Integrated Delivery Systems for Hospital Inpatient Surgeries

While integrated delivery systems (lDSs) have been shown to improve quality and lower costs in ambulatory care settings, a study found that costs and quality outcomes for inpatient surgeries in IDS settings were largely indistinguishable from hospitals without IDSs. The findings from the retrospective study, which set out to anticipate the effects of accountable care organizations (ACOs) on inpatient surgery, were reported in JAMA Surgery [2013;148(6):549-554].

According to the study's authors, previous research into the benefits of IDSs has been used to support the movement toward ACOs. This research has suggested that IDSs can improve performance on measures of quality and cost in the ambulatory care setting, but less data are available to assess the impact these systems could have on inpatient surgery, a major and costly component of healthcare services.

To better gauge the possible impact of IDSs on inpatient surgery, researchers compared quality and cost measures for patients undergoing several types of surgical procedures in IDS-affiliated hospitals with those undergoing the same procedures in non–IDS-affiliated centers using national Medicare data from January 1, 2005, to November 30, 2007.

For the study, researchers used patients who were undergoing coronary artery bypass grafting, hip replacement, back surgery, or a colectomy and examined other claims relevant to the surgical hospitalization to assess operative mortality, postoperative complications, and readmissions. In an effort to learn more about the cost implications, researchers also measured total and component surgical costs.

To identify IDS-affiliated hospitals in the country, researchers used the Integrated Healthcare Network Profiling Solution database from IMS Health before also identifying a comparison sample of non–IDS-affiliated hospitals with similar structural characteristics.

The mean case volumes of the IDS-affiliated hospitals and the non–IDS-affiliated hospitals were evenly matched; however, researchers did note that patients treated within the IDS hospitals varied somewhat from those treated within non-IDS hospitals in characteristics such as race, admission acuity, and comorbidity.

The primary outcomes of the study were operative mortality, postoperative complications, readmissions, total surgical costs, and component surgical costs.

Researchers found that the adjusted rates for the study's quality measures were generally similar for patients in both study groups. However, they did find that those patients in IDS-affiliated hospitals who were undergoing colectomy were less likely to be readmitted (12.6%) than patients in non–IDS-affiliated hospitals (13.5%) who had the same procedure (P=.03).

When they examined the patient costs, researchers also found little difference in price-standardized total costs or component episode payments between the 2 groups after they accounted for differences in patient demographics and illness severity. There was a significant difference, however, in cost outcomes for patients receiving hip replacements. According to the data, patients undergoing hip replacement in IDS-affiliated hospitals had total episode payments that were 4% lower (P<.001) than their counterparts in non–IDS-affiliated hospitals. Researchers believed this difference was primarily due to lower expenditures for care following discharge.

They concluded the study by saying that additional efforts to improve quality and reduce costs within hospitals may be needed in addition to ACOs. However, they did acknowledge several limitations to their study. These limitations included that there is no standardized definition of an IDS, the analysis was based on only a sample of hospitals, and the study's reliance on administrative data.