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Bundled Payments for Appendectomy: A Model of Financial Implications to Institutions
Vol. 225, No. 4S1, October 2017
Scientific Forum Abstracts
INTRODUCTION: Despite the value of ACS-NSQIP, 30-day outcomes abstraction remains laborious. We applied supervised machine learning algorithms, previously developed for surgical site infection (SSI) detection from electronic health record structured clinical data and unstructured documents through natural language processing (NLP) at a single institution for semi-automated overall and organ-space SSI abstraction. METHODS: A Lasso-penalized logistic regression model was trained on 2011 to 2013 data. Training dataset performance with 10-fold cross-validation and thresholds stratifying patients into “negative”, “positive”, and “possible” SSI tiers were established. Algorithms were separately evaluated on 2014 data overall and by tier. RESULTS: With 2011 to 2013 data as training (n ¼ 6,188) and 2014 as evaluation (n ¼ 2,750), algorithms had good performance (Table). “Negative” and “positive” overall and organ-space SSI tiers had <1% false-negatives and 6 and 4 false-positives, respectively. Given high predictive “positive” and “negative” tier performance, manual extraction is primarily required for the “possible” tier, with 153 and 40 “possible” overall and organ-space SSIs corresponding to decreased abstraction by 94% and 98%. Blinded review of the “possible” tier, considering only the features selected by the algorithm, resulted in high agreement with the surgical clinical reviewer’s (SCR) assessment based on full chart abstraction, pointing toward additional efficiency. Table. Overall SSI 2011e2013 training dataset
Variable SSI rate (n, % total) 389 Sensitivity Specificity “Negative” tier (n, % total) False negative cases (n, % “Negative” tier) “Positive” tier (n, % total) False positive cases (n, % “Positive” tier) “Possible” tier (n, % total) Blinded review vs SCR review agreement (% agreement, kappa statistic)
(6.3) 94.8 75.3 e
2014 evaluation dataset 97 (3.5) 70.4 99.8 2,553 (92.8)
Organ space SSI 2011e2013 training dataset 129 (2.1) 85.7 94.7 e
2014 evaluation dataset 42 (1.5) 37.5 99.8
19 (0.7)
e
20 (0.7)
e
44 (1.6)
e
14 (0.5)
6 (13.6)
e
e
153 (5.6)
e
e
83.6% (k ¼ 0.61)
e
postoperative outcomes and reduce cost barriers for wider ACS-NSQIP adoption. Acute Rejection after ABO Incompatible Kidney Transplantation: Results of a National Study Margaux N Mustian, MD, Robert M Cannon, MD, Rhiannon D Reed, MPH, Brittany Shelton, MPH, Paul MacLennan, MPH, PhD, Jayme E Locke, MD, FACS University of Alabama at Birmingham, Birmingham, AL INTRODUCTION: Widespread adoption of ABO incompatible (ABOi) living donor kidney transplantation has been proposed as a means to partially ameliorate the national shortage of deceased donor kidneys, particularly for highly sensitized patients who may otherwise face prolonged waiting times. Acceptance of this practice has been encouraged by reports from experienced centers, demonstrating acute rejection (AR) rates similar to those obtained with ABO compatible (ABOc) kidney transplantation (KT). The AR rate after ABOi KT on a national level, however, has yet to be determined. METHODS: A retrospective cohort study was carried out, using data from 2000 to 2013, for all adult live kidney donor transplant recipients from the Scientific Registry of Transplant Recipients. There were 787 ABOi kidney transplant recipients who were compared with their 79,095 ABOc counterparts, and AR rate within 1 year of transplantation was the primary outcome of interest. RESULTS: Patients undergoing ABOi KT were found to have an AR rate of 17.4%, compared to 9.4% for ABOc recipients (p < 0.0001). Additionally, after adjusting for relevant risk factors, ABOi KT recipients had a 1.79-fold greater risk (95% CI, 1.58e2.08) for AR within 1 year, compared to ABOc recipients. This risk of AR for ABOi was found to be greater than the risk posed by either high level of panel reactive antibody (aRR 1.42, 95% CI, 1.3 to 1.55) or human leukocyte antigen mismatch (aRR 1.56, 95% CI, 1.48e1.64).
