The Impact of Provider Volume on Outcomes From Urological Cancer Therapy

Joudi, Fadi N.; Konety, Badrinath R.

doi:10.1097/01.ju.0000165340.53381.48

Cited by 92 publications

(74 citation statements)

References 30 publications

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“…2 2 In terms of urological oncology several recently reviewed studies demonstrated improved outcomes at HVHs for cancer surgery. 5 Volume-outcomes relationships have been least explored for renal cancer surgery, which interestingly demonstrated the greatest regionalization in the current study.…”

Section: Discussionmentioning

confidence: 80%

“…3,4 Evidence for and against the volume-quality association was recently reviewed. 5 Although the strength and importance of associations between volume and quality remain subject to varying degrees of controversy depending on the procedure, some evidence exists that the migration of care to HVHs and high volume surgeons is already occurring, with some hospitals abandoning high risk procedures altogether. 6,7 We examined data from a large national hospital admissions database to analyze trends during a 15-year period in the concentration of inpatient surgical and nonsurgical care at HVHs for bladder, renal and prostate cancer.…”

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confidence: 99%

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Trends in Regionalization of Inpatient Care for Urological Malignancies, 1988 to 2002

2007

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Purpose: Higher hospital and clinician volumes may be associated with improved patient outcomes for complex surgical and medical care, although the strength and consistency of this association varies markedly across specific conditions and procedures. Pressures from payors and policymakers exist to move complex care to high volume hospitals. The net effect of these pressures may be the regionalization of care. We quantified trends in the regionalization of inpatient care for urological oncology in a national administrative database. Materials and Methods: The Nationwide Inpatient Sample, a 20% stratified sample of United States community hospital admissions, was queried for surgical and nonsurgical admissions for bladder, renal and prostate cancer care between 1988 and 2002. Hospitals were grouped into tertiles by annual surgical volume. Trends over time in the annual discharge rate by hospital volume tertile, geographic region and insurance status were analyzed. Results: High volume hospitals were defined by at least 22, 12 and 26 cases per year for bladder, renal and prostate cancer, respectively. High volume hospital discharges increased significantly as a proportion of all discharges for bladder (67% to 70%) and renal (67% to 73%) cancer surgery, and they were essentially constant for prostate surgery (76%). Trends were similar for Medicare and Medicaid patients except high volume hospital discharges for prostate cancer decreased during the study period. Significant regional variation was observed for the regionalization of surgical and nonsurgical care. Conclusions: Nationwide Inpatient Sample data demonstrate the ongoing regionalization of urological oncology care. The policy implications of this trend are complex with potentially important benefits and risks in terms of access to and quality of care.

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Section: Discussionmentioning

confidence: 80%

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confidence: 99%

Trends in Regionalization of Inpatient Care for Urological Malignancies, 1988 to 2002

2007

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“…Nonetheless, our study does corroborate previous findings documenting the effect of AHC on RP outcomes. [16][17][18][19] Specifically, RP performed at high AHC hospitals were associated with fewer blood transfusions, were less frequently associated with intraoperative or postoperative complications, and less frequently resulted in length of stay beyond the median. Table 4b-d demonstrates the complex link between AHC and insurance status.…”

