Elective one to three level ACDFs at physician-owned hospitals cost less and have fewer complications

First author Azeem Tariq Malik

The results of a recent study suggest that elective one to three level anterior cervical discectomy with fusion surgeries (ACDFs) at physician-owned hospitals have significant cost savings, while having lower odds of experiencing 90-day medical complications and readmissions. These findings were presented by first author Azeem Tariq Malik during a Best Paper session at the 34th Annual Meeting of the North American Spine Society (NASS 2019; 25–28 September, Chicago, USA).

The study team, led by Azeem Tariq Malik and Safdar N Khan, note that due to concerns regarding higher cost and low quality of case provided in physician-owned hospitals, the Affordable Care Act (ACA) imposed sanctions that prevented the formation of new physician-owned hospitals and limited expansion of current facilities in the nation. They argue that with the demand for spine care growing across the USA, there is a need for re-evaluation and assessment of quality of spine surgical care provided at these physician-owned hospitals.

Malik and colleagues utilised the 2005–2014 Medicare 100% Standard Analytical Files (SAF100) to identify patients undergoing elective one to three level ACDFs at physician-owned and non-physician-owned hospitals. The investigators report that a total of 6,692 (2.7%) patients received an elective ACDF at a physician-owned hospital (n=45; 2.4%) whereas 249,499 (97.3%) received surgery at non-physician-owned hospitals (n=1,843; 97.6%). The majority of patients in both the physician-owned hospital cohort and the non-physician-owned hospital group were above 65 years of age (40.3% and 39.1%, respectively).

There were more female than male patients in both groups and the majority were from the South. Just over 70% of hospitals included in the physician-owned group were rural, compared to just over 50% of the non-physician-owned hospitals. Interestingly, the authors did not observe any meaningful clinical differences in the average co-morbidity burden among patients presenting at both hospital types.

After controlling for age, gender, region, hospital factors (including socio-economic status, urban versus rural location and volume) and Elixhauser Comorbidity Index, they found that undergoing ACDFs at physician-owned hospitals was associated with lower odds of cardiac complications (OR 0.8 [95% CI 0.73–0.86]; p<0.001), septic complications (OR 0.87 [95% CI 0.71–0.96]; p=0.007), deep venous thrombosis (OR 0.71 [95% CI 0.54–0.93]; p=0.015), renal complications (OR 0.74 [95% CI 0.64–0.86]; p<0.001) and readmissions (OR 0.83 [95% CI 0.71–0.97]; p=0.019).

They found no significant differences between physician-owned versus non-physician-owned hospitals with regards to wound complications (p=0.187), pulmonary complications (p=0.241), urinary tract infections (p=0.077), pain complications (p=0.984), dysphagia (p=0.905), and revision surgery (p=0.209).In addition, they note that ACDFs being performed at physician-owned hospitals versus non-physician-owned hospitals had lower risk-adjusted inpatient costs (-US$1,517) and 90-day costs (-US$1,927).

While the authors do caution readers about possible unseen selection bias, the results of the study do show that patients undergoing surgery at physician-owned hospitals do not have a worse outcome. The findings promote the re-introduction of physician-owned facilities in the current value-based healthcare system.


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