2,694 (98.0)
e
e
S111
4 (28.6) 40 (1.5)
90.0% (k ¼ 0.71)
CONCLUSIONS: Semi-automated SSI detection greatly accelerates manual abstraction. This could be translated to other
CONCLUSIONS: Based on these findings, it appears that the low rates of AR for ABOi KT presented in single center series may not be sustainable on a national level. So more expansive implementation of ABOi KT should be approached with caution. Bundled Payments for Appendectomy: A Model of Financial Implications to Institutions Udai S Sibia, MD, Justin Turcotte, MBA, Brooke M Buckley, MD, FACS Anne Arundel Medical Center, Annapolis, MD INTRODUCTION: Bundled payments are becoming increasingly common in surgery, yet little is known regarding their potential impact on reimbursement for appendectomies. METHODS: We reviewed hospital costs for all patients who underwent an inpatient appendectomy from July 2014 through June
S112
Scientific Forum Abstracts
J Am Coll Surg
2016 using Medicare Severity Diagnosis Related Group (MS-DRG) coding. Net margins were calculated as the difference between hospital costs and reimbursements.
Table.
RESULTS: A total of 167 patients were reviewed. Mean age was 41.2 years, with 53% male. Mean length of stay was 3.7 days (range 1e17 days). The 30-day and 90-day readmission rates were 4.8% and 6.0%, respectively. Average hospital costs were substantially higher for procedures with complicated principal diagnosis (MSDRG 338e340, $8,521) compared to those with uncomplicated principal diagnosis (MS-DRG 341e343, $5,708), highlighting the variability in clinical presentation. The average cost among all patients was $7,885 (range $3,335e$25,541), resulting in a net margin (loss) of $206 per patient, with 40% of patients contributing to an overall negative margin. Ninety-day readmissions increased the average cost per patient to $8283. Under a bundled payment model using the average reimbursement ($7,679) for the index admission, the net margin per patient would be (loss) $604, with 42% of patients contributing to a net negative margin.
Variable Virtual clinic review, n ¼ 108 Standard clinic review n ¼ 102
CONCLUSIONS: Longer hospital stays and higher complication rates significantly increase the overall cost of appendectomy. Due to the heterogeneous nature of patients requiring appendectomy, current reimbursement systems may undercompensate hospitals delivering care to these patients, and future bundled payment models should reflect the true cost of care.
Comparative Analysis of Physician Reimbursement for Open and Laparoscopic Colorectal Surgery: Is Reimbursement Aligned with Effort? Deborah S Keller, MD, Alyssa Mercadel, Jessie Ho, Warren E Lichliter, MD Baylor University Medical Center, Texas A&M Health Sciences Center, Dallas, TX
Can a Virtual Clinic Review Replace a Surgical Clinic Visit after Discharge? A Randomized Controlled Trial Paul Healy, MCh MB ChB, Liam F McCrone, MB BCh BAO, Emer Flannery, Roisin Tully, Karen McNamara, Aoife Flynn, Gary Bass, Thomas N Walsh, MCh MD, FRCSI Connolly Hospital Dublin, Royal College of Surgeons In Ireland, Dublin, Ireland INTRODUCTION: After discharge, it is common practice to review patients in the surgical outpatient department. The value of this practice has been questioned because unnecessary appointments can delay access to assessment of serious conditions and place a social and financial burden on patients and relatives. The aim of this study was to determine whether a virtual outpatient clinic via telephone review was an acceptable alternative to clinic attendance for a broad range of general surgical patients discharged from the hospital. METHODS: Ethical approval was obtained and the trial registered at clinicaltrials.gov. All discharges over a 3-month period were assessed for inclusion criteria. Patients requiring further investigations, treatment, and cancer surveillance were excluded. Eligible patients were consented and randomized to a scheduled telephone call assessment or to a clinic appointment. RESULTS: Of 366 patients discharged, 210 were eligible and recruited for the study. One hundred two patients were randomized to clinic and 108 patients were randomized to phone-call follow-up. Those attending follow-up arrangements, including their outcomes, are outlined in the Table.
