Gourin Christine G, Vosler Peter S, Mandal Rajarsi, Pitman Karen T, Fakhry Carole, Eisele David W, Frick Kevin D, Austin J Matthew
Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland.
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland.
JAMA Otolaryngol Head Neck Surg. 2019 Oct 1;145(10):939-947. doi: 10.1001/jamaoto.2019.2303.
High-volume hospital care for laryngectomy has been shown to be associated with reduced morbidity, mortality, and costs; however, most hospitals in the United States do not perform high volumes of laryngectomies. The influence of market competition on charges and costs for such patients has not been defined.
To examine the association between regional hospital market concentration, hospital charges, and costs for laryngectomy.
DESIGN, SETTING, AND PARTICIPANTS: The Nationwide Inpatient Sample was used to identify 34 193 patients who underwent laryngectomy for a malignant laryngeal or hypopharyngeal neoplasm from January 1, 2003, to December 31, 2011. Hospital laryngectomy volume was modeled as a categorical variable. Hospital market concentration was evaluated using a variable-radius Herfindahl-Hirschman Index from the 2003, 2006, and 2009 Hospital Market Structure Files. Statistical analysis was performed from May 19 to August 15, 2018.
Multivariable generalized linear regression was used to evaluate associations between market concentration and total charges and costs for laryngectomy.
Among the 34 193 patients (19.3% female and 80.7% male; mean age, 62.7 years [range, 20.0-96.0 years]), 69.2% of procedures were performed at hospitals in highly concentrated (noncompetitive) markets and 26.2% were performed at hospitals in unconcentrated (highly competitive) markets. Most high-volume hospitals (68.0%) were located in highly concentrated markets, followed by unconcentrated markets (32.0%). Market share and volume were not associated with significant differences in total charges. Unconcentrated markets were associated with 28% higher costs (95% CI, 8%-53%) relative to moderately concentrated and highly concentrated markets. High-volume hospitals were associated with 22% lower costs (95% CI, -36% to -5%).
Competition among hospitals is associated with increased costs of care for laryngectomy. High-volume hospital care is associated with lower costs of care. These data suggest that hospital market consolidation of laryngectomy at centers able to meet minimum volume thresholds may improve health care value.
已表明高容量的喉切除术医院护理与发病率、死亡率降低及成本降低相关；然而，美国大多数医院进行的喉切除术数量并不多。市场竞争对此类患者费用的影响尚未明确。
研究地区医院市场集中度、医院收费与喉切除术成本之间的关联。
设计、设置和参与者：使用全国住院患者样本确定2003年1月1日至2011年12月31日期间因喉或下咽恶性肿瘤接受喉切除术的34193例患者。将医院喉切除术数量建模为分类变量。使用2003年、2006年和2009年医院市场结构文件中的可变半径赫芬达尔-赫希曼指数评估医院市场集中度。于2018年5月19日至8月15日进行统计分析。
采用多变量广义线性回归评估市场集中度与喉切除术总费用和成本之间的关联。
在这34193例患者中（女性占19.3%，男性占80.7%；平均年龄62.7岁[范围20.0 - 96.0岁]），69.2%的手术在高度集中（非竞争性）市场的医院进行，26.2%在非集中（高度竞争性）市场的医院进行。大多数高容量医院（68.0%）位于高度集中的市场，其次是非集中市场（32.0%）。市场份额和数量与总费用的显著差异无关。相对于中度集中和高度集中的市场，非集中市场的成本高出28%（95%置信区间，8% - 53%）。高容量医院的成本低22%（95%置信区间， - 36%至 - 5%）。
医院之间的竞争与喉切除术护理成本增加相关。高容量的医院护理与较低的护理成本相关。这些数据表明，在能够达到最低数量阈值的中心对喉切除术进行医院市场整合可能会提高医疗保健价值。
