Trends in Regionalization of Inpatient Care for Urological Malignancies: A Health Care Utilization Project Nationwide Inpatient Sample Study

Slide Presentation from the AHRQ 2008 Annual Conference

On September 10, 2008, Matthew R. Cooperberg, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (2.9 MB).

Slide 1

Trends in Regionalization of Inpatient Care for Urological Malignancies: A Health Care Utilization Project Nationwide Inpatient Sample Study 

• Department of Urology, University of California, San Francisco (UCSF)
• Presented by:
  • Matthew R. Cooperberg, M.D., Ph.D. University of California, San Francisco
• Co-authors:
  • Sanjutka Modak, M.S., University of California, San Francisco
  • Badrinath R. Konety, M.D., M.B.A., University of California, San Francisco

Slide 2

Introduction: Surgical Volume and Outcomes

Slide 3

Associating volume and outcomes

• 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 [Healthcare Cost and Utilization Project Nationwide Inpatient Sample ] 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 [High-volume hospital] status for other urologic or non-urologic surgery not assoc with outcomes [Konety et al. J Clin Oncol 2006; 24:2006]

Slide 4

"Getting under the hood"

• 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, length of stay (LOS), other procedures [Hollenbeck et al. J Urol 2007; 177:2095; Konety et al. J Urol 2004; 172:1056; Konety et al. J Urol 2005; 173:1695]

Slide 5

Volume-outcomes continued.

• Institute of Medicine (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 (National Surgical Quality Improvement Program [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 coronary artery bypass grafting (CABG): during period of declining volume, 50% decline in proportion of HVH, mortality declined consistently with greatest decline among low-volume hospitals (LVHs) [Ricciardi et al. Arch Surg 2008; 143:338]
• Regionalization already supported by policy (public and private, mostly reimbursement-driven) in some cases.

Slide 6

Methods

Slide 7

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.

Slide 8

Results

Slide 9

Surgical volume thresholds

• Table with these column headings: Blank-Bladder cancer; Sub-headings, Surgery, No surgery-Renal cancer; Sub-headings, Surgery, No surgery-Prostate cancer; Sub-headings, Surgery, No surgery.
• # Cases-26,770-134,713-64,857-21,415-178,210-146,311.
• # Hospitals-1764-2645-2182-2288-2065-2775.
• Volume thresholds: Low—<4—<12—<6—<3—<8—<9.
• Moderate-4-5-12-21-6-11-3-4-8-25-9-26.
• High—>5—>21—>11—>4—>25—>26.

Slide 10

Trends in Admissions

• Table with these headings: 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.

Slide 11

Trends in Admissions

• Table with these headings: 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.

Slide 12

Trends in Admissions

• Table with these headings: 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.

Slide 13

Trends: Medicare/Medicaid

• Table with these headings: Hospital Type-1988-1992-1993-1997-1998-2002.
• Bladder Cancer.
• Surgical volume: p=0.003.
• High-65.7-66.1-68.5.
• Moderate/Low-34.3-33.9-31.5.
• Non-surgical volume: p<0.0001.
• High-69.8-71.7-71.4.
• Moderate/Low-30.2-28.3-28.6.

Slide 14

Trends: Medicare/Medicaid

• Table with these headings: 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.

Slide 15

Trends: Medicare/Medicaid

• Table with these headings: Hospital Type-1988-1992-1993-1997-1998-2002.
• 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.

Slide 16

Bladder Cancer HVH Admissions: Northeast

• Line graphs compare surgical with non-surgical admissions in the Northeast from 1988 to 2002; numbers are approximate.
• Scale on left goes from 0 to 100.
  • Surgical rates show an increase from about 66 in 1988 to about 71 in 2002.
  • Non-surgical rates show an increase from about 81 in 1988 to about 89 in 2002.

Slide 17

Bladder Cancer HVH Admissions: Midwest

• Line graphs compare surgical with non-surgical admissions in the Midwest from 1988 to 2002; numbers are approximate.
• Scale on left goes from 0 to 100.
  • Surgical rates show an increase from about 57 in 1988 to about 80 in 2002.
  • Non-surgical rates show an increase from about 60 in 1988 to about 74 in 2002.

