A Comparison of Quality and Cost

Indicators by Surgical Specialty for

Lobectomy of the Lung

Richard K. Freeman Richard K. Freeman MD MD MBA, J. Russell MBA, J. Russell Dilts MS,Dilts MS,Richard K. Freeman Richard K. Freeman MD MD MBA, J. Russell MBA, J. Russell Dilts MS,Dilts MS,

Anthony J. Anthony J. Ascioti MD, Ascioti MD, Theresa Giannini Theresa Giannini ARNP, ARNP,

Raja Raja S. S. Mahidhara MD Mahidhara MD

St Vincent St Vincent Hospital, Hospital, Indianapolis, Indiana, USA Indianapolis, Indiana, USA

andand

Ascension Health, St Louis, Ascension Health, St Louis, Missouri, Missouri, USA USA

No disclosures

Does Does Surgeon Surgeon Specialty Training Effect Specialty Training Effect

Surgical OutcomesSurgical Outcomes

Previous InvestigationsPrevious Investigations

� Silvestri et al 1998

� Goodney et al 2005

CriticismsCriticisms

�� Isolated claims data (NIS) Isolated claims data (NIS)

and/or nonand/or non--consecutive consecutive

sampling databasessampling databases

� Schipper et al 2009

2011

�� Farjah et alFarjah et al 20092009

sampling databasessampling databases

�� CaseCase--mix designation of mix designation of

surgeon specialtysurgeon specialty

�� Mixture of procedures Mixture of procedures

analyzedanalyzed

�� No comparison of costsNo comparison of costs

MethodsMethods

�� Retrospective Retrospective CCohort Analysis ohort Analysis –– IRB approvedIRB approved

�� Patients undergoing lobectomy for NSCLCA 2005Patients undergoing lobectomy for NSCLCA 2005--20092009

�� CPT 32480CPT 32480

�� ICDICD--9 162 & 162.3,4,59 162 & 162.3,4,5

Ascension Health Hospitals across the United States (76)Ascension Health Hospitals across the United States (76)�� Ascension Health Hospitals across the United States (76)Ascension Health Hospitals across the United States (76)

�� >> 50 lobectomies during the study period50 lobectomies during the study period

�� Surgeon specialty assigned by national provider number & board Surgeon specialty assigned by national provider number & board

certification statuscertification status

�� Cardiothoracic Surgeon Cardiothoracic Surgeon (TS)(TS)

�� General SurgeonGeneral Surgeon (GS)(GS)

Data SourcesData Sources

Premier Database ACS Tumor Registry

Age ✔ ✔

Sex ✔ ✔

PFT’s* ✔

CT Imaging* ✔

Pre-lobectomy mediastinal staging* ✔ ✔Pre-lobectomy mediastinal staging*

Neoadjuvant chemo/radiation therapy ✔ ✔

Intraoperative mediastinal staging* ✔ ✔

Pathologic stage (AJCC 7th edition) ✔

Charlson comorbidity index ✔

Readmission ✔

Morbidity ✔

Mortality ✔ ✔

* Indicates an NCCN guideline criteria

Costs of TreatmentCosts of Treatment

�� GGross hospital charges (prior to contractual adjustment)ross hospital charges (prior to contractual adjustment)

�� Postings from day of surgery until discharge or death Postings from day of surgery until discharge or death

�� PProfessional fees were excludedrofessional fees were excluded�� PProfessional fees were excludedrofessional fees were excluded

�� Readmission charges, if applicable, were not includedReadmission charges, if applicable, were not included

�� PParity of charges was tested by comparing each facility’s charge arity of charges was tested by comparing each facility’s charge

per nonper non--adjusted discharge indexadjusted discharge index

ResultsResults

General Surgeon Thoracic Surgeon p

Lobectomies 2823 3653

Surgeons 46 29

Hospitals 30 14

Age (mean years) 63 + 13 67 + 17 <0.0001

Male 1502 1932 0.052Male 1502 1932 0.052

Comorbidity Index

(mean)

6 + 3 9 + 4 <0.0001

Stage (pathologic)

I 1256 1399 0.21

II 1077 1569 0.08

IIIA 229 547 <0.0001

IIIB 261 138 <0.0001

ResultsResults

General Surgeon Thoracic Surgeon p

NCCN Guideline

Adherence

1609 (57%) 3142 (86%) <0.0001

Preoperative

chemo &/or

26 (0.9%) 467 (13%) <0.0001

chemo &/or

radiation therapy

Length of stay

(mean days)

9 + 11 6 + 7 <0.0001

Prolonged length

of stay (<14 days)*

213 (8%) 186 (5%) <0.0001

Readmission 163 (6%) 249 (7%) 0.09

*Kozower et al. STS database risk models: predictors of mortality and major morbidity for lung cancer resection.

Ann Thorac Surg 2010;90:875-883

ResultsResults

�� Hospital ChargesHospital Charges

�� Global parity between facilities found when charges per discharge Global parity between facilities found when charges per discharge

indices were comparedindices were compared

�� ∆∆$11,000 $11,000

76% ($8360.00) attributed to differences in LOS &/or morbidities76% ($8360.00) attributed to differences in LOS &/or morbidities�� 76% ($8360.00) attributed to differences in LOS &/or morbidities76% ($8360.00) attributed to differences in LOS &/or morbidities

General

Surgeon

Thoracic

Surgeon

p

Charges

(mean dollars)

$89,000 $78,000 <0.0001

ResultsResults

General

Surgeon

Thoracic

Surgeon

p Odds

Ratio/95% CI

Morbidity 310 (11%) 146 (4%) <0.0001

Prolonged air leak 136 42 <0.0001

Reoperation for

bleeding 81 21 <0.0001

Operative 198 (7%) 73 (2%) <0.0001Operative

Mortality

198 (7%) 73 (2%) <0.0001

Operative

Mortality(Adjusted for

comorbidity and age)

_ _ <0.0001 0.37

0.13 – 0.59

Operative

Mortality (adjusted for hospital

and surgeon volume)

_ _ <0.0001 0.60

0.53 – 0.72

LimitationsLimitations

�� Retrospective analysisRetrospective analysis

�� Attempted to validate by using more than one data sourceAttempted to validate by using more than one data source

�� Effect of surgeon and facility volume Effect of surgeon and facility volume

�� Adjusted in analysisAdjusted in analysis�� Adjusted in analysisAdjusted in analysis

�� May ignore the “system” or “team” influence May ignore the “system” or “team” influence

�� Volume adjustments Volume adjustments maymay minimize the effectminimize the effect

�� Measures charges as a surrogate for costMeasures charges as a surrogate for cost

�� Gross charges are a valid comparison Gross charges are a valid comparison if facility parity if facility parity can be showncan be shown

ConclusionsConclusions

�� A comparison of patients undergoing lobectomy for NSCLCA by A comparison of patients undergoing lobectomy for NSCLCA by

either a general surgeon or a thoracic surgeon at geographically either a general surgeon or a thoracic surgeon at geographically

diverse institutions found;diverse institutions found;

�� Measurable indicators for quality of care and outcomes superior for Measurable indicators for quality of care and outcomes superior for

thoracic surgeonsthoracic surgeonsthoracic surgeonsthoracic surgeons

�� Overall charges higher for general surgeonsOverall charges higher for general surgeons

�� These findings, These findings, aalong with the work of previous investigators, may long with the work of previous investigators, may

find influence in economic and procedural credentialing by find influence in economic and procedural credentialing by

treatment facilities and payers. treatment facilities and payers.