Bhattacharyya N, Abemayor E. Combined Changing Patterns of Hospital Utilization for Head and Neck Cancer CareImplications for Future Care. JAMA Otolaryngol Head Neck Surg. 2013;139(10):1043-1048. doi:10.1001/jamaoto.2013.4525
The care of patients with head and neck cancer is labor and cost intensive. Although several studies have focused on clinical outcomes with regionalization of care of such patients, it remains uncertain if and where such concentrations of care are occurring. A better understanding of how care is distributed will improve our understanding of the financial and educational impact of compacting treatment of these patients.
To determine if regionalization of head and neck cancer care has occurred over the past decade with respect to hospital size and teaching hospital status.
Design and Setting
Secondary analysis of national health care database.
All inpatient admissions with a primary head and neck cancer diagnosis contained within the Nationwide Inpatient Sample during the calendar years 2000, 2005, and 2010.
Main Outcomes and Measures
The percentage distributions of head and neck cancer cases with respect to hospital teaching status, hospital bed size, and primary payer were compared according to calendar year to determine temporal changes. Multivariate analysis was conducted to determine year-to-year changes in proportion of head neck cancer admissions, controlling for geographic region, hospital bed size, and expected source of payment.
The estimated inpatient hospital head and neck cancer stays in the United States in 2000, 2005, and 2010 (with standard error of the national estimate) were 28 862 (2067), 33 517 (3080), and 37 354 (4194), respectively. The percentage of admissions to teaching hospitals increased from 61.7% to 64.2% and 79.8%, respectively. Similarly, the percentage (with standard error) of cases in large–bed-size hospitals increased from 69.2% (2.8%) to 71.4% (3.8%) and 73.3% (4.8%), respectively. The primary expected payer distribution did not change significantly over the study (Medicare, 39.6% [1.4%]; Medicaid, 17.4% [2.2%]; private insurance, 33.3% [2.4%]; and other, 9.7% [1.5%] in 2010). The adjusted odds ratio for head neck cancer case being admitted to a teaching institution for 2010 vs 2000 was 2.5 (95% CI, 1.6-3.7).
Conclusions and Relevance
Head and neck oncologic care is increasingly being regionalized to teaching hospitals and academic centers. Such regionalization also has important implications for future education of residents and measures of achieved competency.
The care of patients with head and neck cancer is arguably one of the most labor-intensive and resource-consuming aspects of the practice of otolaryngology–head and neck surgery. Providing clinical care to such patients has always been challenging because they are commonly older individuals with concurrent comorbidities, including histories of smoke and alcohol abuse, poor nutrition, and other age- and substance-related medical comorbidities.1 Furthermore, the advent of chemotherapy and radiotherapy for malignant neoplasms of the head and neck has further skewed a portion of the head and neck cancer population, particularly those undergoing salvage surgery, to an even more complex disease state.
Over the past decade, we have observed a trend toward a greater number of patients with head and neck cancer receiving care at teaching hospitals and academic institutions, as opposed to local or community-based institutions. While the reasons for this are multifactorial, a shift in the burden of care for head neck cancer to academic and teaching institutions will likely have major implications in the provision, costs, and accessibility of care. In addition, because many patients with head and neck cancer are uninsured or underinsured, a shift in the demographics of head and neck cancer care may unfairly burden certain types of institutions not only with cases of increasingly complicated and advanced-stage head neck cancer, but also with the difficulty of poorer reimbursement for such care.2,3
We sought to determine recent temporal trends in the distribution of head and neck cancer care among teaching and nonteaching institutions, as well as insurance aspects that may affect the reimbursement for this care. Improving our understanding of trends in head and neck cancer care is likely to have important implications for resident training, patient expectations, and future resource allocation for the cohort of patients with head and neck cancer.
The data source for this study consisted of the Nationwide Inpatient Sample (NIS) for the calendar years 2000, 2005, and 2010. This study was deemed exempt from review by our hospital institutional review board. For each of these calendar years, all admissions with a primary diagnosis of head and neck cancer were extracted according to the diagnosis clinical classification software code for head and neck cancer (group 11, “cancer of the head and neck”). Admissions could be for surgical and/or nonsurgical services. The data were then imported into SPSS version 17.0 statistical software (SPSS Inc) for analysis. For each admission, extracted data included International Classification of Diseases, Ninth Revision (ICD-9) codes, hospital bed size, hospital teaching status, and primary expected payer for the hospital stay. In the NIS, hospital bed size is categorized as small, medium, or large. The primary expected payer field is classified as Medicare, Medicaid, private insurance, or other.