Slide 18

Bladder Cancer HVH Admissions: South

• Line graphs compare surgical and non-surgical admissions in the South from 1988 to 2002; numbers are approximate.
• Scale on left goes from 0 to 100.
  • Surgical rates show an increase from about 71 in 1988 to about 75 in 2002.
  • Non-surgical rates show an increase from about 68 in 1988 to about 81 in 2002.

Slide 19

Bladder Cancer HVH Admissions: West

• Line graphs compare surgical and non-surgical admissions in the West from 1988 to 2002; numbers are approximate.
• Scale on left goes from 0 to 100.
  • Surgical rates show an increase from about 72 in 1988 to about 77 in 2002.
  • Non-surgical rates show an increase from about 63 in 1988 to about 80 in 2002.

Slide 20

Renal Cancer HVH Admissions: Northeast

• Line graphs compare surgical with non-surgical admissions in the Northeast from 1988 to 2002; numbers are approximate.
• Scale on left goes from 0 to 100.
  • Surgical rates show an increase from about 70 in 1988 to about 79 in 2002.
  • Non-surgical rates show a decrease from about 71 in 1988 to about 62 in 2002.

Slide 21

Renal Cancer HVH Admissions: Midwest

• Line graphs compare surgical with non-surgical admissions in the Midwest from 1988 to 2002; numbers are approximate.
• Scale on left goes from 0 to 100.
  • Surgical rates show an increase from about 67 in 1988 to about 75 in 2002.
  • Non-surgical rates show an increase from about 58 in 1988 to about 67 in 2002.

Slide 22

Renal Cancer HVH Admissions: South

• Line graphs compare surgical with non-surgical admissions in the South from 1988 to 2002; numbers are approximate.
• Scale on left goes from 0 to 100.
  • Surgical rates show an increase from about 73 in 1988 to about 74 in 2002.
  • Non-surgical rates show an increase from about 60 in 1988 to about 68 in 2002.

Slide 23

Renal Cancer HVH Admissions: West

• Line graphs compare surgical with non-surgical admissions in the West from 1988 to 2002; numbers are approximate.
• Scale on left goes from 0 to 100.
  • Surgical rates show an increase from about 68 in 1988 to about 77 in 2002.
  • Non-surgical rates show an increase from about 58 in 1988 to about 70 in 2002.

Slide 24

Prostate Cancer HVH Admissions: Northeast

• Line graphs compare surgical with non-surgical admissions in the Northeast from 1988 to 2002; numbers are approximate.
• Scale on left goes from 0 to 100.
  • Surgical rates show an increase from about 68 in 1988 to about 77 in 2002.
  • Non-surgical rates show an increase from about 73 in 1988 to about 76 in 2002.

Slide 25

Prostate Cancer HVH Admissions: Midwest

• Line graphs compare surgical with non-surgical admissions in the Midwest from 1988 to 2002; numbers are approximate.
• Scale on left goes from 0 to 100.
  • Surgical rates show an increase from about 71 in 1988 to about 78 in 2002.
  • Non-surgical rates show an increase from about 66 in 1988 to about 71 in 2002.

Slide 26

Prostate Cancer HVH Admissions: South

• Line graphs compare surgical with non-surgical admissions in the South from 1988 to 2002; numbers are approximate.
• Scale on left goes from 0 to 100.
  • Surgical rates show a decrease from about 72 in 1988 to about 68 in 2002.
  • Non-surgical rates show a decrease from about 80 in 1988 to about 69 in 2002.

Slide 27

Prostate Cancer HVH Admissions: West

• Line graphs compare surgical with non-surgical admissions in the West from 1988 to 2002; numbers are approximate.
• Scale on left goes from 0 to 100.
  • Surgical rates show a decrease from about 81 in 1988 to about 80 in 2002.
  • Non-surgical rates show an increase from about 59 in 1988 to about 61 in 2002.

Slide 28

Conclusions and Implications

Slide 29

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.

Slide 30

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]

Slide 31

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]

Slide 32

Urologist Distribution: Data from Health Resources and Services Administration (HRSA) Resource File, 2006

• Map of the 48 contiguous United States broken into counties shows the concentrations of urologists per 100,000 people. Odisho et al. J Urol, in press.

Slide 33

Urologist Distribution: Data from HRSA Resource File, 2006

• Map of the 48 contiguous United States broken into counties shows the concentrations of urologists under age 45 per 100,000 people. Odisho et al. J Urol, in press.

Slide 34

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.