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

Chukmaitov, Askar; Harless, David W.; Menachemi, Nir; Saunders, Charles; Brooks, Robert G.

doi:10.1007/s10729-009-9101-3

Cited by 7 publications

(8 citation statements)

References 27 publications

(52 reference statements)

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“…Our study found that endoscopists in all specialty and volume categories could safely use cold biopsy forceps. These findings corroborate the literature suggesting that cold polypectomy techniques are the safest in terms of risks of serious GI adverse events . More research is warranted on cold polypectomy techniques and post‐colonoscopy CRC, as some studies reported that residual polyp tissues were discovered after cold forceps .…”

Section: Discussionsupporting

confidence: 88%

“…Health insurance types were categorized as Medicare, Medicare HMO, Medicaid, Medicaid HMO, commercial indemnity, commercial Health Maintenance Organizations (HMO), commercial Preferred Provider Organizations (PPO), self‐pay or charity, and others. Diagnostic cost groups/hierarchical condition categories (DCG/HCC), which used all available ICD‐9‐CM diagnostic codes to categorize patients, were used to incorporate all comorbid conditions and indicate a greater severity of illness among patients with higher risk scores . Finally, unobserved changes over time common for both ASCs and HOPDs (e.g., changes in practice guidelines, new policy recommendations) were controlled by including a set of dummy variables for each year between 1999 and 2001.…”

Section: Methodsmentioning

confidence: 99%

“…Diagnostic cost groups/hierarchical condition categories (DCG/HCC), which used all available ICD-9-CM diagnostic codes to categorize patients, were used to incorporate all comorbid conditions and indicate a greater severity of illness among patients with higher risk scores [22][23][24]. Finally, unobserved changes over time common for both ASCs and HOPDs (e.g., changes in practice guidelines, new policy recommendations) were controlled by including a set of dummy variables for each year between 1999 and 2001.…”

Section: Key Explanatory Variablesmentioning

confidence: 99%

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Polypectomy techniques, endoscopist characteristics, and serious gastrointestinal adverse events

et al. 2014

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Background A use of polypectomy techniques by endoscopist specialty (primary care, surgery, and gastroenterology) and experience (volume), and associations with serious gastrointestinal adverse events, were examined. Methods A retrospective follow-up study with ambulatory surgery and hospital discharge datasets from Florida, 1999–2001, was used. Thirty-day hospitalizations due to colonic perforations and gastrointestinal bleeding were investigated for 323,585 patients. Results Primary care endoscopists and surgeons used hot biopsy forceps/ablation, while gastroenterologists provided snare polypectomy or complex colonoscopy. Low-volume endoscopists were more likely to use simpler rather than complex procedures. For hot forceps/ablation and snare polypectomy, low- and medium-volume endoscopists reported higher odds of adverse events. For complex colonoscopy, higher odds of adverse events were reported for primary care endoscopists (1.74 [95% CI, 1.18–2.56]) relative to gastroenterologists. Conclusions Endoscopists regardless of specialty and experience can safely use cold biopsy forceps. For hot biopsy and snare polypectomy, low volume, but not specialty, contributed to increased odds of adverse events. For complex colonoscopy, primary care specialty, but not low volume, added to the odds of adverse events. Comparable outcomes were reported for surgeons and gastroenterologists. Cross-training and continuing medical education of primary care endoscopists in high-volume endoscopy settings are recommended for complex colonoscopy procedures.