Section: Resultsmentioning

confidence: 99%

Morbidity and mortality of radical prostatectomy differs by insurance status

Trinh

Schmitges

Sun

et al. 2011

Cancer

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BACKGROUND: Private insurance status may favorably affect various health outcomes including those associated with radical prostatectomy (RP). We explored the effect of insurance status on 5 short‐term RP outcomes. METHODS: Within the Health Care Utilization Project Nationwide Inpatient Sample (NIS) we focused on RPs performed within the 5 most contemporary years (2003‐2007). We tested the rates of blood transfusions, extended length of stay, intraoperative and postoperative complications, as well as in‐hospital mortality, stratified according to insurance status. Multivariable logistic regression analyses, fitted with general estimation equations for clustering among hospitals, adjusted for confounding factors. RESULTS Overall, 61,167 RPs were identified. Of those, private insurance accounted for the majority of cases (n = 41,312, 67.5%), followed by Medicare (n = 18,759, 30.7%) and Medicaid (n = 1096, 1.8%). Insurance status other than private was associated with higher rates of blood transfusions (P < .001), higher overall postoperative complication rates (P < .001), higher rates of hospital stay above the median (P < .001), as well as higher in‐hospital mortality (P = .01). In multivariable analyses, compared with patients with private insurance, Medicaid patients had higher rates of blood transfusion (odds ratio [OR] = 1.45, P < .001), length of stay beyond the median (OR = 1.61, P < .001) postoperative complications (OR= 1.24, P = .02), and in‐hospital mortality (OR = 4.91, = .01). Similarly, Medicare patients had higher rates of blood transfusions (OR = 1.21, P < .001), overall postoperative complications (OR = 1.17, P×< .001) and length of stay beyond the median (OR = 1.25, P < .001). CONCLUSIONS: Even after adjusting for confounding factors, patients with private insurance have better outcomes than their counterparts with nonprivate insurance. Cancer 2012;. © 2011 American Cancer Society.

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“…Actuarial 5-year overall survival after radical cystectomy, for example, was 39.0% at high-volume hospitals vs. 35.4% at low-volume hospitals, whereas survival following esophagectomy was 33.7% and 17.4% at high-and low-volume hospitals, respectively [22]. In urologic oncology specifically, most of the focus on volume and outcomes to date has been on radical prostatectomy and radical cystectomy, with fewer studies to date on radical nephrectomy and testis cancer management [23]; these will be discussed in further depth in the articles that follow.…”

Section: The Question Of Surgical Volumementioning

confidence: 99%

Defining high quality health care

Cooperberg

Birkmeyer

Litwin

2009

Urologic Oncology: Seminars and Original Investigations

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Most health care quality improvement efforts target measures of health care structures, processes, and/or outcomes. Structural measures examine relatively fixed aspects of health care delivery such as physical plant and human resources. Process measures, the focus of the largest proportion of quality improvement efforts, assess specific transactions in clinical-patient encounters, such as use of appropriate surgical antibiotic prophylaxis, which are expected to improve outcomes. Outcome measures, which comprise quality of life endpoints as well as morbidity and mortality, are of greatest interest to clinicians and patients, but entail the greatest complexity, as the majority of variance in outcomes is attributable to patient and environmental factors that may not be readily modifiable. Selecting among structure, process, and outcome measures for quality improvement efforts generally will be dictated by the specific clinical situation for which improvement is desired.One aspect of health care quality that has received a great deal of attention in recent years is the relationship between surgical volume and health outcomes. Volume, an inherent characteristic of a health care facility or provider, is generally considered a structural measure of quality. Many studies have demonstrated a positive association between volume and outcomes, and policymakers in the private and public sectors have begun to consider volume in certification and reimbursement decisions. The volume-outcome association is not without controversy, however. Most studies in the field are limited by the nature of the administrative data on which they are based, and some studies have found that variation in quality within volume quantiles exceeds differences between quantiles. Moreover, regionalization driven by a focus on volume may exert adverse effects on access to care.The movement for health care quality improvement faces substantial methodological, clinical, financial, and political challenges. Despite these challenges, it is a movement that is gaining momentum, and the emphasis on quality in health care delivery is likely only to increase in the future. It is crucial, therefore, that physicians assume increasing leadership roles in efforts to define, measure, report, and improve quality of care.

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The Impact of Provider Volume on Outcomes From Urological Cancer Therapy

Cited by 92 publications

References 30 publications

Trends in Regionalization of Inpatient Care for Urological Malignancies, 1988 to 2002

Trends in Regionalization of Inpatient Care for Urological Malignancies, 1988 to 2002

Morbidity and mortality of radical prostatectomy differs by insurance status

Defining high quality health care

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