Pituitary (2016) 19:515–521 DOI 10.1007/s11102-016-0738-x
Geographic variation in cost of care for pituitary tumor surgery Charles C. Lee1,5 • Kristopher T. Kimmell1 • Amy Lalonde2 • Peter Salzman2 Matthew C. Miller3 • Laura M. Calvi4,5 • Ekaterina Manuylova4,5 • Ismat Shafiq4,5, • G. Edward Vates1,3,4,5
•
Published online: 11 August 2016 Ó Springer Science+Business Media New York 2016
Abstract Purpose Geography is known to affect cost of care in surgical procedures. Understanding the relationship between geography and hospital costs is pertinent in the effort to reduce healthcare costs. We studied the geographic variation in cost for transsphenoidal pituitary surgery in hospitals across New York State. Methods Using the Healthcare Cost and Utilization Project State Inpatient Database for New York from 2008 to 2011, we analyzed records of patients who underwent elective transsphenoidal pituitary tumor surgery and were discharged to home or self-care. N.Y. State was divided into five geographic regions: Buffalo, Rochester, Syracuse, Albany, and Downstate. These five regions were compared according to median charge and cost per day. Results From 2008 to 2011, 1803 transsphenoidal pituitary tumor surgeries were performed in New York State. Mean & Charles C. Lee [email protected] 1
Department of Neurosurgery, School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY 14642, USA
2
Department of Biostatistics and Computational Biology, University of Rochester Medical Center, 601 Elmwood Ave, Box 630, Rochester, NY 14642, USA
3
Department of Otolaryngology, University of Rochester Medical Center, 601 Elmwood Ave, Box 629, Rochester, NY 14642, USA
4
Division of Endocrine, Diabetes, and Metabolism, University of Rochester Medical Center, 601 Elmwood Ave, Box 693, Rochester, NY 14642, USA
5
UR Medicine Pituitary Program, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY 14642, USA
patient age was 50.7 years (54 % were female). Adjusting prices for length of stay, there was substantial variation in prices. Median charges per day ranged from $8485 to $13,321 and median costs per day ranged from $2962 to $6837 between the highest and lowest regions from 2008 to 2011. Conclusion Within New York State, significant geographic variation exists in the cost for transsphenoidal pituitary surgery. The significance of and contributors to such variation is an important question for patients, providers, and policy makers. Transparency of hospital charges, costs, and average length of stay for procedures to the public provides useful information for informed decision-making, especially for a highly portable disease entity like pituitary tumors. Keywords Charges Costs Geographic variation Pituitary tumor surgery
Introduction Healthcare spending varies considerably across the United States [1–7]. The costs of common procedures like spine surgery [8] and cardiac catheterization [9] vary widely due to a variety of factors. Such discrepancies adversely affect consumers and ultimately increase the United States’ national health expenditure [10]. Furthermore, higher costs do not always correlate with better outcomes [2]. To reduce healthcare expenditures while maintaining high quality of care, geographic variation of cost must be studied and understood. To examine this issue more carefully, we analyzed data on hospital prices in a small, well-defined population of patients who underwent transsphenoidal pituitary tumor
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surgery in New York State (NYS) from 2008 to 2011. While not a common surgery, pituitary surgery has well established indications and techniques [11–16]; thus, variations in costs among providers due to differences in patient selection, procedural coding and technique are minimal. By studying a well described disease and intervention, we hoped to address the question of whether geographic location affects hospital costs. Specifically, we divided NYS into five major regions and examined the differences in hospital cost of care for patients having pituitary tumor surgery.
Methods Data from the 2008 to 2011 Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) were used to examine geographic variation in hospital cost and charges across NYS for transsphenoidal pituitary surgery. Sponsored by the Agency for Healthcare Research and Quality (AHRQ), the HCUP SID captures hospital inpatient discharge records for all participating States and encompasses about 97 percent of all U.S. community hospital discharges. The SID contains individual patientlevel records of all ages and payers.
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craniopharyngeal duct), and 253.8 (Other disorders of the pituitary and other syndromes of diencephalohypophyseal origin). The ‘‘Others’’ category was included for comparison. On average, 87 % of the transsphenoidal pituitary tumor surgeries performed in New York State from 2008 to 2011 were represented by 227.3. Target population All patients who underwent transsphenoidal pituitary tumor surgery in NYS were selected by a combination of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and primary procedures codes (diagnosis code 227.3 for benign neoplasm of pituitary gland and craniopharyngeal duct and primary procedure codes of 07.14, 07.62, or 07.65 for biopsy, partial excision, and total excision of pituitary gland—transsphenoidal approach, respectively). Basic patient demographics (including age, gender, and race) were also analyzed. All payers were included in our study. All subjects were classified as undergoing inpatient procedures; readmissions for post-operative complications, recurrence of the tumor, or any other complications were not available in the database. Therefore, all hospital charges and costs analyzed in this study indicate a single episode of transsphenoidal pituitary tumor surgery per patient.
