Is Bigger Better? The Effect of Hospital Consolidation on Index Hospitalization Costs and Outcomes Among Privately Insured Recipients of Immediate Breast Reconstruction
Is Bigger Better? The Effect of Hospital Consolidation on Index Hospitalization Costs and Outcomes Among Privately Insured Recipients of Immediate Breast Reconstruction
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DOI：
10.1097/sla.0000000000003481
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发表时间：
2019-10-01
影响因子：
9
通讯作者：
Offodile, Anaeze C., II
中科院分区：
文献类型：
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作者：
Cerullo, Marcelo;Sheckter, Clifford C.;Offodile, Anaeze C., II
目的：和住院费用，程序加价，住院并发症，住院时间的私人保险患者接受乳房切除术后立即重建。方法：对2009 ~ 2011年全国范围内自费女性乳房再造患者进行回顾性横断面分析。采用赫芬达尔-赫希曼指数描述医院市场竞争；通过调整患者、医院和市场特征的分层模型来探索与结果的关联。结果：确定了42,411名患者的加权总数；5920例（14.0%）行游离皮瓣重建。在非竞争市场中，6.8% （n=857）的患者接受了自由皮瓣重建，而在高度竞争市场中，这一比例为13.6% (n=2773)，在中度竞争市场中，这一比例为24.6% （n=2290）。市场上每增加5家医院，自由皮瓣重建的调整成本增加6.6% (95% CI: 2.8%-10.5%)，非自由皮瓣重建的调整成本增加5.1% （95% CI: 2.0%-8.4%）。同样，较高的手术加价与非游离皮瓣重建（增加5.5%,95% CI: 1.1%-10.1%）和自由皮瓣重建（增加8.2%,95% CI: 1.8%-15.0%）的医院市场竞争加剧有关。值得注意的是，在自由皮瓣或非自由皮瓣重建患者中，住院并发症的发生率或住院时间的延长与医院市场竞争无关。结论：市场竞争的减少与住院费用的降低和临床结果的不确定性有关。这表明，在医院合并后，由于市场力量增强而获得的规模经济、资本获取和医疗服务效率，会以较低的成本转嫁给支付者和消费者。
Objectives: and inpatient costs, procedural markup, inpatient complications, and length of stay among privately insured patients undergoing immediate reconstruction after mastectomy.Methods: A retrospective cross-sectional analysis of privately insured female patients undergoing immediate breast reconstruction in the 2009 to 2011 Nationwide Inpatient Sample was performed. The Herfindahl-Hirschman index was used to describe hospital market competition; associations with outcomes were explored via hierarchical models adjusting for patient, hospital, and market characteristicsResults: A weighted total of 42,411 patients were identified; 5920 (14.0%) underwent free flap reconstruction. In uncompetitive markets, 6.8% (n=857) underwent free flap reconstruction, compared with 13.6% (n=2773) in highly competitive markets and 24.6% (n=2290) in moderately competitive markets. For every 5 additional hospitals in a market, adjusted costs were 6.6% higher (95% CI: 2.8%-10.5%), for free flap reconstruction, and 5.1% higher (95% CI: 2.0%-8.4%) for nonfree flap reconstruction. Similarly, higher procedural markup was associated with increased hospital market competition both for nonfree flap reconstruction (5.5% increase, 95% CI: 1.1%-10.1%) and for free flap reconstruction (8.2% increase, 95% CI: 1.8%-15.0%). Notably, there was no association between incidence of inpatient complications or extended length of stay and hospital market competition among either free flap or nonfree flap reconstruction patients.Conclusions: Decreasing market competition was associated with lower inpatient costs and equivocal clinical outcomes. This suggests that some of the economies of scale, access to capital and care delivery efficiencies gained from increased market power following hospital mergers are passed onto payers and consumers as lower costs.