For each of the 3 sampled calendar years, the raw sample size, weighted estimate, and percentage distribution of head and neck cancer cases with respect to teaching status, hospital bed size, and primary expected payer were determined. Taking into account weighting and stratification variables in the NIS that account for sampling and survey design, we conducted univariate χ2 comparisons for these proportions according to calendar year to determine if changes in the distribution of cases among these differing hospitals’ characteristics occurred over time. Next, multivariate analysis was conducted with logistic regression to determine if year-to-year changes in the proportion of head neck cancer admissions to the teaching hospital setting were significant, while controlling for hospital geographic region, hospital bed size, and expected source of payment.
Finally, the distribution of the primary expected payer across hospital teaching status over time (2010 vs 2000) was also compared. Statistical significance was set at P = .05. Statistics are presented as the weighted estimate and standard error where appropriate. Statistics were considered reliable if the relative standard error was less than 30% according to published recommendations.
The estimated inpatient hospital head and neck cancer stays in the United States in 2000, 2005, and 2010 (with standard error of the national estimate) were 28 862 (2067), 33 517 (3080), and 37 354 (4194), respectively (unweighted numbers, 5869, 6759, and 7371, respectively). Table 1 demonstrates the top 25 annual admitting ICD-9 diagnoses averaged over the aggregate 3 yearly cohorts.
Table 2 and Table 3 present the relative distributions of head neck cancer inpatient stays over the 3 calendar years according to hospital status, teaching vs nonteaching. A statistically significant increase in proportion of stays for teaching hospitals from 61.7% to ultimately 79.8% (P < .001) was observed, with the predominant change occurring between 2005 and 2010.
Table 2 and Table 3 also present the relative distribution of inpatient head neck cancer stays according to hospital bed size. The number of admissions to medium–bed-size hospitals for head neck cancer inpatient stays decreased by 2010, although the overall change was not statistically significant (P = .36). Multivariate logistic regression analysis determined that the increase in proportion of cases at teaching hospitals over the calendar years of the study, particularly for the shift in proportion from 2005 to 2010, remained significant even when adjusting for hospital region, hospital bed size, and expected source of payment (P < .001). The adjusted odds ratio for a head neck cancer case being admitted to a teaching institution for 2005 vs 2000 was 1.1 (95% CI, 0.7-1.7). In contrast, adjusted odds ratio for a case being admitted to a teaching institution for 2010 vs 2000 was 2.5 (95% CI, 1.6-3.7).
Finally, Table 2 and Table 3 demonstrate the distribution of expected primary payer for the inpatient head neck cancer stay across the initial and final calendar years of the study. Medicare and Medicaid together accounted for greater than 50% of the expected primary payer source throughout the study, with no significant differences between the calendar years 2000 and 2010 (P = .82).
Table 4 depicts the expected primary payer distribution in 2010 vs 2000 according to teaching status of the hospital for the inpatient stay. In 2010, teaching hospitals had slightly lower rates of Medicare primary care and slightly higher rates of Medicaid and private insurance as the primary payers compared with nonteaching hospitals. Overall, there was no statistically significant difference in payer mix between teaching and nonteaching hospitals (P = .07).
The present data demonstrate several noteworthy points. First, as expected, and in keeping with a slowly increasing aging population, there were an increasing number of inpatient hospital stays for head and neck cancer over the 3 study years, each spaced 5 years apart. This represents a percentage increase of approximately 29%. Second, we found a relative concentration or “regionalization” of inpatient head and neck cancer care evolving by the year 2010, such that almost 80% of inpatient cancer care occurred at teaching hospitals. We did not find a significant overall change in the distribution of cases among size of hospital, nor did we find a change in the distribution of payers for the inpatient cancer care.
Although not analyzed in the present study, the proportional increase in head and neck cancer care in teaching hospitals is expected to continue beyond 2013, as it did between 2000 and 2010.These data parallel studies by Gourin et al4 and Jalisi et al,5 who reported increasing volumes of high-intensity head and neck surgical procedures in high-volume hospitals. The expectation would be that a higher-volume inpatient surgical care should result in an overall decrease in complications due to integration of care. However, a recent study by Miller et al6 fails to support this hypothesis. They compared the quality and cost of inpatient surgery among patients receiving 4 common surgical procedures including coronary artery bypass grafting, hip replacement, colectomy, and back surgery performed in integrated vs nonintegrated delivery systems. They found that the putative benefits of lower complications and cost containment observed in outpatient integrated health systems may not be seen in inpatient surgical procedures in integrated health systems. Thus, although counterintuitive, increasing regionalization of head and neck cancer care may not necessarily be reflected in overall decreased patient cost. Although not analyzed in the present study, it is possible that increased regionalization of care to academic institutions could potentially result in an increase in overall costs of care. This implication argues for a review of reimbursement formulas used by Medicare and private insurers with careful attention to complexity of care and not just using isolated billing codes. Because it seems likely that “bundling” of hospital payments will be the future norm, the onus is clearly shifting to the surgical community to produce improved measures of risk and outcome and not tying reimbursement to ICD-9 codes and complications alone.7
Regionalization of high-intensity head and neck cancer care is not a new concept and has been advocated on multiple occasions. Weber8 cited an increased direction of patients with head and neck cancer to regional and tertiary care facilities with specialty expertise as a method for reducing costs and improving the quality of care, and Cummings9 also advocated such a shift. The present data support the suspicion that regionalization of head and neck cancer care is indeed occurring, particularly in the latter half of this decade, even while adjusting for other factors such as hospital geographic region, hospital bed size, and expected source of payment. Whether such regionalization will be followed by decreased unit costs of care remains to be determined.