Case mix Geography We investigated case mix for patients who underwent pituitary surgery in New York State from 2008 to 2011. Specifically, we looked at the number of unique ICD-9 diagnosis codes associated with patients who had the following ICD-9 principal procedure codes: 07.14, 07.62, or 07.65 (biopsy, partial excision, and total excision of pituitary gland—transsphenoidal approach, respectively). From this population, we sought subjects who only underwent elective surgery and were subsequently discharged to home or self-care. This excluded emergent or urgent circumstances (such as pituitary apoplexy), which are not characteristic of the majority of pituitary tumor surgeries. Discharge status allowed us to link directly the outcomes of pituitary tumor surgery, such as length of stay and pituitary dysfunction—avoiding any other medical conditions that could have significantly impacted the subjects’ health status after surgery. These selection processes helped us target subjects with pituitary tumor as their primary medical condition. Overall, we observed 64 distinct ICD-9 diagnosis codes from 2008 to 2011. In Table 1, we list the top three most frequent codes that appeared for each year—they were consistent throughout 2008–2011: 227.3 (Benign neoplasm of pituitary gland and craniopharyngeal duct), 237.0 (Neoplasm of uncertain behavior of pituitary gland and
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In order to assess geographic variation in cost of pituitary tumor surgery within NYS, New York was divided into five geographic regions. The demarcations were determined by considering locations of service and the Metropolitan Statistical Areas (MSAs). MSAs are geographic delineations made by the Office of Management and Budget for use by federal statistical agencies. Every MSA contains a core urban area of at least 50,000 population and adjacent counties that have high-level social and economic communication with the urban core [17]. This led to the identification of five geographic divisions within New York (regions A–E). Due to the HCUP Data Use Agreement, the regions have been anonymized to protect privacy of individual hospitals and providers. Charges, cost-to-charge ratios, and costs In order to assess economic outcomes for transsphenoidal surgery, we analyzed hospital charges and costs provided by and derived from HCUP, respectively. Hospital charges are the hospital bill for the entire hospital stay of a patient and are reported through HCUP. Hospital costs are what the hospital spends to provide hospital services during the
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Table 1 Case mix of patients undergoing transsphenoidal pituitary tumor surgery
Total number of surgeries Top 3 most frequent ICD-9 diagnosis code and associated frequencies
Others
2008
2009
2010
2011 505
553
534
484
227.3
473 (85.5 %)
457 (85.6 %)
426 (88 %)
447 (88.5 %)
237.0
21 (3.8 %)
22 (4.1 %)
20 (4.1 %)
19 (3.8 %)
253.8
27 (4.9 %)
27 (5.1 %)
16 (3.3 %)
13 (2.6 %)
253.0
1 (0.2 %)
1 (0.2 %)
3 (0.6 %)
1 (0.2 %)
255.0
8 (1.4 %)
10 (1.9 %)
6 (1.2 %)
9 (1.8 %)
227.3—Benign neoplasm of pituitary gland and craniopharyngeal duct 237.0—Neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct 253.8—Other disorders of the pituitary and other syndromes of diencephalohypophyseal origin 253.0—Acromegaly and gigantism 255.0—Cushing’s syndrome
hospital stay and are derived from the HCUP data (see below). Of note, hospital charges and costs do not include professional fees. Cost-to-Charge Ratio (CCR) is the ratio of what hospitals spent to what the hospitals charged to provide hospital services. Hospital-specific CCRs are derived from all-payer inpatient cost-to-charge ratio (APICC) provided by HCUP. APICC represents hospital-specific cost-to-charge ratios (CCR) that are constructed from the all-payer, inpatient cost and charge reports by hospitals to the Center for Medicare and Medicaid Services (CMS). Individual patient claims data from the 2008 to 2011 NYS Inpatient Databases record total charges per claim. Total charges were then converted into total cost estimates by multiplying the total charges by the CCR described above. To account for fluctuations in average length of stay for transsphenoidal pituitary tumor surgery in different regions within NYS, we calculated daily charges (ratio of charges to length of stay) and costs (ratio of cost to length of stay) of pituitary tumor surgery in each region and compared them. Median values were reported for robustness against extreme values (typically driven by extended lengths of stay). Statistical methods Daily charges and daily costs were computed for each patient and statistical analysis was performed using R (version 3.0.3). To compare patient demographics in lowand high-volume groups, t test was used for age and Chisquare test was used for gender and race.
Results From 2008 to 2011, 1865 transsphenoidal pituitary tumor surgeries were performed in NYS in 58 hospitals by 161 neurosurgeons. The predominant majority of the surgeries (87 %) were associated with ICD-9 Diagnosis Code 227.3.