Did not attend/ Referred Booked answer/ to other Further for Attended cancel Discharged service review procedure
69% n ¼ 70
31% n ¼ 32
71% n ¼ 50
90.7% n ¼ 98
9.2% n ¼ 10
89.8% n ¼ 88
5.7% n¼4
0
4.2% n¼3
19% n ¼ 13
5.1% n¼5
5.1% n¼5
CONCLUSIONS: Routine follow-up via telephone should be the norm rather than the exception for a broad range of general surgical patients, and a reduction in unnecessary appointments can lead to greater efficiencies and access to outpatient services for newly referred patients. A follow-up assessment of patient satisfaction about their experience with such a service is ongoing.
INTRODUCTION: Laparoscopic colorectal surgery has proven clinical and overall cost benefit over open surgery, but under utilization in appropriate cases remains an issue. New targets to increase laparoscopy are needed, with pressures to improve quality. Our goal was to compare reimbursement rates across approach and payor for common colorectal procedures. METHODS: Healthcare Common Procedure Coding System (HCPCS) Criteria were mapped for 10 common open and laparoscopic colorectal procedures. The average 2015 Centers for Medicare and Medicaid Services (CMS) and commercial insurer reimbursement amounts were compared across open and laparoscopic platforms. The main outcomes measure was the difference in reimbursement between laparoscopic and open approaches by payor. RESULTS: For CMS, laparoscopic approaches were reimbursed less than open surgery for 6 procedures (range $9e$384). For the 4 procedures for which laparoscopy was reimbursed more, the amount was not substantial ($6e$204). With commercial payors, laparoscopic approaches were reimbursed less than open for 3 procedures (range $481e$773). For the procedures for which laparoscopy had higher physician payments, the amount was not substantial (range $185e$1,084). CMS payments were consistently lower than commercial, with corresponding lower reward for providing a laparoscopic approach. CONCLUSIONS: Reimbursement for laparoscopic colorectal surgery is comparatively lower than for open surgery from federal and commercial payors. A paradigm shift is needed to align
Scientific Forum Abstracts
INTRODUCTION: Despite the value of ACS-NSQIP, 30-day outcomes abstraction remains laborious. We applied supervised machine learning algorithms, previously developed for surgical site infection (SSI) detection from electronic health record structured clinical data and unstructured documents through natural language processing (NLP) at a single institution for semi-automated overall and organ-space SSI abstraction. METHODS: A Lasso-penalized logistic regression model was trained on 2011 to 2013 data. Training dataset performance with 10-fold cross-validation and thresholds stratifying patients into “negative”, “positive”, and “possible” SSI tiers were established. Algorithms were separately evaluated on 2014 data overall and by tier. RESULTS: With 2011 to 2013 data as training (n ¼ 6,188) and 2014 as evaluation (n ¼ 2,750), algorithms had good performance (Table). “Negative” and “positive” overall and organ-space SSI tiers had <1% false-negatives and 6 and 4 false-positives, respectively. Given high predictive “positive” and “negative” tier performance, manual extraction is primarily required for the “possible” tier, with 153 and 40 “possible” overall and organ-space SSIs corresponding to decreased abstraction by 94% and 98%. Blinded review of the “possible” tier, considering only the features selected by the algorithm, resulted in high agreement with the surgical clinical reviewer’s (SCR) assessment based on full chart abstraction, pointing toward additional efficiency. Table. Overall SSI 2011e2013 training dataset
Variable SSI rate (n, % total) 389 Sensitivity Specificity “Negative” tier (n, % total) False negative cases (n, % “Negative” tier) “Positive” tier (n, % total) False positive cases (n, % “Positive” tier) “Possible” tier (n, % total) Blinded review vs SCR review agreement (% agreement, kappa statistic)
(6.3) 94.8 75.3 e
2014 evaluation dataset 97 (3.5) 70.4 99.8 2,553 (92.8)