On the positive side, regionalization of head and neck cancer care to teaching institutions is likely to offer significant individual patient and societal benefit, although such benefits will need to be confirmed over time. First, teaching institutions are more likely to have in place the necessary support staff, adjunct services, and familiarity with recovery for complex head and neck surgical procedures. The value and necessity of multidisciplinary care for the head and neck surgical patient is becoming increasingly important and recognized.10 Second, teaching hospitals are more likely to achieve higher volumes for many of the less commonly performed head and neck surgical procedures such as microvascular free tissue transfer. The net result of such an increase in volume would be anticipated improved quality and outcomes.
However, this trend of concentration of care also compels us to reconsider the goals of basic otolaryngology–head and neck surgical training. Simply put, although residents may have significant exposure to complex head and neck surgical procedures during training, the evidenced regionalization of procedures implies that after completion of residency training and while in clinical practice, subsequent exposure to such cases may be rather limited. This suggests that a revamping of the goals and objectives of residency training as they pertain to head and neck surgical oncology might need to be undertaken, especially if concentration trends continue.
Low-intensity head and neck procedures (arbitrarily defined by a group of operations, eg, neck dissections, total laryngectomies) certainly should form a portion of basic resident education. However, it cannot be expected that the practitioner in a nonacademic setting should assume the responsibility or difficulties of managing free tissue transfers, partial laryngeal surgery, or the like. The observed regionalization of complex head and neck cases logically requires revision of what constitutes the basic body of knowledge needed to certify the majority of trainees in otolaryngology vs the more specialized body of knowledge (a step below fellowship education) needed for more-focused, high-volume care. For example, there are significant differences between a total laryngectomy without prior radiation therapy and a total laryngectomy after chemoradiotherapy.
Such a shift in resident education accompanying increasing regionalization of care has been eloquently advocated for general surgery by Pellegrini et al11 and, most recently, for head and neck surgery by Weber.12 With the demonstrated regionalization in head and neck cancer care, early subspecialization should strongly be considered for integration into the resident curriculum. This would be particularly appropriate for trainees with a strong interest in a career in head and neck oncology. Indeed, early subspecialization, with the increasing skills required for complex surgical procedures, has also been advocated and been shown to be a viable model for general surgery.13 As Weber12 has pointed out, such a “paradigm shift” in resident education would require active participation by a variety of stake holders and not be generalized across all training program. We acknowledge, however, that this will likely remain controversial.
In an important part of our analysis, we did not find any substantial changes in the distribution of payer for inpatient head neck cancer stays. This is not surprising because most head neck cancer occurs among patients older than 65 years, and most of this patient population would be covered by Medicare. Surprisingly, we did not find any maldistribution of payers among teaching hospitals across the calendar years of study. In other words, whereas cases seem to be shifting toward teaching institutions, teaching institutions are not yet being burdened with an unfair distribution of payers. Whether such a trend persists into the era of rising HPV-related head and neck tumors remains to be determined. Despite the lack of maldistribution of payers, it is more than likely that academic institutions will be prone to suffering fiscal consequences because of the intrinsic discrepancies between reimbursement and costs of head and neck cancer care. The cost of treating patients with head and neck cancer is high, especially those treated with 3 modalities.14 With this in mind, irrespective of payer distribution, such intrinsically more-expensive care must be part of the discussion between hospitals, health care providers, and payers when bundled payments are made if the fiscal viability of academic institutions is to be maintained.
Submitted for Publication: June 9, 2013; final revision received July 11, 2013; accepted July 17, 2013.
Corresponding Author: Elliot Abemayor, MD, PhD, Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, CHS 62-132, Los Angeles, CA 90095-1624 (firstname.lastname@example.org).
Published Online: September 5, 2013. doi:10.1001/jamaoto.2013.4525.
Author Contributions: Drs Bhattacharyya and Abemayor had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Both authors.
Acquisition of data: Both authors.
Analysis and interpretation of data: Both authors.
Drafting of the manuscript: Both authors.
Critical revision of the manuscript for important intellectual content: Both authors.
Statistical analysis: Bhattacharyya.
Administrative, technical, or material support: Both authors.
Study supervision: Bhattacharyya.
Conflict of Interest Disclosures: None reported.
Correction: This article was corrected on December 19, 2013 for an error in the title.