected after adjusting for confounding factors including comorbidity burden. These findings provide reassurance to providers who perform these procedures in either surgical setting.

Trends in the Setting and Cost of Ambulatory Urological Surgery: An Analysis of Five States in the Healthcare Cost and Utilization Project

IntroductionWith the rising costs of healthcare, surgical procedures have migrated from the inpatient to outpatient setting with >60% of urological procedures performed in the ambulatory setting. Ambulatory surgical centers (ASCs) can potentially reduce costs but may also lead to overutilization. We assessed utilization of ASCs for urological procedures, case-mix distribution compared to hospital-based outpatient surgery departments (HOPD), and cost implications. MethodsAll outpatient urological procedures were identified from 5 states in the United States (2010-2014) using all-payer data. Patient demographics, regional data, facility type (ASC vs. HOPD), and total charges (converted to costs and inflation adjusted to 2014 USD) were determined. Analyses of overall number of procedures, population-adjusted rates, annual percent change (APC), and adjusted linear regression models were performed. ResultsOf >37 million surgical procedures, 1,842,630 (4.9%) were urological with overall APC +0.97% (+1.09% HOPD vs. +0.41% ASCs) and 20.0% performed in ASCs. The proportion performed in ASCs slightly decreased over time (-0.48%/year, p<0.001). Overall costs totaled $4.78 billion representing 7.6% of all ambulatory surgery (average cost/procedure $2,603.76). All procedures demonstrated reduced costs/case when performed in ASCs (range -$800 to -$1800). Unadjusted net cost increase/procedure/year was +$147.79 (+$113.98 adjusted). Providers performing the top quartile (Q1) of procedures demonstrated reduced costs. ConclusionsAmbulatory urological surgery represents 5% of all surgical cases, but 7.6% of costs. The rate of procedures is increasing steadily with performance in ASCs outpaced by those in HOPD. The cost of ambulatory urological surgery is rising out of proportion to explanation by inflation, patient factors, or case-mix.

Meteorological factors, air pollutants, and emergency department visits for otitis media: a time series study.

AbstractOtitis media (OM) is a very common disease in children, which results in a significant economic burden to the healthcare system for hospital-based outpatient departments, emergency departments (EDs), unscheduled medical examinations, and antibiotic prescriptions. The aim of this retrospective observational study is to investigate the association between climate variables, air pollutants, and OM visits observed in the 2007-2010 period at the ED of Cuneo, Italy. Measures of meteorological parameters (temperature, humidity, atmospheric pressure, wind) and outdoor air pollutants (particulate matter, ozone, nitrous dioxide) were analyzed at two statistical stages and in several specific steps (crude and adjusted models) according to Poisson's regression. Response variables included daily examinations for age groups 0-3, 0-6, and 0-18. Control variables included upper respiratory infections (URI), flu (FLU), and several calendar factors. A statistical procedure was implemented to capture any delayed effects. Results show a moderate association for temperature (T), age 0-3, and 0-6 with P<0.05, as well as nitrous dioxide (NO2) with P<0.005 at age 0-18. Results of subsequent models point out to URI as an important control variable. No statistical association was observed for other pollutants and meteorological variables. The dose-response models (DLNM-final stage) implemented separately on a daily and hourly basis point out to an association between temperature (daily model) and RR 1.44 at age 0-3, CI 1.11-1.88 (lag time 0-1days) and RR 1.43, CI 1.05-1.94 (lag time 0-3days). The hourly model confirms a specific dose-response effect for T with RR 1.20, CI 1.04-1.38 (lag time range from 0 to 11 to 0-15h) and for NO2 with RR 1.03, CI 1.01-1.05 (lag time range from 0 to 8 to 0-15h). These results support the hypothesis that the clinical context of URI may be an important risk factor in the onset of OM diagnosed at ED level. The study highlights the relevance of URI as a control variable to be included in the statistical analysis in association with meteorological factors and air pollutants. The study also points out to a moderate association of OM with low temperatures and NO2, with specific risk factors for this variable early in life. Further studies are needed to confirm these findings, particularly with respect to air pollutants in larger urban environments.

