1. 1 The Impact of Volume of Outpatient Surgical Procedures on Quality Outcomes: 1997-2004 AcademyHealth: June 4, 2007

2. FSU C OLLEGE OF M EDICINE 2 Research Team  Askar Chukmaitov, M.D., Ph.D.  Nir Menachemi, Ph.D., M.P.H.  Steven Brown, M.S.  Charles Saunders, Ph.D.  Robert Brooks, M.D., M.B.A.  Funding support from the Florida Agency for Health Care Administration (AHCA)

3. FSU C OLLEGE OF M EDICINE 3  Inverse relationship between hospital/surgical volume and adverse patient outcomes in inpatient settings  Better outcomes for high-volume hospitals and high-volume surgeons  Lack of research on volume-quality relationship in outpatient surgical settings  Important issue, because:  60-70% of all surgeries are performed now in outpatient settings  Medicare payment for outpatient procedures has doubled over the last decade Rationale for the Study

4. FSU C OLLEGE OF M EDICINE 4 Methods  Design – Longitudinal analysis of 1997-2004 data  Data – Ambulatory discharge, hospital discharge, vital statistics  Sampling – Colonoscopies (n=2,820,769), Cataracts (n=2,058,090), and upper gastrointestinal endoscopies (n=1,348,121) in ASCs and HOPDs  Analytical Approach  Physician volume and patient outcomes (Model 1)  Outpatient facility volume and patient outcomes (Model 2)  Combined surgeon and facility volume and patient outcomes (Model 3)  Controls: Patient severity, age, gender, payer type, location of care, time fixed effects, and clustering of outcomes

5. FSU C OLLEGE OF M EDICINE 5 Key Variables  Adverse patient outcomes – 7- and 30-day unexpected hospitalization – 7- and 30-day mortality  Physician and Facility Volume – Ranked providers according to volume tertiles: low ( 67%, the reference group)  Patient Severity/Risk Adjustment – Relative Risk Scores calculated using DCG/HCC methodology

6. FSU C OLLEGE OF M EDICINE 6  Physicians: 2,857  Facilities: 874 (ASC=61.64%)  Unexpected Hospitalizations less than 5%  Mortality Rates less than 1%  Patient demographics – Age: 65.62 (sd=14.26) – Female: 57.3% – White: 76.79% – Severity risk score: 0.89 (sd=0.82) – Private-pay: 25.92% – Medicare: 54.56% – Medicaid: 1.95% – HMO: 13.42% Results – Descriptive

7. FSU C OLLEGE OF M EDICINE 7 7-day Unexpected Hospitalizations after Colonoscopies  Controlled for patient severity, age, gender, payer type, location of care, time fixed effects, and clustering of outcomes *p<.05 **p<.01 ***p<.001

8. FSU C OLLEGE OF M EDICINE 8 7-day Unexpected Hospitalizations after Colonoscopies  Controlled for patient severity, age, gender, payer type, location of care, time fixed effects, and clustering of outcomes *p<.05 **p<.01 ***p<.001

9. FSU C OLLEGE OF M EDICINE 9 7-day Unexpected Hospitalizations after Colonoscopies  Controlled for patient severity, age, gender, payer type, location of care, time fixed effects, and clustering of outcomes *p<.05 **p<.01 ***p<.001

10. Patterns in 7- and 30-day Mortality Outcomes by Volume Category (1997-2004)

11. FSU C OLLEGE OF M EDICINE 11  Consistent, dose-responsive, inverse relationship between volume and outcomes for unexpected hospitalization  Physician volume demonstrated stronger effects than facility volume  In terms of mortality, a similar pattern was noted. The lack of statistically significant findings may be due to the rarity of deaths Conclusions

12. FSU C OLLEGE OF M EDICINE 12 Significance to Policy  Further research is needed to validate these findings with data from other states, using different outcome measures, risk adjustment techniques, and analytical approaches  Volume of outpatient surgical procedures may indicate improved provider skills and processes of care delivery  Possible development of outpatient standards/guidelines (e.g., Leap Frog)  Volume-based outpatient referrals should be considered by patients, providers, payers, and policy-makers