Original article
General thoracic
Outcomes and Costs for Major Lung Resection in the United States: Which Patients Benefit Most From High-Volume Referral?

https://doi.org/10.1016/j.athoracsur.2015.03.076Get rights and content

Background

Accountable care organizations are designed to improve value by decreasing costs and maintaining quality. Strategies to maximize value are needed for high-risk surgery. We wanted to understand whether certain patient groups were differentially associated with better outcomes at high-volume hospitals in terms of quality and cost.

Methods

In all, 37,746 patients underwent elective major lung resection in 1,273 hospitals in the Nationwide Inpatient Sample from 2007 to 2011. Patients were stratified by hospital volume quartile and substratified by preoperative mortality risk, age, and chronic obstructive pulmonary disease status. Mortality was evaluated using clustered multivariable hierarchical logistic regression controlling for patient comorbidity, demographics, and procedure. Adjusted cost was evaluated using generalized linear models fit to a gamma distribution.

Results

Patients were grouped into volume quartiles based on cases per year (less than 21, 21 to 40, 40 to 78, and more than 78). Patient characteristics and procedure mix differed across quartiles. Overall, mortality decreased across volume quartiles (lowest 1.9% versus highest 1.1%, p < 0.0001). Patients aged more than 80 years were associated with greater absolute and relative mortality rates than patients less than 60 years old in highest volume versus lowest volume hospitals (age more than 80 years, 4.2% versus 1.3%, p < 0.0001, odds ratio 3.31, 95% confidence interval: 1.89 to 5.80; age less than 60 years, 1.0% versus 0.8%, p = 0.19, odds ratio 1.38, 95% confidence interval: 0.74 to 2.56). Patients with high preoperative risk (more than 75th percentile) were also associated with lower absolute mortality in high-volume hospitals. Adjusted costs were not significantly different across quartiles or patient strata.

Conclusions

Older patients show a significantly stronger volume-outcome relationship than patients less than 60 years of age. Costs were equivalent across volume quartile and patient strata. Selective patient referral may be a strategy to improve outcomes for elderly patients undergoing lung resection.

Section snippets

Data Sources

Patient-level discharge data were obtained using the Nationwide Inpatient Sample (NIS) for years 2007 to 2011. The NIS is a stratified, survey-weighted 20% sample of all US hospitals provided by the Healthcare Cost and Utilization Project of the Agency for Healthcare Quality Research [11]. The NIS contains data on procedures, comorbid conditions, insurance status, and demographic characteristics. It also contains certain hospital characteristics (size, teaching status, ownership, rural/urban

Hospital Volume and Characteristics

Volume cutoffs were set at less than 21, 21 to 40, 40 to 78, and more than 78 total lung resections per year. Comparing VHV to LV hospitals, volume was seen to be associated with hospital size, teaching status, and urban location. No clear association between hospital region and volume was observed.

Patient Demographics and Characteristics

Patient demographic and clinical characteristics are shown in Table 1. Patients in VHV hospitals differed from those in LV hospitals. They were younger (age less than 60 years, 31.7% versus 26.9%),

Comment

Improving value in surgery will require innovative strategies to match patients to hospitals to improve outcomes and decrease cost. In this study, we evaluated potential referral strategies for patients undergoing elective lung surgery. We found that both elderly patients and high-risk patients were associated with a significantly greater volume-mortality relationship as compared with younger and lower risk patients. Costs remained approximately equivalent across volume quartiles, and few

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