Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA.
Ann Surg Oncol. 2018 Apr;25(4):856-863. doi: 10.1245/s10434-017-6312-6. Epub 2017 Dec 29.
Integrated delivery systems (IDSs) are postulated to reduce spending and improve outcomes through successful coordination of care across multiple providers. Nonetheless, the actual impact of IDSs on outcomes for complex multidisciplinary care such as major cancer surgery is largely unknown.
Using 2011-2013 Medicare data, this study identified patients who underwent surgical resection for prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, or ovarian cancer. Rates of readmission, 30-day mortality, surgical complications, failure to rescue, and prolonged hospital stay for cancer surgery were compared between patients receiving care at IDS hospitals and those receiving care at non-IDS hospitals. Generalized estimating equations were used to adjust results by cancer type and patient- and hospital-level characteristics while accounting for clustering of patients within hospitals.
The study identified 380,053 patients who underwent major resection of cancer, with 38% receiving care at an IDS. Outcomes did not differ between IDS and non-IDS hospitals regarding readmission and surgical complication rates, whereas only minor differences were observed for 30-day mortality (3.5% vs 3.2% for IDS; p < 0.001) and prolonged hospital stay (9.9% vs 9.2% for IDS; p < 0.001). However, after adjustment for patient and hospital characteristics, the frequencies of adverse perioperative outcomes were not significantly associated with IDS status.
The collective findings suggest that local delivery system integration alone does not necessarily have an impact on perioperative outcomes in surgical oncology. Moving forward, stakeholders may need to focus on surgical and oncology-specific methods of care coordination and quality improvement initiatives to improve outcomes for patients undergoing cancer surgery.
集成式交付系统（IDS）通过成功协调多个医疗机构的护理工作，被认为可以降低成本并改善治疗效果。然而，IDS 对复杂多学科护理（如主要癌症手术）的实际效果在很大程度上仍是未知的。
本研究使用了 2011-2013 年的 Medicare 数据，确定了接受前列腺、膀胱、食管、胰腺、肺、肝、肾、结肠直肠或卵巢癌手术切除术的患者。比较了在 IDS 医院和非 IDS 医院接受治疗的患者的再入院率、30 天死亡率、手术并发症、抢救失败率和癌症手术的住院时间延长率。使用广义估计方程调整了癌症类型和患者及医院水平特征对结果的影响，同时考虑了患者在医院内的聚类。
本研究确定了 380053 名接受主要癌症切除术的患者，其中 38%在 IDS 医院接受治疗。在再入院率和手术并发症率方面，IDS 和非 IDS 医院的结果没有差异，而 30 天死亡率（IDS 为 3.5%，非 IDS 为 3.2%；p<0.001）和住院时间延长率（IDS 为 9.9%，非 IDS 为 9.2%；p<0.001）则仅观察到较小的差异。然而，在调整了患者和医院特征后，不良围手术期结局的发生频率与 IDS 状态并无显著关联。
总体研究结果表明，局部交付系统的整合本身并不一定会对癌症手术的围手术期结果产生影响。未来，利益相关者可能需要专注于外科和肿瘤学特定的护理协调方法和质量改进计划，以改善接受癌症手术的患者的治疗效果。
