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A National Comparison of Laparoscopic versus Open Colectomy Using NSQIP

Anthony J Senagore M.D, M.S., M.B.A.VP/CAO, Spectrum Health

Professor of Surgery, Michigan State UniversityGrand Rapids, MI

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Anxiety About Health Care ($$)

Employers: premiums growing at 2-3x wages; affecting profits and competitiveness

Consumers: higher out-of-pocket costs keeping real wage growth down; fear of losing insurance; lack of information for confident decisions

Insurers: pressure from employer customers to control rising costs

Doctors and Hospitals: Medicare reimbursement rates; administrative challenges of data collection, performance measurement and reporting

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Defining Value

Risk Adjusted Comparison Outcomes defined Resource Consumption Transparency of Reporting

Hospital/Physician Comparison Informed Consent

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Complex Interactions:Quality

Hospital Systems Diagnostic Equipment/access Staffing OR equipment

Operative Technique Postoperative Care

Preoperative Evaluation/Optimization Enhanced Recovery Protocols Post-Discharge care plans

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Sources of Surgical Cost

Hospital Issues Beds Personnel OR’s Diagnostic

equipment

Doctor Issues # admissions/ LOS Complications Case volume/mix Duration of Surgery Equipment used Tests ordered Readmissions

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Potential Administrative Data Sources

CMS National Inpatient Census

Premier ACS-NSQIP Surgical Risk Formulae

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What is NSQIP

30 day observational database Trained and audited nurse evaluators 121 sites in the US (academic and

community hospitals)

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NSQIP Model vs Others

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NSQIP Lap v Open

Kennedy et al. Ann Surg 2009;249: 596–601

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NSQIP Lap v Open

Kennedy et al. Ann Surg 2009;249: 596–601

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NSQIP Lap v Open

Kennedy et al. Ann Surg 2009;249: 596–601

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NSQIP Lap v Open

Kennedy et al. Ann Surg 2009;249: 596–601

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NSQIP Lap v Open

Kennedy et al. Ann Surg 2009;249: 596–601

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NSQIP Lap v Open: Outcomes

Senagore et al. DCR 2009 52: 183-6

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NSQIP Lap v Open: ? cohorts

Senagore et al. DCR 2009 52: 183-6

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Departmental length of stay1991-19991991-1999 19991999 3-6/2000 3-6/2000

nn LOSLOS nn LOSLOS nn LOSLOS

DRG 148DRG 148study team study team 17841784 9.59.5 185185 8.68.6 6262 5.7 *5.7 *other CR teamsother CR teams 64596459 9.89.8 824824 8.88.8 162162 10.110.1LaparoscopicLaparoscopic 2424 3.2 *3.2 *

DRG 149DRG 149study teamstudy team 742742 6.46.4 6969 5.25.2 4444 3.5 †3.5 †other CR teamsother CR teams 22562256 6.46.4 327327 5.15.1 111111 4.54.5LaparoscopicLaparoscopic 1818 2.5 *2.5 *

DRG 148 & 149DRG 148 & 149study teamstudy team 25262526 8.68.6 254254 7.77.7 106106 4.7 4.7 §§other CR teamsother CR teams 87158715 8.98.9 11511151 7.77.7 273273 7.77.7LaparoscopicLaparoscopic 4242 2.92.9 **

* * pp<0.0001; † <0.0001; † pp=0.002; =0.002; §§ pp<0.001, Student’s t test<0.001, Student’s t test

Delaney, Fazio, Senagore et al, Br J Surg, 2001

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The Future ??

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Conclusion

Belief in a system approach Align stakeholder incentives Understanding Cost/Quality Impacts Report OUR Value Proposition