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Trends in Regionalization of Inpatient Care for Urological Malignancies Matthew R. Cooperberg Sanjukta Modak Badrinath R. Konety Department of Urology University of California, San Franicsco AHRQ Annual Conference Bethesda, MD September 10, 2008 A Heath Care Utilization Project Nationwide Inpatient Sample Study

Trends in Regionalization of Inpatient Care for Urological Malignancies Matthew R. Cooperberg Sanjukta Modak Badrinath R. Konety Department of Urology

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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

Surgical Volume and Outcomes

Introduction

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

Methods

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

Results

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

Conclusions and Implications

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