Complete cost-to-charge ratios were available for 1803 patients who underwent transsphenoidal surgery for pituitary tumors. The 2008–2011 NYS HCUP SID provided individual patient-level hospital charges, which were subsequently converted into hospital costs using cost-to-charge ratios (CCR). Overall, mean patient age was 50.7 years, 53.7 % were females, and majority of the patients were Caucasian (Table 2). Patient demographics in the five regions revealed statistically significant differences in gender (p = 0.03) and race (p \ 0.001), but not age (p = 0.09). However, neither gender nor race was related to daily costs and charges across the regions (Table 3). In regions A–D, the 2nd median household income quartile contained the highest percentage of patients who underwent pituitary tumor surgery; in region E, the 4th quartile contained the highest percentage of patients (Table 5). We observed a range of 1–19 total number of diagnoses at discharge and no statistically significant differences between the averages of the total number of diagnoses at discharge in the 5 regions (Table 5), suggesting that the severity of illness (or case mix) did not differ across the regions. Adjusting prices for length of stay, there was substantial variation in pituitary tumor surgery charges and costs across the five defined regions of NYS. Table 4 lists the five regions of NYS and each region’s associated median daily charges, costs, cost-to-charge ratios (CCR), and length of stay for transsphenoidal pituitary tumor surgery. Median charges per day ranged from $8485 to $13,322 and median costs per day ranged from $2962 to $6837 between the lowest and highest pricing regions from 2008 to 2011 (Table 5). Hospitals in region C had the highest charge and cost per day ($13,322 and $6837, respectively) for transsphenoidal pituitary tumor surgery. Hospitals in region A had the lowest charge per day ($8485) and hospitals in region D had the lowest cost per day ($2962). Interestingly, hospitals in regions B and C had the shortest median length of stay of
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Table 2 Number of patients of each race
Table 3 Demographics within regions of New York State undergoing pituitary tumor surgery
Caucasian
Hispanic
Other
Unidentified
Number of patients
1165
246
168
220
4
Percentage (%)
64.6
13.7
9.3
12.2
0.2
Five regions of New York
Table 4 Median daily charges, costs, cost-to-charge ratios (CCRs), and length of stay (LOS) for transsphenoidal surgery for pituitary tumors
African American
Age
Gender
Race
Mean ± S.D.
Male (%)
Female (%)
Caucasian (%)
Others (%)
A
54.2 ± 16.5
38.6
61.4
78.9
21.1
B
50.6 ± 16.8
47.9
52.1
73.2
26.8
C
52.0 ± 16.1
52.0
48.0
89.3
10.7
D
51.1 ± 14.3
59.4
40.6
84.2
15.8
E
50.3 ± 15.5
46.2
53.8
56.1
43.9
Five regions of New York State A
B
C
D
E
Median daily charges
$8485
$10,397
$13,322
$9527
$12,420
Median daily costs
$3903
$5328
$6837
$2962
$3996
Median cost-to-charge ratios (CCRs)
0.43
0.5
0.5
0.31
0.33
Median length of stay (LOS)
4
1
1
3
3
one day and hospitals in region A had the longest median length of stay of four days. The difference between regions of longest and shortest length of stay was three days. We also analyzed cost-to-charge ratios for each region and compared them. Hospitals in regions B and C had the highest median cost-to-charge ratio of 0.5 and hospitals in region D had the lowest median cost-to-charge ratio of 0.31. This indicates that hospitals in regions B and C had the lowest charge inflation and hospitals in region D had highest charge inflation among the five regions.
Discussion While safety and efficacy of transsphenoidal pituitary tumor surgery is well established [18–21], factors that affect costs associated with the surgery are poorly
understood. Because higher costs do not necessarily translate into higher quality of care [2], it is important to combine our understanding of the efficacy of the transsphenoidal approach with knowledge regarding influences that affect costs to improve quality of care for patients undergoing pituitary tumor surgery. Observing case mix of the overall pituitary tumor surgery patient population allowed us to pinpoint our target population—patients with ICD-9 principal diagnosis code: 227.3. From 2008 to 2011, the top three most frequent diagnosis codes were 227.3, 237.0, and 253.8. However, the frequencies of 237.0 and 253.8 combined never exceed 10 % of the total population in any given year (Table 1). Furthermore, diseases like Cushing’s syndrome and Acromegaly are rarer. Therefore, patients with ICD-9 principal diagnosis code 227.3 provides us with robust representation of the entire patient population.
Table 5 2008–2011 quartile classification of the median household income for New York State and total number of diagnoses coded on the discharge record Median household income state quartile for patient ZIP code Regions
Homeless or Foreign (%)
1 (poorest) (%)
2 (%)
3 (%)
Total number of diagnoses upon discharge 4 (wealthiest) (%)
Range
Mean ± SD
A
4.9
34
35.9
22.3
2.9
2–16
7.0 ± 3.1
B
1.4
22.4
35.7
29.4
11.1
1–14
5.5 ± 3.0
C
1.7
33.9
43.2
17.8
3.4
1–15
7.3 ± 3.2
D
2.5
10
38.8
31.3
17.4
2–16
7.1 ± 3.6
E
1.6
16.9
15.8
24.5
41.2
1–19
5.4 ± 3.0
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By utilizing the Metropolitan Statistical Area (MSA), we were able to link areas of densely populated regions in New York with each region’s major medical centers. This allowed us to divide NYS into five logical geographic regions. In regions A–D, we observed that the highest percentage of pituitary tumor patients were in the 2nd median household income quartile. However, in region E, the highest percentage of patients were in the 4th quartile (Table 5). There does not seem to be any correlation between patients’ median household income and hospital costs. Despite having 41.2 % of the total patient population from the wealthiest quartile, region E has the 3rd lowest median daily hospital cost ($3996). We also looked at the total number of diagnoses at discharge for each region. Table 5 shows that no one region had more or less of healthier or sicker patient populations than those of other regions. After analyzing hospital charges and costs of elective transsphenoidal pituitary tumor surgery cases across the five regions, it is clear that there is significant variation in charges and costs for transsphenoidal surgery within New York. Among the five major regions, the greatest difference in median daily charges and costs were $4837 and $3875, respectively. Hospitals charged 2–3.23 times the costs of pituitary tumor surgery, but higher daily charges did not indicate higher daily costs, or vice versa. Variations in cost-to-charge ratios show distinct charge inflations per region. It is important to note that our data source did not include actual hospital reimbursements or professional fees. Consequently, we cannot say that hospitals were paid what