Organ space SSI 2011e2013 training dataset 129 (2.1) 85.7 94.7 e
2014 evaluation dataset 42 (1.5) 37.5 99.8
19 (0.7)
e
20 (0.7)
e
44 (1.6)
e
14 (0.5)
6 (13.6)
e
e
153 (5.6)
e
e
83.6% (k ¼ 0.61)
e
postoperative outcomes and reduce cost barriers for wider ACS-NSQIP adoption. Acute Rejection after ABO Incompatible Kidney Transplantation: Results of a National Study Margaux N Mustian, MD, Robert M Cannon, MD, Rhiannon D Reed, MPH, Brittany Shelton, MPH, Paul MacLennan, MPH, PhD, Jayme E Locke, MD, FACS University of Alabama at Birmingham, Birmingham, AL INTRODUCTION: Widespread adoption of ABO incompatible (ABOi) living donor kidney transplantation has been proposed as a means to partially ameliorate the national shortage of deceased donor kidneys, particularly for highly sensitized patients who may otherwise face prolonged waiting times. Acceptance of this practice has been encouraged by reports from experienced centers, demonstrating acute rejection (AR) rates similar to those obtained with ABO compatible (ABOc) kidney transplantation (KT). The AR rate after ABOi KT on a national level, however, has yet to be determined. METHODS: A retrospective cohort study was carried out, using data from 2000 to 2013, for all adult live kidney donor transplant recipients from the Scientific Registry of Transplant Recipients. There were 787 ABOi kidney transplant recipients who were compared with their 79,095 ABOc counterparts, and AR rate within 1 year of transplantation was the primary outcome of interest. RESULTS: Patients undergoing ABOi KT were found to have an AR rate of 17.4%, compared to 9.4% for ABOc recipients (p < 0.0001). Additionally, after adjusting for relevant risk factors, ABOi KT recipients had a 1.79-fold greater risk (95% CI, 1.58e2.08) for AR within 1 year, compared to ABOc recipients. This risk of AR for ABOi was found to be greater than the risk posed by either high level of panel reactive antibody (aRR 1.42, 95% CI, 1.3 to 1.55) or human leukocyte antigen mismatch (aRR 1.56, 95% CI, 1.48e1.64).
2,694 (98.0)
e
e
S111
4 (28.6) 40 (1.5)
90.0% (k ¼ 0.71)
CONCLUSIONS: Semi-automated SSI detection greatly accelerates manual abstraction. This could be translated to other
CONCLUSIONS: Based on these findings, it appears that the low rates of AR for ABOi KT presented in single center series may not be sustainable on a national level. So more expansive implementation of ABOi KT should be approached with caution. Bundled Payments for Appendectomy: A Model of Financial Implications to Institutions Udai S Sibia, MD, Justin Turcotte, MBA, Brooke M Buckley, MD, FACS Anne Arundel Medical Center, Annapolis, MD INTRODUCTION: Bundled payments are becoming increasingly common in surgery, yet little is known regarding their potential impact on reimbursement for appendectomies. METHODS: We reviewed hospital costs for all patients who underwent an inpatient appendectomy from July 2014 through June
S112
Scientific Forum Abstracts
J Am Coll Surg
2016 using Medicare Severity Diagnosis Related Group (MS-DRG) coding. Net margins were calculated as the difference between hospital costs and reimbursements.
Table.
RESULTS: A total of 167 patients were reviewed. Mean age was 41.2 years, with 53% male. Mean length of stay was 3.7 days (range 1e17 days). The 30-day and 90-day readmission rates were 4.8% and 6.0%, respectively. Average hospital costs were substantially higher for procedures with complicated principal diagnosis (MSDRG 338e340, $8,521) compared to those with uncomplicated principal diagnosis (MS-DRG 341e343, $5,708), highlighting the variability in clinical presentation. The average cost among all patients was $7,885 (range $3,335e$25,541), resulting in a net margin (loss) of $206 per patient, with 40% of patients contributing to an overall negative margin. Ninety-day readmissions increased the average cost per patient to $8283. Under a bundled payment model using the average reimbursement ($7,679) for the index admission, the net margin per patient would be (loss) $604, with 42% of patients contributing to a net negative margin.