Assessment of WHO/INRUD core drug use indicators in two tertiary care hospitals of Bahawalpur, Punjab, Pakistan.

BackgroundMedicines are a main therapeutic intervention provided within hospitals and their proper use in the outpatient setting is important for patients and the community. The objective of this study was to evaluate drug use patterns in the outpatient departments (OPDs) of two tertiary care hospitals (Bahawal Victoria Hospital and Civil Hospital) in the Bahawalpur district of the Punjab province of Pakistan by employing the standard World Health Organization/International Network of Rational Use of Drugs (WHO/INRUD) drug use indicators. MethodsA descriptive, cross-sectional study design was employed. For assessing the prescribing indicators a sample of 2400 prescriptions were systematically reviewed out of a total of 1,560,000 prescriptions written from 1st April 2014 to 31st March 2015. A total of 600 randomly selected patients and all pharmacy personnel were observed and interviewed to investigate the patient-care and facility-specific indicators. We used the published ideal standards for each of the WHO/INRUD indicators for comparison purposes.ResultsAmong the prescribing indicators, the average number of drugs per prescription was 2.8 (SD = 1.3), the drugs prescribed by generic name were 56.6 %, the encounters with an antibiotic prescribed were 51.5 %, no injections were prescribed and 98.8 % of the drugs prescribed were from the Essential Drugs List (EDL). Among the patient-care indicators, the average consultation time was 1.2 min (SD = 0.8), the average dispensing time was 8.7 s (SD = 4.9), the percentage of drugs actually dispensed was 97.3 %, the percentage of drugs adequately labeled was 100 % and the patients’ knowledge of correct dosage schedule was 61.6 %. Among the facility-specific indicators, all OPDs had a copy of the EDL and 72.4 % of the key drugs were available in stock.ConclusionIrrational use of drugs was observed in both OPDs. Polypharmacy, brand prescribing, over-prescribing of antibiotics, short consultation and dispensing times, lack of patients’ knowledge about prescribed medicines and unavailability of all key drugs in stock were the major issues that need attention of the healthcare authorities. This study necessitates the requirement to implement the relevant WHO recommended core interventions to promote rational use of medicines in these hospital-based OPDs.

Nationwide use and outcomes of ambulatory surgery in morbidly obese patients in the United States

Study ObjectiveTo compare the overall characteristics and perioperative outcomes in morbidly obese and nonobese patients undergoing ambulatory surgery in the United States. DesignRetrospective, propensity-matched cohort study. SettingAcademic medical center. MeasurementsThe association between duration of surgical procedures, postoperative complications, and unplanned hospital admission was assessed in a propensity-matched cohort of morbidly obese and nonobese patients derived from the 2006 National Survey of Ambulatory Surgery. Main ResultsOnly 0.32% of the ambulatory procedures were performed on morbidly obese patients. The morbidly obese were significantly younger but had a higher burden of comorbidities, were more likely to undergo the procedure in hospital-based outpatient departments (HOPD; 80.1% vs 56.5%; P = 0.004), and had significantly shorter procedures than the nonobese (median [interquartile range], 28 [21–38] vs 42 [22–65] min; P < 0.0001). The incidences of postoperative hypertension, hypotension, hypoxia, cancellation of surgery, and unplanned hospital admissions did not differ significantly between groups. Similarly, adjusted rates of delayed discharge were similar in morbidly obese and nonobese patients (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.18 - 1.15; P = 0.09). In contrast, morbid obesity was associated with decreased odds of postoperative nausea and vomiting (OR, 0.27; CI, 0.09 - 0.84; P = 0.01). ConclusionsIn 2006 in the U.S., the prevalence of ambulatory surgery in the morbidly obese was low, with most of the procedures being performed in the HOPD facilities, suggesting a conservative patient selection. The incidence of adverse postoperative outcomes and delayed discharge, as well as unplanned hospital admission after ambulatory surgery in the morbidly obese, was similar to that reported in the nonobese.