they charged, and hospital payment is often affected by negotiations with payers as well as factors that remain poorly understood [22, 23]. Nonetheless, if the chargemaster is the starting point for negotiations with payers (exclusive of CMS) then hospital charges and actual payments should correlate. CMS had recently made efforts to introduce more transparency in this area, but much remains to be done before this important aspect of medical economics can be addressed, and specifically the CMS data released to date does not include transsphenoidal surgery [24]. The interplay between hospital charges, costs, cost-tocharge ratios, and length of stay provided unique characteristics of each of the five major regions. For example, length of stay is a significant driver of hospital charges and costs. To account for fluctuations in length of stay for transsphenoidal pituitary tumor surgery across NYS, total hospital charges and costs were divided by total length of stay for each region. Ultimately, there were considerable variations among median daily charges and costs for pituitary tumor surgery. Furthermore, we were able to observe a trend–regions with lower median length of stay,
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had higher daily charges and costs for pituitary surgery than those of regions with higher length of stay. Cost-to-charge ratios (CCR) serve two main purposes: to convert hospital charges to hospital costs, and to provide a measure of charge inflation. A CCR of 1 indicates that the hospital charged exactly what it paid for service. A CCR of 0.5 indicates that the hospital charged twice the amount of hospital cost. As CCR decreases, the gap between hospital charges and costs (or charge inflation) increases. Interestingly, regions B and C, which had lower median length of stays and higher daily charges and costs, also had highest cost-to-charge ratios (or lowest charge inflation). On the other hand, region D, which had higher median length of stay and lower daily charges and costs, had the lowest costto-charge ratios (or highest charge inflation). It would appear from our analysis that daily prices and charge inflation are inversely proportional: regions with higher daily prices have low charge inflation and vice versa. These results have important implications for patients, providers, and other stakeholders in healthcare delivery. Significant difference in prices for transsphenoidal surgery for pituitary tumors across New York allows us to ask how geography leads to such variation. In addition, public transparency of cost differences can be incorporated into shared decision making. Uwe Reinhardt has compared the current plight of patients trying to make decisions about the cost of their care to ‘‘blindfolding shoppers entering a department store in the hope that inside they can and will then shop smartly for the merchandise they seek [25].’’ The vast majority of patients diagnosed with pituitary surgery do not require urgent surgery; therefore, many of these patients can make decisions informed by cost and quality outcomes when choosing a medical center for their surgery. As we analyzed patients who were able to make their own decisions about surgery and were discharged to home or self-care after surgery, these patients can also incorporate cost information into their decision-making process. Transsphenoidal surgery is the dominant approach for treating patients with pituitary tumors who require surgery and we need to define more clearly the costs for the patients, providers, and stakeholders to establish consistently high quality of care for these diseases. There are several limitations in our work. First, this study included single episodes of transsphenoidal pituitary tumor surgery per patient. We did not include cost information of post-operative events such as post-operative complications, recurrences of pituitary tumors, and other lines of treatment, such as radiation therapy or medical management. This kind of information would be helpful in developing models that could be translated into alternative payment models of patient care, a growing area of interest for CMS and other payers [26–29]. Nonetheless, a study along these lines would require access to both outpatient
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and inpatient data which is not possible at this time and is outside the specific scope of our study. Second, we included only one specific ICD-9-CM code (227.3—benign neoplasm of pituitary gland and craniopharyngeal duct), thus we cannot delineate cost information for non-functional versus functional pituitary tumors. While it is possible that surgery for patients with functional tumors (e.g., Cushing’s disease) may be associated with higher hospital charges and costs, the preponderance of cases (Table 1) are likely to be non-functioning adenomas based on the epidemiology of pituitary adenoma [30–33] and thus would not significantly impact costs analysis. Third, we only included patients who underwent elective surgery and were discharged to home or self-care. We did not include patients who were treated emergently, and we did not include patients who were discharged to short-term hospitals, hospice, skilled nursing facility, or other facilities. It is reasonable to assume these situations would result in higher costs, charges, and longer lengths of stay, but our study included [87 % of all patients undergoing pituitary tumor surgery in New York from 2008 to 2011, suggesting that our study applies to the vast majority of cases generally. Fourth, because we combined cost information from all hospitals within specified regions, we were not able to distinguish the variability of costs between high-volume centers and low-volume centers. It is well established that higher volume is associated with fewer complications in pituitary tumor surgery [18, 34–36], but our goal was to focus specifically on the role (if any) that geography has on hospital costs, charges, and charge inflation. Lastly, there are the inherent limitations of analyzing an administrative database including coding errors, lack of important clinical factors that may impact outcomes, missing CCRs, and the inclusion of cases from only one state (New York). Future studies will need to validate our findings to establish its generalizability to all patients who undergo transsphenoidal surgery.
Conclusion We studied a small, well-defined population of patients who underwent transsphenoidal surgery for pituitary tumors in New York State from 2008 to 2011. NYS was divided into five major regions and hospital charge and cost comparisons were made between all regions. Our findings showed significant geographic variation in the cost of pituitary tumor surgery within a single state. Funding The research reported in this manuscript received intramural funding by the UR Medicine Pituitary Program, University of Rochester Medical Center.
