Browsing by Author "Aloia, Thomas A."
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Item Can postoperative process of care utilization or complication rates explain the volume-cost relationship for cancer surgery?(Elsevier, 2017) Ho, Vivian; Short, Marah N.; Aloia, Thomas A.Background: Past studies identify an association between provider volume and outcomes, but less is known about the volume-cost relationship for cancer surgery. We analyze the volume-cost relationship for 6 cancer operations and explore whether it is influenced by the occurrence of complications and/or utilization of processes of care. Methods: Medicare hospital and inpatient claims for the years 2005 through 2009 were analyzed for 6 cancer resections: colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection. Regressions were first estimated to quantify the association of provider volume with costs, excluding measures of complications and processes of care as explanatory variables. Next, these variables were added to the regressions to test whether they weakened any previously observed volume-cost relationship. Results: Higher hospital volume is associated with lower patient costs for esophagectomy but not for other operations. Higher surgeon volume reduces costs for most procedures, but this result weakens when processes of care are added to the regressions. Processes of care that are frequently implemented in response to adverse events are associated with 14% to 34% higher costs. Utilization of these processes is more prevalent among low-volume versus high-volume surgeons. Conclusion: Processes of care implemented when complications occur explain much of the surgeon volume–cost relationship. Given that surgeon volume is readily observed, better outcomes and lower costs may be achieved by referring patients to high-volume surgeons. Increasing patient access to surgeons with lower rates of complications may be the most effective strategy for avoiding costly processes of care, controlling expenditure growth.Item Certificate of Need Regulations and the Availability and Use of Cancer ResectionsShort, Marah Noel; Aloia, Thomas A.; Ho, Vivian; James A. Baker III Institute for Public PolicyBackground: Several states use certificate of need regulations (CON) to control the growth of acute-care services, but the possible association between these restrictions and the provision of cancer surgery has not been assessed. This study examines the association between acute-care CON, the availability of cancer surgery hospitals, and provision of six cancer operations. Methods: Medicare data were collected for beneficiaries treated with one of six cancer resections and an associated cancer diagnosis from 1989 to 2002. Hospital, procedure, and incidence rates for each cancer diagnosis were stratified by state and year. The number of hospitals performing each operation per cancer incident, the number of procedures performed per cancer incident, and hospital volume were compared between states with and without CON, and those that discontinued CON during the sample period were noted. Results: The number of hospitals per cancer incident was lower in CON states versus non-CON states for colectomy (P = .022), rectal resection (P = .026), and pulmonary lobectomy (P = .032). Hospital volume was significantly higher in CON states versus non-CON states for colectomy (P = .006) and pulmonary lobectomy (P = .043). There were no differences between states with and without CON in the number of procedures per cancer incident. Conclusion: Although use of cancer procedures was similar in CON and non-CON states, those with acute-care CON had fewer facilities performing oncologic resections per cancer patient. Correspondingly, average hospital procedure volume tended to be higher in CON states. These differences may have important implications for patient outcomes and costs.Item Could substantial health care savings be achieved by reducing complications from cancer surgery?Short, Marah Noel; Ho, Vivian; Aloia, Thomas A.; James A. Baker III Institute for Public PolicyItem Functional framework for change leaders: results of a qualitative study(BMJ, 2020) Woods, Amanda L.; Luciano, Margaret M.; Aloia, Thomas A.; Gottumukkala, Vijaya; Salas, EduardoBackground: Healthcare organisations are increasingly placing the onus on care providers to lead change initiatives to improve patient care. This requires care providers to perform tasks in addition to their core job roles and often outside of their formal training. The existing literature provides few insights regarding the functions required of change leaders in healthcare organisations. Objective: To identify the core functions required of effective change leaders in healthcare organisations. Design: Qualitative interview study. Participants: Data were collected from semistructured interviews with 31 individuals employed by a large cancer centre in a variety of different positions (eg, surgeons, anaesthesiologists, nurse anaesthetists, nurses, project consultants and research coordinators) who had been involved in successful quality improvement initiatives. Results: Using inductive content analysis, we identified six core pillars of leading change, which are supported by a foundation of effective communication. Within these six pillars, there were 12 functions, including explain why, demonstrate value, create consensus, align efforts, generate enthusiasm, motivate commitment, institute structure, explain how, facilitate taskwork, promote accountability, enable adjustment and sustain effort. Our model offers unique insights on leading sustainable change in healthcare organisations. Conclusion: Using inductive content analysis of semistructured interviews, we have identified 12 important change leader functions and have organised them into a conceptual framework for leading change in healthcare. Individuals involved in leading change initiatives or developing training programmes to help others become effective change leaders can use this framework to ensure they are comprehensively addressing the necessary tasks for sustainable change.Item Impact of processes of care aimed at complication reduction on the cost of complex cancer surgeryShort, Marah Noel; Ho, Vivian; Aloia, Thomas A.; National Cancer Institute, National Institutes of Health; Cancer Prevention and Research Institute of Texas; James A. Baker III Institute for Public PolicyBackground and Objectives: Health care providers add multiple processes to the care of complex cancer patients, believing they prevent and/or ameliorate complications. However, the relationship between these processes, complication remediation, and expenditures is unknown. Methods: Data for patients with cancer diagnoses undergoing colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection were obtained from hospital and inpatient physician Medicare claims for the years 2005 to 2009. Risk-adjusted regression analyses measured the association between hospitalization costs and processes presumed to prevent and/or remedy complications common to high-risk procedures. Results: After controlling for comorbidities, analysis identified associations between increased costs and the use of multiple processes, including arterial lines (4-12% higher; p<0.001), central venous catheters (11-22% higher; p<0.001) and pulmonary artery catheters (23-33% higher; p<0.001). Epidural analgesia was not associated with higher costs. Consultations were associated with 24-44% (p<0.001) higher costs, and total parenteral nutrition was associated with 13-31% higher costs for multiple procedures (p<0.001) Conclusions: Many frequently utilized processes and services presumed to avoid and/or ameliorate complications are associated with increased surgical oncology costs. This suggests that the patient-centered value of each process should be measured on a procedure-specific basis. Likewise, further attention should be focused on defining the efficacy of each of these costly, but frequently unproven, additions to perioperative care.Item The Influence of Complications on the Costs of Complex Cancer Surgery(Wiley) Short, Marah Noel; Aloia, Thomas A.; Ho, Vivian; James A. Baker III Institute for Public PolicyIt is widely known that outcomes after cancer surgery vary widely, depending on interactions between patient, tumor, neoadjuvant therapy, and provider factors. Within this complex milieu, the influence of complications on the cost of surgical oncology care remains unknown. The authors examined rates of Patient Safety Indicator (PSI) occurrence for 6 cancer operations and their association with costs of care. The Agency for Healthcare Research and Quality (AHRQ) PSI definitions were used to identify patient safety-related complications in Medicare claims data. Hospital and inpatient physician claims for the years 2005 through 2009 were analyzed for 6 cancer resections: colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection. Risk-adjusted regression analyses were used to measure the association between each PSI and hospitalization costs. Overall PSI rates ranged from a low of 0.01% for postoperative hip fracture to a high of 2.58% for respiratory failure. Death among inpatients with serious treatable complications, postoperative respiratory failure, postoperative thromboembolism, and accidental puncture/laceration were >1% for all 6 cancer operations. Several PSIs?including decubitus ulcer, death among surgical inpatients with serious treatable complications, and postoperative thromboembolism?raised hospitalization costs by ? 20% for most cancer surgery types. Postoperative respiratory failure resulted in a cost increase >50% for all cancer resections. The consistently higher costs associated with cancer surgery PSIs indicate that substantial health care savings could be achieved by targeting these indicators for quality improvement.