Statewide Episode Spending Variation of Mastectomy for Breast Cancer

Abstract

BACKGROUND: Centralizing complex cancer operations, such as pancreatectomy and esophagectomy, has been shown to increase value, largely due to reduction in complications. For high-volume operations with low complication rates, it is unknown to what degree value varies between facilities, or by what mechanism value may be improved. To identify possible opportunities for value enhancement for such operations, we sought to describe variations in episode spending for mastectomy with a secondary aim of identifying patient- and facility-level determinants of variation. STUDY DESIGN: Using the Michigan Value Collaborative risk-adjusted, price-standardized claims data, we evaluated mean spending for patients undergoing mastectomy at 74 facilities (n = 7,342 patients) across the state of Michigan. Primary outcomes were 30- and 90-day episode spending. Using linear mixed models, facility- and patient-level factors were explored for association with spending variability. RESULTS: Among 7,342 women treated across 74 facilities, mean 30-day spending by facility ranged from $11,129 to $20,830 (median $14,935). Ninety-day spending ranged from $17,303 to $31,060 (median $23,744). Patient-level factors associated with greater spending included simultaneous breast reconstruction, bilateral surgery, length of stay, and readmission. Among women not undergoing reconstruction, variation persisted, and length of stay, bilateral surgery, and readmission were all associated with increased spending. CONCLUSION: Michigan hospitals have significant variation in spending for mastectomy. Reducing length of stay through wider adoption of same-day discharge for mastectomy and reducing the frequency of bilateral surgery may represent opportunities to increase value, without compromising patient safety or oncologic outcomes.

Surgeon Perspectives on Determinants of Same-Day Mastectomy: A Roadmap for Implementing Change

“…This study was limited to surgeons in Michigan as the objective of this study was to use a qualitative approach to identify determinants of same-day discharge following previous work that demonstrated a wide variation in same-day mastectomy rates across the state of Michigan. 2 , 19 This study followed the Standards for Reporting Qualitative Research guideline. 20…”

“…Surgeons were only recruited if they performed MwoR and practiced at hospitals participating in the previous quantitative analysis of same-day discharge at Michigan hospitals. 2 …”

“…Nevertheless, despite surgeons’ overall enthusiasm and support for this practice, same-day discharge remains underutilized. 2 The most common barriers surgeons described were patient anxiety about postoperative care instructions at the patient level; accessibility of evidence, surgeon dogma, and peer influence at the provider level; and team processes and operating room logistics at the hospital system level. Fortunately, these barriers are potentially remediable using evidence-based implementation strategies within the TICD framework (Table 5 ).…”

“… 2 In a recent analysis of the cost of mastectomy between hospitals across Michigan, length of stay was identified as a significant contributor to cost variation. 2 Among facilities, there was wide variation in the percentage of patients discharged the same day as surgery (3–88%). 2 The national rate of outpatient mastectomies has been cited as around 40–60% throughout a similar time period, but this number is challenging to assess on a national scale as estimates from governing bodies (e.g., Agency for Healthcare Research and Quality) have included 23 h observation stays as an outpatient procedure.…”

“… 2 Among facilities, there was wide variation in the percentage of patients discharged the same day as surgery (3–88%). 2 The national rate of outpatient mastectomies has been cited as around 40–60% throughout a similar time period, but this number is challenging to assess on a national scale as estimates from governing bodies (e.g., Agency for Healthcare Research and Quality) have included 23 h observation stays as an outpatient procedure. 3 , 4 Understanding this practice pattern is important as more than 100,000 mastectomies are performed each year in the United States, and unnecessary hospital stays are associated with increased healthcare costs, hospital overcrowding, nosocomial infections, and increased financial burden for patients.…”