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Pituitary (2016) 19:515–521 Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest.
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Geographic variation in cost of care for pituitary tumor surgery Charles C. Lee1,5 • Kristopher T. Kimmell1 • Amy Lalonde2 • Peter Salzman2 Matthew C. Miller3 • Laura M. Calvi4,5 • Ekaterina Manuylova4,5 • Ismat Shafiq4,5, • G. Edward Vates1,3,4,5
•
Published online: 11 August 2016 Ó Springer Science+Business Media New York 2016
Abstract Purpose Geography is known to affect cost of care in surgical procedures. Understanding the relationship between geography and hospital costs is pertinent in the effort to reduce healthcare costs. We studied the geographic variation in cost for transsphenoidal pituitary surgery in hospitals across New York State. Methods Using the Healthcare Cost and Utilization Project State Inpatient Database for New York from 2008 to 2011, we analyzed records of patients who underwent elective transsphenoidal pituitary tumor surgery and were discharged to home or self-care. N.Y. State was divided into five geographic regions: Buffalo, Rochester, Syracuse, Albany, and Downstate. These five regions were compared according to median charge and cost per day. Results From 2008 to 2011, 1803 transsphenoidal pituitary tumor surgeries were performed in New York State. Mean & Charles C. Lee [email protected] 1
Department of Neurosurgery, School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY 14642, USA
2
Department of Biostatistics and Computational Biology, University of Rochester Medical Center, 601 Elmwood Ave, Box 630, Rochester, NY 14642, USA
3
Department of Otolaryngology, University of Rochester Medical Center, 601 Elmwood Ave, Box 629, Rochester, NY 14642, USA
4
Division of Endocrine, Diabetes, and Metabolism, University of Rochester Medical Center, 601 Elmwood Ave, Box 693, Rochester, NY 14642, USA
5
UR Medicine Pituitary Program, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY 14642, USA
patient age was 50.7 years (54 % were female). Adjusting prices for length of stay, there was substantial variation in prices. Median charges per day ranged from $8485 to $13,321 and median costs per day ranged from $2962 to $6837 between the highest and lowest regions from 2008 to 2011. Conclusion Within New York State, significant geographic variation exists in the cost for transsphenoidal pituitary surgery. The significance of and contributors to such variation is an important question for patients, providers, and policy makers. Transparency of hospital charges, costs, and average length of stay for procedures to the public provides useful information for informed decision-making, especially for a highly portable disease entity like pituitary tumors. Keywords Charges Costs Geographic variation Pituitary tumor surgery
Introduction Healthcare spending varies considerably across the United States [1–7]. The costs of common procedures like spine surgery [8] and cardiac catheterization [9] vary widely due to a variety of factors. Such discrepancies adversely affect consumers and ultimately increase the United States’ national health expenditure [10]. Furthermore, higher costs do not always correlate with better outcomes [2]. To reduce healthcare expenditures while maintaining high quality of care, geographic variation of cost must be studied and understood. To examine this issue more carefully, we analyzed data on hospital prices in a small, well-defined population of patients who underwent transsphenoidal pituitary tumor
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surgery in New York State (NYS) from 2008 to 2011. While not a common surgery, pituitary surgery has well established indications and techniques [11–16]; thus, variations in costs among providers due to differences in patient selection, procedural coding and technique are minimal. By studying a well described disease and intervention, we hoped to address the question of whether geographic location affects hospital costs. Specifically, we divided NYS into five major regions and examined the differences in hospital cost of care for patients having pituitary tumor surgery.
Methods Data from the 2008 to 2011 Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) were used to examine geographic variation in hospital cost and charges across NYS for transsphenoidal pituitary surgery. Sponsored by the Agency for Healthcare Research and Quality (AHRQ), the HCUP SID captures hospital inpatient discharge records for all participating States and encompasses about 97 percent of all U.S. community hospital discharges. The SID contains individual patientlevel records of all ages and payers.
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craniopharyngeal duct), and 253.8 (Other disorders of the pituitary and other syndromes of diencephalohypophyseal origin). The ‘‘Others’’ category was included for comparison. On average, 87 % of the transsphenoidal pituitary tumor surgeries performed in New York State from 2008 to 2011 were represented by 227.3. Target population All patients who underwent transsphenoidal pituitary tumor surgery in NYS were selected by a combination of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and primary procedures codes (diagnosis code 227.3 for benign neoplasm of pituitary gland and craniopharyngeal duct and primary procedure codes of 07.14, 07.62, or 07.65 for biopsy, partial excision, and total excision of pituitary gland—transsphenoidal approach, respectively). Basic patient demographics (including age, gender, and race) were also analyzed. All payers were included in our study. All subjects were classified as undergoing inpatient procedures; readmissions for post-operative complications, recurrence of the tumor, or any other complications were not available in the database. Therefore, all hospital charges and costs analyzed in this study indicate a single episode of transsphenoidal pituitary tumor surgery per patient.
