Cheryl Fahlman, PhD Phil Kletke, PhD Chuck Wentworth, MS Jon Gabel, MS

1. A Comparison of Quality of Care in General Hospitals, Specialty Hospitals, and Ambulatory Surgery Centers Academy Health Annual Research Meeting 2006 Seattle WA Cheryl Fahlman, PhD Phil Kletke, PhD Chuck Wentworth, MS Jon Gabel, MS Funded by the BlueCross BlueShield Association

2. INTRODUCTION • Currently more than 100 physician owned niche hospitals and 3800 ASCs • Supporters claim they are “focused factories” more efficient at delivering selected services • Offering higher “quality” of care relative to general hospitals • Very limited published research on quality in physician owned niche hospitals and none for ASCs

3. Background • MedCath funded 2 studies that found their hospitals had lower mortality rates then competitors • CMS (2005) reported cardiac hospitals performed better on 13 of 14 AHRQ Patient Safety Indicators • NBER researchers looked at one-year readmission and mortality rates for CHF or AMI, they found no differences • Cram et al (2005) found no differences after adjusting for patient characteristics and procedure volume

4. Purpose • Provide additional information on the quality of care provided in specialty hospitals compared to general hospitals • Look at the quality of care in ASCs as opposed to hospital outpatient departments

5. Methodology • Design – • Retrospective claims analysis using logistic regression • Sample population – • Members of a large national health plan, continuously enrolled for 2001-2003 • Concentrated in areas with high ASC or niche hospital activity (TX, PA, KS, AZ, CA and LA) • Members between 18 and 64 years old • Unit of analysis – • Episode of care (as defined by Symmetry Health Data Systems software)

6. Methodology • Quality of care (DV) was defined as • Readmission rates within 30 days • Additional surgery within 30 days • Surgical complications within 30 days • Mortality rates within 30 days • Explanatory variables (IV) were: • Severity of illness (based on services and expenditures in the previous year) • Socio-demographic characteristics of the patient • Socio-economic characteristics of the patient’s county of residence

7. Results • Inpatient care procedures included: • Knee replacements (n=556) • Hip replacements (n=1,005) • Coronary artery bypass grafts (CABG) (n=843) • Percutaneous coronary interventions (PCI) (n=1,824) • Heart stents (n=135) • Ambulatory care procedures included: • Gastrointestinal procedures (n=49,914) • Back procedures (n=2,652) • Finger/hand/wrist procedures (n=4,009)

8. Results • Very few adverse outcomes associated with any facility type for either outpatient or inpatient procedures • Most common adverse outcome for all procedures in any setting was the occurrence of additional surgery within 30 days • Specialty hospitals had lower overall rates of negative outcomes for all the in-patent hospital procedures • not statistically significant due to the small number of observations for specialty hospitals

9. Results • ASCs have fewer adverse outcomes for outpatient gastrointestinal procedures (OR=0.73; 95% CI=0.58-0.92 • In specialty hospitals only cardiac procedures have fewer adverse outcomes (OR=0.15; 95% CI=0.04-0.60). • Based on the risk adjustor there was no “cherry-picking”

10. Study Limitations • Episode software is unable to distinguish between additional surgery required because of the course of the condition and surgery directly related to an adverse outcome • While a patient is in the hospitals we are unable to measure selected outcomes of interest • Study sample is younger and more likely healthier than the Medicare population

11. Summary • Quality of care in ASCs and specialty hospitals is equal to or better than care in general hospitals

12. Policy Significance • For insurers, public policy makers, and beneficiaries the most important fact is that both ASCs and specialty hospitals have similar or even slightly better quality of care for a working age population