Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia.
Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia.
JAMA Netw Open. 2023 Feb 1;6(2):e2255999. doi: 10.1001/jamanetworkopen.2022.55999.
Variation in outcomes across hospitals adversely affects surgical patients. The use of high-quality hospitals varies by population, which may contribute to surgical disparities.
To simulate the implications of data-driven hospital selection for social welfare among patients who underwent colorectal cancer surgery.
DESIGN, SETTING, AND PARTICIPANTS: This economic evaluation used the hospital inpatient file from the Florida Agency for Health Care Administration. Surgical outcomes of patients who were treated between January 1, 2016, and December 31, 2018 (training cohort), were used to estimate hospital performance. Costs and benefits of care at alternative hospitals were assessed in patients who were treated between January 1, 2019, and December 31, 2019 (testing cohort). The cohorts comprised patients 18 years or older who underwent elective colorectal resection for benign or malignant neoplasms. Data were analyzed from March to October 2022.
Using hierarchical logistic regression, we estimated the implications of hospital selection for in-hospital mortality risk in patients in the training cohort. These estimates were applied to patients in the testing cohort using bayesian simulations to compare outcomes at each patient's highest-performing and chosen local hospitals. Analyses were stratified by race and ethnicity to evaluate the potential implications for equity.
The primary outcome was the mean patient-level change in social welfare, a composite measure balancing the value of reduced mortality with associated costs of care at higher-performing hospitals.
A total of 21 098 patients (mean [SD] age, 67.3 [12.0] years; 10 782 males [51.1%]; 2232 Black [10.6%] and 18 866 White [89.4%] individuals) who were treated at 178 hospitals were included. A higher-quality local hospital was identified for 3057 of 5000 patients (61.1%) in the testing cohort. Selecting the highest-performing hospital was associated with a 26.5% (95% CI, 24.5%-29.0%) relative reduction and 0.24% (95% CI, 0.23%-0.25%) absolute reduction in mortality risk. A mean amount of $1953 (95% CI, $1744-$2162) was gained in social welfare per patient treated. Simulated reassignment to a higher-quality local hospital was associated with a 23.5% (95% CI, 19.3%-32.9%) relative reduction and 0.26% (95% CI, 0.21%-0.30%) absolute reduction in mortality risk for Black patients, with $2427 (95% CI, $1697-$3158) gained in social welfare.
In this economic evaluation, using procedure-specific hospital performance as the primary factor in the selection of a local hospital for colorectal cancer surgery was associated with improved outcomes for both patients and society. Surgical outcomes data can be used to transform care and guide policy in colorectal cancer.
医院间结局的差异对手术患者不利。优质医院的使用因人群而异，这可能导致手术差异。
模拟基于数据的医院选择对接受结直肠癌手术患者的社会福利的影响。
设计、地点和参与者：本经济评估使用了佛罗里达州医疗保健管理局的住院患者档案。对 2016 年 1 月 1 日至 2018 年 12 月 31 日（培训队列）接受治疗的患者的手术结果进行了分析，以估计医院的绩效。在 2019 年 1 月 1 日至 2019 年 12 月 31 日（测试队列）接受治疗的患者中评估了替代医院的护理成本和效益。队列包括年龄在 18 岁或以上的接受择期结直肠切除术治疗良性或恶性肿瘤的患者。数据于 2022 年 3 月至 10 月进行分析。
使用分层逻辑回归，我们估计了医院选择对培训队列中患者住院死亡率风险的影响。使用贝叶斯模拟将这些估计应用于测试队列中的患者，以比较每位患者表现最佳和选择的当地医院的结果。按种族和民族进行分层，以评估公平性的潜在影响。
主要结果是患者社会福利水平的平均变化，这是一个平衡死亡率降低价值与高绩效医院相关护理成本的综合指标。
共纳入 21098 名患者（平均[标准差]年龄为 67.3[12.0]岁；男性 10782 名[51.1%]；黑人 2232 名[10.6%]和 18866 名白人[89.4%]），他们在 178 家医院接受治疗。在测试队列的 5000 名患者中，有 3057 名（61.1%）确定了当地更高质量的医院。选择表现最佳的医院与死亡率风险相对降低 26.5%（95%CI，24.5%-29.0%）和绝对降低 0.24%（95%CI，0.23%-0.25%）相关。每位接受治疗的患者的社会福利平均增加了 1953 美元（95%CI，1744 美元-2162 美元）。模拟重新分配到更高质量的当地医院与黑人患者的死亡率风险相对降低 23.5%（95%CI，19.3%-32.9%）和绝对降低 0.26%（95%CI，0.21%-0.30%）相关，社会福利增加了 2427 美元（95%CI，1697 美元-3158 美元）。
在这项经济评估中，使用特定手术的医院绩效作为选择结直肠癌手术当地医院的主要因素，与患者和社会的结局改善相关。手术结果数据可用于改善结直肠癌的护理并指导政策。