Case mix Geography We investigated case mix for patients who underwent pituitary surgery in New York State from 2008 to 2011. Specifically, we looked at the number of unique ICD-9 diagnosis codes associated with patients who had the following ICD-9 principal procedure codes: 07.14, 07.62, or 07.65 (biopsy, partial excision, and total excision of pituitary gland—transsphenoidal approach, respectively). From this population, we sought subjects who only underwent elective surgery and were subsequently discharged to home or self-care. This excluded emergent or urgent circumstances (such as pituitary apoplexy), which are not characteristic of the majority of pituitary tumor surgeries. Discharge status allowed us to link directly the outcomes of pituitary tumor surgery, such as length of stay and pituitary dysfunction—avoiding any other medical conditions that could have significantly impacted the subjects’ health status after surgery. These selection processes helped us target subjects with pituitary tumor as their primary medical condition. Overall, we observed 64 distinct ICD-9 diagnosis codes from 2008 to 2011. In Table 1, we list the top three most frequent codes that appeared for each year—they were consistent throughout 2008–2011: 227.3 (Benign neoplasm of pituitary gland and craniopharyngeal duct), 237.0 (Neoplasm of uncertain behavior of pituitary gland and
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In order to assess geographic variation in cost of pituitary tumor surgery within NYS, New York was divided into five geographic regions. The demarcations were determined by considering locations of service and the Metropolitan Statistical Areas (MSAs). MSAs are geographic delineations made by the Office of Management and Budget for use by federal statistical agencies. Every MSA contains a core urban area of at least 50,000 population and adjacent counties that have high-level social and economic communication with the urban core [17]. This led to the identification of five geographic divisions within New York (regions A–E). Due to the HCUP Data Use Agreement, the regions have been anonymized to protect privacy of individual hospitals and providers. Charges, cost-to-charge ratios, and costs In order to assess economic outcomes for transsphenoidal surgery, we analyzed hospital charges and costs provided by and derived from HCUP, respectively. Hospital charges are the hospital bill for the entire hospital stay of a patient and are reported through HCUP. Hospital costs are what the hospital spends to provide hospital services during the
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Table 1 Case mix of patients undergoing transsphenoidal pituitary tumor surgery
Total number of surgeries Top 3 most frequent ICD-9 diagnosis code and associated frequencies
Others
2008
2009
2010
2011 505
553
534
484
227.3
473 (85.5 %)
457 (85.6 %)
426 (88 %)
447 (88.5 %)
237.0
21 (3.8 %)
22 (4.1 %)
20 (4.1 %)
19 (3.8 %)
253.8
27 (4.9 %)
27 (5.1 %)
16 (3.3 %)
13 (2.6 %)
253.0
1 (0.2 %)
1 (0.2 %)
3 (0.6 %)
1 (0.2 %)
255.0
8 (1.4 %)
10 (1.9 %)
6 (1.2 %)
9 (1.8 %)
227.3—Benign neoplasm of pituitary gland and craniopharyngeal duct 237.0—Neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct 253.8—Other disorders of the pituitary and other syndromes of diencephalohypophyseal origin 253.0—Acromegaly and gigantism 255.0—Cushing’s syndrome
hospital stay and are derived from the HCUP data (see below). Of note, hospital charges and costs do not include professional fees. Cost-to-Charge Ratio (CCR) is the ratio of what hospitals spent to what the hospitals charged to provide hospital services. Hospital-specific CCRs are derived from all-payer inpatient cost-to-charge ratio (APICC) provided by HCUP. APICC represents hospital-specific cost-to-charge ratios (CCR) that are constructed from the all-payer, inpatient cost and charge reports by hospitals to the Center for Medicare and Medicaid Services (CMS). Individual patient claims data from the 2008 to 2011 NYS Inpatient Databases record total charges per claim. Total charges were then converted into total cost estimates by multiplying the total charges by the CCR described above. To account for fluctuations in average length of stay for transsphenoidal pituitary tumor surgery in different regions within NYS, we calculated daily charges (ratio of charges to length of stay) and costs (ratio of cost to length of stay) of pituitary tumor surgery in each region and compared them. Median values were reported for robustness against extreme values (typically driven by extended lengths of stay). Statistical methods Daily charges and daily costs were computed for each patient and statistical analysis was performed using R (version 3.0.3). To compare patient demographics in lowand high-volume groups, t test was used for age and Chisquare test was used for gender and race.
Results From 2008 to 2011, 1865 transsphenoidal pituitary tumor surgeries were performed in NYS in 58 hospitals by 161 neurosurgeons. The predominant majority of the surgeries (87 %) were associated with ICD-9 Diagnosis Code 227.3.