Variable Virtual clinic review, n ¼ 108 Standard clinic review n ¼ 102
CONCLUSIONS: Longer hospital stays and higher complication rates significantly increase the overall cost of appendectomy. Due to the heterogeneous nature of patients requiring appendectomy, current reimbursement systems may undercompensate hospitals delivering care to these patients, and future bundled payment models should reflect the true cost of care.
Comparative Analysis of Physician Reimbursement for Open and Laparoscopic Colorectal Surgery: Is Reimbursement Aligned with Effort? Deborah S Keller, MD, Alyssa Mercadel, Jessie Ho, Warren E Lichliter, MD Baylor University Medical Center, Texas A&M Health Sciences Center, Dallas, TX
Can a Virtual Clinic Review Replace a Surgical Clinic Visit after Discharge? A Randomized Controlled Trial Paul Healy, MCh MB ChB, Liam F McCrone, MB BCh BAO, Emer Flannery, Roisin Tully, Karen McNamara, Aoife Flynn, Gary Bass, Thomas N Walsh, MCh MD, FRCSI Connolly Hospital Dublin, Royal College of Surgeons In Ireland, Dublin, Ireland INTRODUCTION: After discharge, it is common practice to review patients in the surgical outpatient department. The value of this practice has been questioned because unnecessary appointments can delay access to assessment of serious conditions and place a social and financial burden on patients and relatives. The aim of this study was to determine whether a virtual outpatient clinic via telephone review was an acceptable alternative to clinic attendance for a broad range of general surgical patients discharged from the hospital. METHODS: Ethical approval was obtained and the trial registered at clinicaltrials.gov. All discharges over a 3-month period were assessed for inclusion criteria. Patients requiring further investigations, treatment, and cancer surveillance were excluded. Eligible patients were consented and randomized to a scheduled telephone call assessment or to a clinic appointment. RESULTS: Of 366 patients discharged, 210 were eligible and recruited for the study. One hundred two patients were randomized to clinic and 108 patients were randomized to phone-call follow-up. Those attending follow-up arrangements, including their outcomes, are outlined in the Table.
Did not attend/ Referred Booked answer/ to other Further for Attended cancel Discharged service review procedure
69% n ¼ 70
31% n ¼ 32
71% n ¼ 50
90.7% n ¼ 98
9.2% n ¼ 10
89.8% n ¼ 88
5.7% n¼4
0
4.2% n¼3
19% n ¼ 13
5.1% n¼5
5.1% n¼5
CONCLUSIONS: Routine follow-up via telephone should be the norm rather than the exception for a broad range of general surgical patients, and a reduction in unnecessary appointments can lead to greater efficiencies and access to outpatient services for newly referred patients. A follow-up assessment of patient satisfaction about their experience with such a service is ongoing.
INTRODUCTION: Laparoscopic colorectal surgery has proven clinical and overall cost benefit over open surgery, but under utilization in appropriate cases remains an issue. New targets to increase laparoscopy are needed, with pressures to improve quality. Our goal was to compare reimbursement rates across approach and payor for common colorectal procedures. METHODS: Healthcare Common Procedure Coding System (HCPCS) Criteria were mapped for 10 common open and laparoscopic colorectal procedures. The average 2015 Centers for Medicare and Medicaid Services (CMS) and commercial insurer reimbursement amounts were compared across open and laparoscopic platforms. The main outcomes measure was the difference in reimbursement between laparoscopic and open approaches by payor. RESULTS: For CMS, laparoscopic approaches were reimbursed less than open surgery for 6 procedures (range $9e$384). For the 4 procedures for which laparoscopy was reimbursed more, the amount was not substantial ($6e$204). With commercial payors, laparoscopic approaches were reimbursed less than open for 3 procedures (range $481e$773). For the procedures for which laparoscopy had higher physician payments, the amount was not substantial (range $185e$1,084). CMS payments were consistently lower than commercial, with corresponding lower reward for providing a laparoscopic approach. CONCLUSIONS: Reimbursement for laparoscopic colorectal surgery is comparatively lower than for open surgery from federal and commercial payors. A paradigm shift is needed to align