Faculty Bibliography

INTRODUCTION/BACKGROUND:Today, many hospitals are part of a multihospital network, which changes the context in which surgeons are asked to lead. This study explores key leadership competencies that surgical leaders use to navigate this hospital network expansion. METHODS:In this qualitative study, 30 surgical leaders were interviewed. Interviews were coded and analyzed via thematic analysis. RESULTS:We identified three key competencies that leaders felt were important leadership skills to successfully navigate expanding hospital networks. First, leaders must steer the departmental vision within the evolving hospital network landscape. Second, leaders must align the visions of the department and of the hospital network. Third, leaders must build a network-oriented culture within their department. CONCLUSIONS:As networks expand, leaders are tasked with unifying vision in their department. Leaders identified a unique opportunity to leverage their growing influence across the hospital network and invested in the people and culture of their department.

OBJECTIVE:To compare out-of-pocket (OOP) costs for patients up to 3 years after bariatric surgery in a large, commercially-insured population. SUMMARY OF BACKGROUND DATA:More information on OOP costs following bariatric surgery may affect patients' procedure choice. METHODS:Retrospective study using the IBM MarketScan commercial claims database, representing patients nationally who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) January 1, 2011 to December 31, 2017. We compared total OOP costs after the surgical episode between the 2 procedures using difference-in-differences analysis adjusting for demographics, comorbidities, operative year, and insurance type. RESULTS:Of 63,674 patients, 64% underwent SG and 36% underwent RYGB. Adjusted OOP costs after SG were $1083, $1236, and $1266 postoperative years 1, 2, and 3. For RYGB, adjusted OOP costs were $1228, $1377, and $1369. In our primary analysis, SG OOP costs were $122 (95% confidence interval [CI]: -$155 to -$90) less than RYGB year 1. This difference remained consistent at -$119 (95%CI: -$158 to -$79) year 2 and -$80 (95%CI: -$127 to -$35) year 3. These amounts were equivalent to relative differences of -7%, -7%, and -5% years 1, 2, and 3. Plan features contributing the most to differences were co-insurance years 1, 2, and 3.The largest clinical contributors to differences were endoscopy and outpatient care year 1, outpatient care year 2, and emergency department use year 3. CONCLUSIONS:Our study is the first to examine the association between bariatric surgery procedure and OOP costs. Differences between procedures were approximately $100 per year which may be an important factor for some patients deciding whether to pursue SG or gastric bypass.

OBJECTIVE:The aim of this study was to evaluate associations between hospital participation in Bundled Payments for Care Improvement (BPCI) and 30-day total episode and post-acute care spending for lower extremity joint replacement (LEJR), coronary artery bypass graft (CABG), and colec-tomy. SUMMARY BACKGROUND DATA/BACKGROUND:BPCI has been shown to reduce spending for LEJR episodes largely from reductions in post-acute care. However, BPCI efficacy in other common elective procedures, including CABG and colec-tomy, remains unclear. It is also unknown whether post-acute care spending reductions drive total spending reductions outside of LEJR. METHODS:Retrospective cohort study using 100% Medicare claims data to identify BPCI (312 total) and non-BPCI (1,977 total) acute care hospitals from January 1, 2010 to November 30, 2016 with Medicare-enrolled patient discharges for at least one of the following BPCI episodes: LEJR (454,369 episodes), CABG (107,307 episodes), or colectomy (73,717 episodes). Along with difference-in-differences (DiD) analysis, we constructed generalized synthetic controls in the presence of nonparallel trends to estimate associations between BPCI participation and 30-day total and post-acute care spending. RESULTS:DiD estimates indicated reduced spending for LEJR (-$541.6 [95% confidence interval (CI): -718.0 to -365.3]) and colectomy (-$582.1 [95% CI: -927.3 to -236.8]) but not CABG (-$268.9 [95% CI: -831.5 to 293.7]). Generalized synthetic control estimates indicated reduced spending for LEJR (-$795.3 [95% CI: -10,22.1 to -582.2]) but not colectomy (-$251.3 [95% CI: -997.9 to 335.2]) or CABG (-$257.8 [95% CI: -10,24.6 to 414.8]).Post-acute care comprised 42.6% of LEJR spending reductions and 53.0% of colectomy spending reductions. CONCLUSIONS:BPCI participation was associated with significant spending reductions for LEJR and colectomy but not CABG. We conclude that BPCI has episode-dependent efficacy, largely determined by post-acute care.

