Divison of Surgical Oncology, Department of Surgery, University of California, Davis, Medical Center, Sacramento.
Center for Healthcare Policy and Research, University of California, Davis, Sacramento.
JAMA Surg. 2019 Oct 1;154(10):e193019. doi: 10.1001/jamasurg.2019.3019. Epub 2019 Oct 16.
Value-based care is increasingly important, with rising health care costs and advances in cancer treatment leading to greater survival for patients with cancer. Regionalization of surgical care for pancreatic cancer has been extensively studied as a strategy to improve perioperative outcomes, but investigation of long-term outcomes relative to health care costs (ie, value) is lacking.
To identify patient and hospital characteristics associated with improved overall survival, decreased costs, and greater value among patients with pancreatic cancer undergoing curative resection.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study identified 2786 patients with stages I to II pancreatic cancer who underwent pancreatic resection at 157 hospitals from January 1, 2004, through December 31, 2012. The study used the California Cancer Registry, which collects data from all California residents newly diagnosed with cancer, linked to the Office of Statewide Health Planning and Development database, which collects administrative data from all California licensed hospitals. Data were analyzed from November 11, 2017, through September 4, 2018.
Pancreatic resection at high-volume and/or National Cancer Institute (NCI)-designated cancer centers.
The primary outcomes were overall survival, surgical hospitalization costs, and value. High value was defined as the fourth quintile or higher for survival and the second quintile or less for costs. Costs were calculated from charges using cost-charge ratios and adjusted for geographic variation and inflation. Multivariable regression models were used to determine factors associated with overall survival, costs, and high value.
Among the 2786 patients included (1394 [50.0%] male; mean [SD] age, 67.0 [10.7] years), postoperative chemotherapy (adjusted hazard ratio [aHR], 0.71; 95% CI, 0.64-0.79; P < .001) and high-volume centers (aHR, 0.78; 95% CI, 0.61-0.99; P = .04) were associated with greater overall survival. Higher Elixhauser comorbidity index scores (estimate, 0.006; 95% CI, 0.003-0.008), complications (estimate, 0.22; 95% CI, 0.17-0.27), readmissions (estimate, 0.34; 95% CI, 0.29-0.39), and longer lengths of stay (estimate, 0.03; 95% CI, 0.03-0.04) were associated with higher costs (P < .001), whereas postoperative chemotherapy was associated with lower costs (estimate, -0.06; 95% CI, -0.11 to -0.02; P = .006). National Cancer Institute-designated and high-volume centers were not associated with costs. Although grades III and IV tumors (odds ratio [OR], 0.65; 95% CI, 0.39-0.91; P = .001), T3 category disease (OR, 0.71; 95% CI, 0.46-0.95; P = .005), complications (OR, 0.68; 95% CI, 0.49-0.86; P < .001), readmissions (OR, 0.64; 95% CI, 0.44-0.84; P < .001), and length of stay (OR, 0.82; 95% CI, 0.78-0.85; P < .001) were inversely associated with high-value care, NCI designation (OR, 1.07; 95% CI, 0.66-1.49; P = .74) and high-volume centers (OR, 1.08; 95% CI, 0.54-1.61; P = .07) were not.
In this study, high-value care was associated with important patient characteristics and postoperative outcomes. However, NCI-designated and high-volume centers were not associated with greater value. These data suggest that targeted measures to enhance value may be needed in these centers.
重要性：随着医疗保健成本的上升和癌症治疗的进步，癌症患者的生存时间延长，基于价值的医疗保健变得越来越重要。为了改善围手术期结果，已经广泛研究了将胰腺癌外科护理区域化作为一种策略，但是缺乏与医疗保健成本（即价值）相关的长期结果的调查。
目的：确定与接受根治性切除术的胰腺癌患者的总体生存率提高、成本降低和价值增加相关的患者和医院特征。
设计、设置和参与者：这项回顾性队列研究纳入了 2004 年 1 月 1 日至 2012 年 12 月 31 日期间在 157 家医院接受胰腺切除术的 2786 例 I 期至 II 期胰腺癌患者。该研究使用加利福尼亚癌症登记处（该登记处收集所有加利福尼亚州新诊断为癌症的居民的数据），并与州卫生规划和发展办公室数据库（该数据库收集所有加利福尼亚州持牌医院的行政数据）相链接。数据分析于 2017 年 11 月 11 日至 2018 年 9 月 4 日进行。
暴露：在高容量和/或国家癌症研究所（NCI）指定的癌症中心进行胰腺切除术。
主要结果和措施：主要结果是总体生存率、手术住院费用和价值。高价值定义为生存率的第四五分位数或更高，而成本的第二五分位数或更低。使用成本-收费比率计算成本，并针对地理位置差异和通货膨胀进行调整。多变量回归模型用于确定与总体生存率、成本和高价值相关的因素。
结果：在纳入的 2786 例患者中（男性 1394 例[50.0%]；平均[SD]年龄为 67.0[10.7]岁），术后化疗（调整后的危险比[aHR]，0.71；95%CI，0.64-0.79；P<0.001）和高容量中心（aHR，0.78；95%CI，0.61-0.99；P=0.04）与总体生存率提高相关。更高的 Elixhauser 合并症指数评分（估计值，0.006；95%CI，0.003-0.008）、并发症（估计值，0.22；95%CI，0.17-0.27）、再入院（估计值，0.34；95%CI，0.29-0.39）和更长的住院时间（估计值，0.03；95%CI，0.03-0.04）与更高的成本相关（P<0.001），而术后化疗与较低的成本相关（估计值，-0.06；95%CI，-0.11 至-0.02；P=0.006）。NCI 指定的和高容量中心与成本无关。尽管 III 级和 IV 级肿瘤（比值比[OR]，0.65；95%CI，0.39-0.91；P=0.001）、T3 类别疾病（OR，0.71；95%CI，0.46-0.95；P=0.005）、并发症（OR，0.68；95%CI，0.49-0.86；P<0.001）、再入院（OR，0.64；95%CI，0.44-0.84；P<0.001）和住院时间（OR，0.82；95%CI，0.78-0.85；P<0.001）与高价值护理呈反比，但 NCI 指定（OR，1.07；95%CI，0.66-1.49；P=0.74）和高容量中心（OR，1.08；95%CI，0.54-1.61；P=0.07）与价值增加无关。
结论和相关性：在这项研究中，高价值护理与重要的患者特征和术后结果相关。然而，NCI 指定的和高容量中心与更高的价值无关。这些数据表明，这些中心可能需要采取有针对性的措施来提高价值。