Medicare Payments for Outpatient Urological Surgery by Location of Care

The cost implications associated with offloading outpatient surgery from hospitals to ambulatory surgery centers and the physician office remain poorly defined. Therefore, we determined whether payments for outpatient surgery vary by location of care. Using national Medicare claims from 1998 to 2006, we identified elderly patients who underwent 1 of 22 common outpatient urological procedures. For each procedure we measured all relevant payments (in United States dollars) made during the 30-day claims window that encompassed the procedure date. We then categorized payment types (hospital, physician and outpatient facility). Finally, we used multivariable regression to compare price standardized payments across hospitals, ambulatory surgery centers and the physician office. Average total payments for outpatient surgery episodes varied widely from $200 for urethral dilation in the physician office to $5,688 for hospital based shock wave lithotripsy. For all but 2 procedure groups, ambulatory surgery centers and physician offices were associated with lower overall episode payments than hospitals. For instance, average total payments for urodynamic procedures performed at ambulatory surgery centers were less than a third of those done at hospitals (p <0.001). Compared to hospitals, office based prostate biopsies were nearly 75% less costly (p <0.001). Outpatient facility payments were the biggest driver of these differences. These data support policies that encourage the provision of outpatient surgery in less resource intensive settings.

Use of Ureteroscopy Before and After Expansion of Lithotripter Ownership in Michigan

To determine whether ureteroscopy (URS) rates decreased following the expansion of lithotripter ownership in Michigan. Historically, Michigan has had limited urologist investment in lithotripters owing to strict Certificate of Need legislation. However, 2 of the nation's largest lithotripsy providers formed Michigan subsidiaries in 2005 and 2006, thereby altering the ownership landscape. Urologists who acquired partnership shares were incentivized to perform shock wave lithotripsy preferentially over URS. Because of ownership expansion, the rates of URS might have decreased. From the Michigan files of the State Ambulatory Surgery Database, we abstracted the discharges for URS performed at hospital-based outpatient departments. We measured the differences between the patients who underwent URS in the year before (2004) and the year after (2007) ownership expansion. We then calculated the annual rates of URS in Michigan and evaluated for changes over time. A total of 5857 and 6294 URSs were performed in 2004 and 2007, respectively. Significant differences in age (P < .001), race (P < .001), primary payer (P < .001), and comorbidity status (P < .001) were observed between the patients who underwent URS before and after ownership expansion. However, the rates of URS in Michigan remained relatively flat despite the increased urologist ownership of lithotripters (P = .129 for the temporal trend). The introduction of physician ownership of lithotripter units in Michigan was not associated with decreased rates of URS but might have influenced treatment selection among certain patient groups.

1689 COMPARISON OF PATIENT SATISFACTION WITH TREATMENT OUTCOMES BETWEEN SHOCK WAVE LITHOTRIPSY AND URETEROSCOPY FOR URETERAL STONES: ANALYSIS IN TERMS OF PATIENT PERCEPTION