BACKGROUND:For patients who wish to undergo bariatric surgery, variation in pre-operative insurance requirements may represent inequity across insurance plan types. We conducted a cross-sectional assessment of the variation in pre-operative insurance requirements. METHODS:Original insurance policy documents for pre-operative requirements were obtained from bariatric surgery programs across the entire USA and online insurance portals. Insurance programs analyzed include commercial, Medicaid, and Medicare/TriCare plans. Poisson regression adjusting for U.S. Census region was used to evaluate variation in pre-operative requirements. Analyses were done at the insurance plan level. Our primary outcome was number of requirements required by each plan by insurance type. Our secondary outcome was number of months required to participate in medically supervised weight loss (MSWL). RESULTS:Among 43 insurance plans reviewed, representing commercial (60.5%), Medicaid (25.6%), and Medicare/TriCare (14.0%) plans, the number of pre-operative requirements ranged from 1 to 8. Adjusted Poisson regression showed significant variation in pre-operative requirements across plan types with Medicaid-insured patients required to fulfill the greatest number (4.1, 95%CI 2.7 to 5.4) compared to 2.7 (95%CI 2.2 to 3.2, P = 0.028) for commercially insured patients and 2.1 (95%CI 1.1 to 3.1, P = 0.047) for Medicare/TriCare-insured patients. Medicaid-insured patients were also required to complete a greater number of months in MSWL (6.6, 95%CI 5.5 to 7.6) compared to commercially (3.8, 95%CI 2.9 to 4.8, P < .001) and Medicare/TriCare-insured patients (1.7, 95%CI 0.3 to 3.0, P = .001). CONCLUSION:The greater frequency of pre-operative requirements in Medicaid plans compared to Medicare/TriCare and commercial plans demonstrates inequity across insurance types which may negatively impact access to bariatric surgery. Pre-operative insurance requirements must be reevaluated and standardized using established evidence to ensure all individuals have access to this life-saving intervention.

OBJECTIVE:To compare safety and healthcare utilization after sleeve gastrectomy versus Roux-en-Y gastric bypass in a national Medicare cohort. SUMMARY BACKGROUND DATA:Though bariatric surgery is increasing among Medicare beneficiaries, no long-term, national studies examining comparative effectiveness between procedures exist. Bariatric outcomes are needed for shared decision-making and coverage policy concerns identified by the cMS Medicare Evidence Development and Coverage Advisory Committee. METHODS:Retrospective instrumental variable analysis of Medicare claims (2012-2017) for 30,105 bariatric surgery patients entitled due to disability or age. We examined clinical safety outcomes (mortality, complications, and reinterventions), healthcare utilization [Emergency Department (ED) visits, rehospitalizations, and expenditures], and heterogeneity of treatment effect. We compared all outcomes between sleeve and bypass for each entitlement group at 30 days, 1 year, and 3 years. RESULTS:Among the disabled (n = 21,595), sleeve was associated with lower 3-year mortality [2.1% vs 3.2%, absolute risk reduction (ARR) 95% confidence interval (CI): -2.2% to -0.03%], complications (22.2% vs 27.7%, ARR 95%CI: -8.5% to -2.6%), reinterventions (20.1% vs 27.7%, ARR 95%CI: -10.7% to -4.6%), ED utilization (71.6% vs 77.1%, ARR 95%CI: -8.5% to -2.4%), and rehospitalizations (47.4% vs 52.3%, ARR 95%Ci: -8.0% to -1.7%). Cumulative expenditures were $46,277 after sleeve and $48,211 after bypass (P = 0.22). Among the elderly (n = 8510), sleeve was associated with lower 3-year complications (20.1% vs 24.7%, ARR 95%CI: -7.6% to -1.7%), reinterventions (14.0% vs 21.9%, ARR 95%CI: -10.7% to -5.2%), ED utilization (51.7% vs 57.2%, ARR 95%CI: -9.1% to -1.9%), and rehospitalizations (41.8% vs 45.8%, ARR 95%Ci: -7.5% to -0.5%). Expenditures were $38,632 after sleeve and $39,270 after bypass (P = 0.60). Procedure treatment effect significantly differed by entitlement for mortality, revision, and paraesophageal hernia repair. CONCLUSIONS:Bariatric surgery is safe, and healthcare utilization benefits of sleeve over bypass are preserved across both Medicare elderly and disabled subpopulations.

OBJECTIVE:To explore challenges and opportunities for surgery departments' academic missions as they become increasingly affiliated with expanding health systems. SUMMARY BACKGROUND DATA:Academic medicine is in the midst of unprecedented change. In addition to facing intense competition, narrower margins, and decreased federal funding, medical schools are becoming increasingly involved with large, expanding health systems. The impact of these health system affiliations on surgical departments' academic missions is unknown. METHODS:Semistructured interviews with 30 surgical leaders at teaching hospitals affiliated with health systems from August - December 2019. Interviews were transcribed verbatim and coded in an iterative process using MaxQDA software. The topic of challenges and opportunities for the academic mission was an emergent theme, analyzed using thematic analysis. RESULTS:Academic health systems typically expanded to support their business goals, rather than their academic mission. Changes in governance sometimes disempowered departmental leadership, shifted traditional compensation models, redirected research programs, and led to cultural conflict. However, at many institutions, health system growth cross-subsidized surgical departments' research and training missions, expanded their clinical footprint, enabled them to improve standards of care, and enhanced opportunities for researchers and trainees. CONCLUSIONS:Although health system expansion generally intended to advance business goals, the accompanying academic and clinical opportunities were not always fully captured. Alignment between medical school and health system goals enabled some surgical department leaders to take advantage of their health systems' reach and resources to support their academic missions.