Complete cost-to-charge ratios were available for 1803 patients who underwent transsphenoidal surgery for pituitary tumors. The 2008–2011 NYS HCUP SID provided individual patient-level hospital charges, which were subsequently converted into hospital costs using cost-to-charge ratios (CCR). Overall, mean patient age was 50.7 years, 53.7 % were females, and majority of the patients were Caucasian (Table 2). Patient demographics in the five regions revealed statistically significant differences in gender (p = 0.03) and race (p \ 0.001), but not age (p = 0.09). However, neither gender nor race was related to daily costs and charges across the regions (Table 3). In regions A–D, the 2nd median household income quartile contained the highest percentage of patients who underwent pituitary tumor surgery; in region E, the 4th quartile contained the highest percentage of patients (Table 5). We observed a range of 1–19 total number of diagnoses at discharge and no statistically significant differences between the averages of the total number of diagnoses at discharge in the 5 regions (Table 5), suggesting that the severity of illness (or case mix) did not differ across the regions. Adjusting prices for length of stay, there was substantial variation in pituitary tumor surgery charges and costs across the five defined regions of NYS. Table 4 lists the five regions of NYS and each region’s associated median daily charges, costs, cost-to-charge ratios (CCR), and length of stay for transsphenoidal pituitary tumor surgery. Median charges per day ranged from $8485 to $13,322 and median costs per day ranged from $2962 to $6837 between the lowest and highest pricing regions from 2008 to 2011 (Table 5). Hospitals in region C had the highest charge and cost per day ($13,322 and $6837, respectively) for transsphenoidal pituitary tumor surgery. Hospitals in region A had the lowest charge per day ($8485) and hospitals in region D had the lowest cost per day ($2962). Interestingly, hospitals in regions B and C had the shortest median length of stay of
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Table 2 Number of patients of each race
Table 3 Demographics within regions of New York State undergoing pituitary tumor surgery
Caucasian
Hispanic
Other
Unidentified
Number of patients
1165
246
168
220
4
Percentage (%)
64.6
13.7
9.3
12.2
0.2
Five regions of New York
Table 4 Median daily charges, costs, cost-to-charge ratios (CCRs), and length of stay (LOS) for transsphenoidal surgery for pituitary tumors
African American
Age
Gender
Race
Mean ± S.D.
Male (%)
Female (%)
Caucasian (%)
Others (%)
A
54.2 ± 16.5
38.6
61.4
78.9
21.1
B
50.6 ± 16.8
47.9
52.1
73.2
26.8
C
52.0 ± 16.1
52.0
48.0
89.3
10.7
D
51.1 ± 14.3
59.4
40.6
84.2
15.8
E
50.3 ± 15.5
46.2
53.8
56.1
43.9
Five regions of New York State A
B
C
D
E
Median daily charges
$8485
$10,397
$13,322
$9527
$12,420
Median daily costs
$3903
$5328
$6837
$2962
$3996
Median cost-to-charge ratios (CCRs)
0.43
0.5
0.5
0.31
0.33
Median length of stay (LOS)
4
1
1
3
3
one day and hospitals in region A had the longest median length of stay of four days. The difference between regions of longest and shortest length of stay was three days. We also analyzed cost-to-charge ratios for each region and compared them. Hospitals in regions B and C had the highest median cost-to-charge ratio of 0.5 and hospitals in region D had the lowest median cost-to-charge ratio of 0.31. This indicates that hospitals in regions B and C had the lowest charge inflation and hospitals in region D had highest charge inflation among the five regions.
Discussion While safety and efficacy of transsphenoidal pituitary tumor surgery is well established [18–21], factors that affect costs associated with the surgery are poorly
understood. Because higher costs do not necessarily translate into higher quality of care [2], it is important to combine our understanding of the efficacy of the transsphenoidal approach with knowledge regarding influences that affect costs to improve quality of care for patients undergoing pituitary tumor surgery. Observing case mix of the overall pituitary tumor surgery patient population allowed us to pinpoint our target population—patients with ICD-9 principal diagnosis code: 227.3. From 2008 to 2011, the top three most frequent diagnosis codes were 227.3, 237.0, and 253.8. However, the frequencies of 237.0 and 253.8 combined never exceed 10 % of the total population in any given year (Table 1). Furthermore, diseases like Cushing’s syndrome and Acromegaly are rarer. Therefore, patients with ICD-9 principal diagnosis code 227.3 provides us with robust representation of the entire patient population.
Table 5 2008–2011 quartile classification of the median household income for New York State and total number of diagnoses coded on the discharge record Median household income state quartile for patient ZIP code Regions
Homeless or Foreign (%)
1 (poorest) (%)
2 (%)
3 (%)
Total number of diagnoses upon discharge 4 (wealthiest) (%)
Range
Mean ± SD
A
4.9
34
35.9
22.3
2.9
2–16
7.0 ± 3.1
B
1.4
22.4
35.7
29.4
11.1
1–14
5.5 ± 3.0
C
1.7
33.9
43.2
17.8
3.4
1–15
7.3 ± 3.2
D
2.5
10
38.8
31.3
17.4
2–16
7.1 ± 3.6
E
1.6
16.9
15.8
24.5
41.2
1–19
5.4 ± 3.0
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By utilizing the Metropolitan Statistical Area (MSA), we were able to link areas of densely populated regions in New York with each region’s major medical centers. This allowed us to divide NYS into five logical geographic regions. In regions A–D, we observed that the highest percentage of pituitary tumor patients were in the 2nd median household income quartile. However, in region E, the highest percentage of patients were in the 4th quartile (Table 5). There does not seem to be any correlation between patients’ median household income and hospital costs. Despite having 41.2 % of the total patient population from the wealthiest quartile, region E has the 3rd lowest median daily hospital cost ($3996). We also looked at the total number of diagnoses at discharge for each region. Table 5 shows that no one region had more or less of healthier or sicker patient populations than those of other regions. After analyzing hospital charges and costs of elective transsphenoidal pituitary tumor surgery cases across the five regions, it is clear that there is significant variation in charges and costs for transsphenoidal surgery within New York. Among the five major regions, the greatest difference in median daily charges and costs were $4837 and $3875, respectively. Hospitals charged 2–3.23 times the costs of pituitary tumor surgery, but higher daily charges did not indicate higher daily costs, or vice versa. Variations in cost-to-charge ratios show distinct charge inflations per region. It is important to note that our data source did not include actual hospital reimbursements or professional fees. Consequently, we cannot say that hospitals were paid what they charged, and hospital payment is often affected by negotiations with payers as well as factors