INTRODUCTION AND OBJECTIVES: Historically, Michigan has had limited urologist investment in lithotripters due to strict Certificate of Need legislation. However, between 2005 and 2006, the ownership landscape changed when two large lithotripsy providers offered partnership shares to urologists in the State for the first time. Those who acquired shares were incentivized to perform shockwave lithotripsy preferentially over ureteroscopy (URS), and rates of URS may have fallen due to technology substitution. We explored this possibility using population-based data. METHODS: From the Michigan files of the State Ambulatory Surgery Database (2004 to 2007), we abstracted discharges for URS performed at hospital-based outpatient departments. We measured differences between patients who underwent URS in the year before (2004) and after (2007) ownership expansion. We calculated annual rates of URS in Michigan and evaluated for significant changes over time. Finally, we compared these rates to those from Florida, which already had a high penetration of physician ownership, over the same time interval. RESULTS: Compared to patients treated prior to ownership expansion, those who underwent URS after ownership expansion were older (P 0.001), less likely to be White (P 0.001), less likely to have private health insurance (P 0.001), and more likely to have a higher Charlson comorbidity index (P 0.001). However, the magnitudes of these differences were small. As Figure 1 shows, rates of URS in Michigan remained relatively stable despite ownership expansion (P 0.129 for the temporal trend); and there were no significant differences in the rates of change of URS between Michigan and Florida during the time of ownership expansion (P 0.479). CONCLUSIONS: The introduction of physician-ownership of lithotripter units in Michigan was not associated with decreased rates of URS. Despite the financial incentives, technology substitution does not appear to occur on a significant scale at the population-level, at least as it pertains to the management of stone disease. Source of Funding: None

1688 EXPANSION OF LITHOTRIPTER OWNERSHIP AND URETEROSCOPY USE: A NATURAL EXPERIMENT

You have accessJournal of UrologyStone Disease: New Technology/SWL, Ureteroscopic or Percutaneous Stone Removal1 Apr 20111688 EXPANSION OF LITHOTRIPTER OWNERSHIP AND URETEROSCOPY USE: A NATURAL EXPERIMENT Hung-Jui Tan, J. Stuart Wolf, Brent K. Hollenbeck, Zaojun Ye, and John M. Hollingsworth Hung-Jui TanHung-Jui Tan Ann Arbor, MI More articles by this author , J. Stuart WolfJ. Stuart Wolf Ann Arbor, MI More articles by this author , Brent K. HollenbeckBrent K. Hollenbeck Ann Arbor, MI More articles by this author , Zaojun YeZaojun Ye Ann Arbor, MI More articles by this author , and John M. HollingsworthJohn M. Hollingsworth Ann Arbor, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1865AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Historically, Michigan has had limited urologist investment in lithotripters due to strict Certificate of Need legislation. However, between 2005 and 2006, the ownership landscape changed when two large lithotripsy providers offered partnership shares to urologists in the State for the first time. Those who acquired shares were incentivized to perform shockwave lithotripsy preferentially over ureteroscopy (URS), and rates of URS may have fallen due to technology substitution. We explored this possibility using population-based data. METHODS From the Michigan files of the State Ambulatory Surgery Database (2004 to 2007), we abstracted discharges for URS performed at hospital-based outpatient departments. We measured differences between patients who underwent URS in the year before (2004) and after (2007) ownership expansion. We calculated annual rates of URS in Michigan and evaluated for significant changes over time. Finally, we compared these rates to those from Florida, which already had a high penetration of physician ownership, over the same time interval. RESULTS Compared to patients treated prior to ownership expansion, those who underwent URS after ownership expansion were older (P<0.001), less likely to be White (P<0.001), less likely to have private health insurance (P<0.001), and more likely to have a higher Charlson comorbidity index (P<0.001). However, the magnitudes of these differences were small. As Figure 1 shows, rates of URS in Michigan remained relatively stable despite ownership expansion (P=0.129 for the temporal trend); and there were no significant differences in the rates of change of URS between Michigan and Florida during the time of ownership expansion (P=0.479). CONCLUSIONS The introduction of physician-ownership of lithotripter units in Michigan was not associated with decreased rates of URS. Despite the financial incentives, technology substitution does not appear to occur on a significant scale at the population-level, at least as it pertains to the management of stone disease. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e679 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hung-Jui Tan Ann Arbor, MI More articles by this author J. Stuart Wolf Ann Arbor, MI More articles by this author Brent K. Hollenbeck Ann Arbor, MI More articles by this author Zaojun Ye Ann Arbor, MI More articles by this author John M. Hollingsworth Ann Arbor, MI More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Physician division of labor and patient selection for outpatient procedures

