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Original Investigation |

Addressing the High Costs of Pancreaticoduodenectomy at Safety-Net Hospitals ONLINE FIRST

Derek E. Go, MS1; Daniel E. Abbott, MD1; Koffi Wima, MS1; Dennis J. Hanseman, PhD1; Audrey E. Ertel, MD, MS1; Alex L. Chang, MD1; Shimul A. Shah, MD, MHCM1; Richard S. Hoehn, MD1
[+] Author Affiliations
1Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
JAMA Surg. Published online July 27, 2016. doi:10.1001/jamasurg.2016.1776
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Importance  Safety-net hospitals care for vulnerable patients, providing complex surgery at increased costs. These hospitals are at risk due to changing health care reimbursement policies and demand for better value in surgical care.

Objective  To model different techniques for reducing the cost of complex surgery performed at safety-net hospitals.

Design, Setting, and Participants  Hospitals performing pancreaticoduodenectomy (PD) were queried from the University HealthSystem Consortium database (January 1, 2009, to December 31, 2013) and grouped according to safety-net burden. A decision analytic model was constructed and populated with clinical and cost data. Sensitivity analyses were then conducted to determine how changes in the management or redistribution of patients between hospital groups affected cost.

Main Outcomes and Measures  Overall cost per patient after PD.

Results  During the 5 years of the study, 15 090 patients underwent PD. Among safety-net hospitals, low-burden hospitals (LBHs), medium-burden hospitals (MBHs), and high-burden hospitals (HBHs) treated 4220 (28.0%), 9505 (63.0%), and 1365 (9.0%) patients, respectively. High-burden hospitals had higher rates of complications or comorbidities and more patients with increased severity of illness. Perioperative mortality was twice as high at HBHs (3.7%) than at LBHs (1.6%) and MBHs (1.7%) (P < .001). In the base case, when all clinical and cost data were considered, PD at HBHs cost $35 303 per patient, 30.1% and 36.2% higher than at MBHs ($27 130) and LBHs ($25 916), respectively. Reducing perioperative complications or comorbidities by 50% resulted in a cost reduction of up to $4607 for HBH patients, while reducing mortality rates had a negligible effect. However, redistribution of HBH patients to LBHs and MBHs resulted in significantly more cost savings of $9155 per HBH patient, or $699 per patient overall.

Conclusions and Relevance  Safety-net hospitals performing PD have inferior outcomes and higher costs, and improving perioperative outcomes may have a nominal effect on reducing these costs. Redirecting patients away from safety-net hospitals for complex surgery may represent the best option for reducing costs, but the implementation of such a policy will undoubtedly meet significant challenges.

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Figure 1.
Decision Analytic Tree Used to Construct a Cost-effectiveness Model

Frequencies and costs for 15 090 patient encounters were classified according to this cost-effectiveness model. Hospitals were first stratified based on safety-net burden group (see the Safety-Net Burden subsection of the Methods section). Patients were then categorized based on their severity of illness, mortality, and complications or comorbidities according to their pertinent diagnosis related group (DRG) code as well as any readmission.

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Figure 2.
Improving Hospital Performance Results in Limited Cost Reductions

Bars represent the reduction in costs at high-burden hospitals (HBHs) as the rates of complications or comorbidities (diagnosis related group codes 405 and 406) (A) and mortality (B) are reduced to half their current rates (dotted dark gray line). Costs after performance improvements are shown below the bars. Costs for low-burden hospitals (LBHs) and medium-burden hospitals (MBHs) are shown by dotted blue lines.

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Figure 3.
Centralizing Care Has a Greater Effect on Cost Savings

Dotted lines indicate the starting costs at hospital groups; bars, the change in costs with redistribution. A, A simulated scenario is shown in which patients from high-burden hospitals (HBHs) are shifted to low-burden hospitals (LBHs). B, A simulated scenario is shown in which patients from HBHs are shifted equally to LBHs and medium-burden hospitals (MBHs). Redistribution was done according to severity of illness rates in the HBH group. Costs before and after redistribution are shown.

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Figure 4.
Cost Savings Result From Improvement Measures

Shown are high-burden hospital (HBH) savings (A) and overall cost savings (B) when hospital performance metrics are reduced compared with patient redistribution. LBHs indicates low-burden hospitals; MBHs, medium-burden hospitals.

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