that remain poorly understood [22, 23]. Nonetheless, if the chargemaster is the starting point for negotiations with payers (exclusive of CMS) then hospital charges and actual payments should correlate. CMS had recently made efforts to introduce more transparency in this area, but much remains to be done before this important aspect of medical economics can be addressed, and specifically the CMS data released to date does not include transsphenoidal surgery [24]. The interplay between hospital charges, costs, cost-tocharge ratios, and length of stay provided unique characteristics of each of the five major regions. For example, length of stay is a significant driver of hospital charges and costs. To account for fluctuations in length of stay for transsphenoidal pituitary tumor surgery across NYS, total hospital charges and costs were divided by total length of stay for each region. Ultimately, there were considerable variations among median daily charges and costs for pituitary tumor surgery. Furthermore, we were able to observe a trend–regions with lower median length of stay,
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had higher daily charges and costs for pituitary surgery than those of regions with higher length of stay. Cost-to-charge ratios (CCR) serve two main purposes: to convert hospital charges to hospital costs, and to provide a measure of charge inflation. A CCR of 1 indicates that the hospital charged exactly what it paid for service. A CCR of 0.5 indicates that the hospital charged twice the amount of hospital cost. As CCR decreases, the gap between hospital charges and costs (or charge inflation) increases. Interestingly, regions B and C, which had lower median length of stays and higher daily charges and costs, also had highest cost-to-charge ratios (or lowest charge inflation). On the other hand, region D, which had higher median length of stay and lower daily charges and costs, had the lowest costto-charge ratios (or highest charge inflation). It would appear from our analysis that daily prices and charge inflation are inversely proportional: regions with higher daily prices have low charge inflation and vice versa. These results have important implications for patients, providers, and other stakeholders in healthcare delivery. Significant difference in prices for transsphenoidal surgery for pituitary tumors across New York allows us to ask how geography leads to such variation. In addition, public transparency of cost differences can be incorporated into shared decision making. Uwe Reinhardt has compared the current plight of patients trying to make decisions about the cost of their care to ‘‘blindfolding shoppers entering a department store in the hope that inside they can and will then shop smartly for the merchandise they seek [25].’’ The vast majority of patients diagnosed with pituitary surgery do not require urgent surgery; therefore, many of these patients can make decisions informed by cost and quality outcomes when choosing a medical center for their surgery. As we analyzed patients who were able to make their own decisions about surgery and were discharged to home or self-care after surgery, these patients can also incorporate cost information into their decision-making process. Transsphenoidal surgery is the dominant approach for treating patients with pituitary tumors who require surgery and we need to define more clearly the costs for the patients, providers, and stakeholders to establish consistently high quality of care for these diseases. There are several limitations in our work. First, this study included single episodes of transsphenoidal pituitary tumor surgery per patient. We did not include cost information of post-operative events such as post-operative complications, recurrences of pituitary tumors, and other lines of treatment, such as radiation therapy or medical management. This kind of information would be helpful in developing models that could be translated into alternative payment models of patient care, a growing area of interest for CMS and other payers [26–29]. Nonetheless, a study along these lines would require access to both outpatient
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and inpatient data which is not possible at this time and is outside the specific scope of our study. Second, we included only one specific ICD-9-CM code (227.3—benign neoplasm of pituitary gland and craniopharyngeal duct), thus we cannot delineate cost information for non-functional versus functional pituitary tumors. While it is possible that surgery for patients with functional tumors (e.g., Cushing’s disease) may be associated with higher hospital charges and costs, the preponderance of cases (Table 1) are likely to be non-functioning adenomas based on the epidemiology of pituitary adenoma [30–33] and thus would not significantly impact costs analysis. Third, we only included patients who underwent elective surgery and were discharged to home or self-care. We did not include patients who were treated emergently, and we did not include patients who were discharged to short-term hospitals, hospice, skilled nursing facility, or other facilities. It is reasonable to assume these situations would result in higher costs, charges, and longer lengths of stay, but our study included [87 % of all patients undergoing pituitary tumor surgery in New York from 2008 to 2011, suggesting that our study applies to the vast majority of cases generally. Fourth, because we combined cost information from all hospitals within specified regions, we were not able to distinguish the variability of costs between high-volume centers and low-volume centers. It is well established that higher volume is associated with fewer complications in pituitary tumor surgery [18, 34–36], but our goal was to focus specifically on the role (if any) that geography has on hospital costs, charges, and charge inflation. Lastly, there are the inherent limitations of analyzing an administrative database including coding errors, lack of important clinical factors that may impact outcomes, missing CCRs, and the inclusion of cases from only one state (New York). Future studies will need to validate our findings to establish its generalizability to all patients who undergo transsphenoidal surgery.
Conclusion We studied a small, well-defined population of patients who underwent transsphenoidal surgery for pituitary tumors in New York State from 2008 to 2011. NYS was divided into five major regions and hospital charge and cost comparisons were made between all regions. Our findings showed significant geographic variation in the cost of pituitary tumor surgery within a single state. Funding The research reported in this manuscript received intramural funding by the UR Medicine Pituitary Program, University of Rochester Medical Center.
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Pituitary (2016) 19:515–521 Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest.
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