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Section: Discussionsupporting

confidence: 88%

Section: Methodsmentioning

confidence: 99%

Section: Key Explanatory Variablesmentioning

confidence: 99%

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Polypectomy techniques, endoscopist characteristics, and serious gastrointestinal adverse events

et al. 2014

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“…Diagnostic cost groups/hierarchical condition categories, which use all available ICD-9-CM diagnostic codes to categorize patients, provided risk scores and indicated a greater severity of illness among patients with higher scores. 13-15 Finally, unobserved changes over time common for both ASCs and HOPDs (eg, changes in practice guidelines, new policy recommendations) were controlled by including a set of dummy variables for each year between 1997 and 2004.…”

Section: Methodsmentioning

confidence: 99%

Association of polypectomy techniques, endoscopist volume, and facility type with colonoscopy complications

Chukmaitov

Dahman

Siangphoe

et al. 2013

Gastrointestinal Endoscopy

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Background and Objective Serious GI adverse events in the outpatient setting were examined by polypectomy technique, endoscopist volume, and facility type (ambulatory surgery center and hospital outpatient department). Design Retrospective follow-up study. Setting Ambulatory surgery and hospital discharge datasets from Florida (1997-2004) were used. Patients A total of 2,315,126 outpatient colonoscopies performed in patients of all ages and payers were examined. Main Outcome Thirty-day hospitalizations because of colonic perforations and GI bleeding, measured as cumulative and specific outcomes, were investigated. Results Compared with simple colonoscopy, the adjusted risks of cumulative adverse events were greater with the use of cold forceps (1.21 [95% CI, 1.01-1.44]), ablation (3.75 [95% CI, 2.97-4.72]), hot forceps (5.63 [95% CI, 4.97-6.39]), snares (7.75 [95% CI, 6.95-8.64]), or complex colonoscopy (8.83 [95% CI, 7.70-10.12]). Low-volume endoscopists had higher risks of adverse events (1.18 [95% CI, 1.07-1.30]). A higher risk of adverse events was associated with procedures performed in ambulatory surgery centers (1.27 [95% CI, 1.16-1.40]). Important findings were also reported for the analyses stratified by specific outcomes and procedures. Limitation The study was constrained by limitations inherent in administrative data pertaining to a single state. Conclusions As the complexity of polypectomy increases, a higher risk of adverse events is reported. Using lower risk procedures when clinically appropriate or referring patients to high-volume endoscopists can reduce the rates of perforations and GI bleeding. Given the large number of colonoscopies performed in the United States, it is critical that the rates of adverse events be considered when choosing procedures.

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“…7 DCG/HCC risk scores are derived from data on patient age, gender, and physician-reported diagnosis codes (ICD-9-CM; U.S. National Center for Health Statistics, 2006). They have been validated as a proper measure of risk adjustment when modeling health outcomes in both the inpatient setting (Ash et al, 2003;Petersen, Pietz, Woodard, & Byrne, 2005) and the outpatient setting Chukmaitov, Harless, Menachemi, Saunders, & Brooks, 2009). DCG/HCC risk scores have also been used by the CMS to risk adjust Medicare payments to private insurers under Part C (Pope et al, 2000;Pope et al, 2004).…”

Section: Methodsmentioning

confidence: 99%

Patient Mix in Outpatient Surgery Settings and Implications for Medicare Payment Policy

2011

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In 2008, Medicare implemented a new payment policy for ambulatory surgical centers (ASCs), which aligns the ASC payment system with that used for hospital outpatient departments and reimburses ASCs approximately 65% of what hospitals receive for the same outpatient surgery. The authors assess patient selection across ASCs and hospital outpatient departments for four common surgeries (colonoscopy, hernia repair, knee arthroscopy, cataract repair), using data on procedures performed in Florida from 2004 to 2008. The authors construct measures of patient illness severity and cost risk and find that ASCs benefit from positive selection. Nonetheless, the degree of selection varies by surgery type and patient population. While similar studies in other states are needed, the findings suggest that modifications to the Medicare outpatient payment system may be appropriate to account for the different populations that each setting attracts.

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

Cited by 7 publications

References 27 publications

Polypectomy techniques, endoscopist characteristics, and serious gastrointestinal adverse events

Polypectomy techniques, endoscopist characteristics, and serious gastrointestinal adverse events

Association of polypectomy techniques, endoscopist volume, and facility type with colonoscopy complications

Patient Mix in Outpatient Surgery Settings and Implications for Medicare Payment Policy

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