Little is known about the ability of incentives to influence decisions by physicians regarding choices of settings for care delivery. In the context of outpatient procedural care, the emergence of freestanding ambulatory surgery centers (ASCs) as alternatives to hospital-based outpatient departments (HOPDs) creates a unique opportunity to study this question. We advance a model where physicians’ division of labor between ASCs and HOPDs affects the medical complexity of patients treated in low-acuity settings (i.e. ASCs). Analyses of outpatient surgical procedure data show that physicians working exclusively in low-acuity settings (i.e. ASCs) treat patients of significantly higher medical complexity in these settings than do physicians who also practice in higher-acuity settings (i.e. HOPDs). This discrepancy shrinks with increasing procedural risk and with increasing distance between ASCs and acute care hospitals.

Changing Access to Emergency Care for Patients Undergoing Outpatient Procedures at Ambulatory Surgery Centers: Evidence From Florida

The growth of ambulatory surgery centers (ASCs) as a setting for care in the United States raises unique safety concerns. In contrast to hospital-based outpatient departments (HOPDs), ASCs offer care at varying distances from hospital services potentially required to treat complications. To describe changes over time in the accessibility of hospital services for procedural outpatients, this study examined 4.3 million discharges for seven outpatient procedures frequently performed at ASCs and HOPDs. Between 2005 and 2007, the mean patient-to-emergency department (ED) distance increased by 12.4%. This change, which resulted from both an increase in the share of procedures performed at ASCs and an increase in the distance between ASCs and EDs, occurred predominantly within procedures that carried an elevated odds of hospital admission relative to the lowest risk procedures. Further research defining the risks associated with these changes in access to emergency care is needed to inform future ASC policy development and regulation.

A comparative study of financial performance of freestanding ambulatory surgery centres and hospital-based outpatient departments: 1997-2004

We compared financial performance of freestanding ambulatory surgery centres (ASCs) and hospital-based outpatient departments (HOPDs). Patient-level ambulatory surgery data (1997-2004) for the state of Florida were assembled and analysed. We used a pooled, cross-sectional design. We applied multiple regression models to study pricing differences for freestanding ASCs and HOPDs. Substantial charge differences exist for patients undergoing the most common outpatient procedures, and that these differentials are in favour of freestanding ASCs over HOPDs in the majority of studied procedures. These differences in charges are large enough to presume that they may translate into similar difference in actual costs. Although previous research does not show a clear 'winner' (neither ASCs nor HOPDs) in terms of quality outcomes, healthcare policymakers, payers, and patients may be led to look more carefully at charge and cost data in their contracting processes, or choosing a certain provider of outpatient services.

How well does diagnosis-based risk-adjustment work for comparing ambulatory clinical outcomes?

This paper examines the empirical consistency of the Diagnosis Cost Groups/Hierarchical Condition Categories (DCG/HCC) risk-adjustment method for comparing 7-day mortality between hospital-based outpatient departments (HOPDs) and freestanding ambulatory surgery centers (ASCs). We used patient level data for the three most common outpatient procedures provided during the 1997-2004 period in Florida. We estimated base-line logistic regression models without any diagnosis-based risk adjustment and compared them to logistic regression models with the DCG/HCC risk-adjustment, and to conditional logit models with a matched cohort risk-adjustment approach. We also evaluated models that adjusted for primary diagnoses only, and then for all available diagnoses, to assess how the frequently absent secondary diagnoses fields in ambulatory surgical data affect risk-adjustment. We found that risk-adjustment using both diagnosis-based methods resulted in similar 7-day mortality estimates for HOPD patients in comparison with ASC patients in two out of three procedures. We conclude that the DCG/HCC risk-adjustment method is relatively consistent and stable, and recommend this risk-adjustment method for health policy research and practice with ambulatory surgery data. We also recommend using risk-adjustment with all available diagnoses.