Accepted Manuscript The shifting economic demands in health care. What is a pituitary surgeon to do? Theodore H. Schwartz, MD PII:
S1878-8750(14)00216-2
DOI:
10.1016/j.wneu.2014.03.003
Reference:
WNEU 2291
To appear in:
World Neurosurgery
Received Date: 20 November 2013 Accepted Date: 4 March 2014
Please cite this article as: Schwartz TH, The shifting economic demands in health care. What is a pituitary surgeon to do?, World Neurosurgery (2014), doi: 10.1016/j.wneu.2014.03.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
The shifting economic demands in health care. What is a pituitary surgeon to do?
RI PT
Theodore H. Schwartz MD
Department of Neurological Surgery, Neurology, Otolaryngology, Weill Cornell Medical
SC
College, New York Presbyterian Hospital, New York, N.Y.
Theodore H. Schwartz MD Department of Neurological Surgery Weill Cornell Medical College New York Presbyterian Hospital
New York, N.Y. 10065 [email protected]
AC C
EP
212-746-5620
TE D
525 East 68th St., Box #99
M AN U
Corresponding Author:
ACCEPTED MANUSCRIPT
As all Americans know, health care costs in the United States form an inordinately large percentage of gross domestic product. The growth of these costs, we are told, are unsustainable and have led to a close scrutiny of health care spending and methods to control cost. Hospitals
RI PT
pressure doctors to find new ways to decrease spending and increase savings, all the time careful to emphasize “quality” as the ultimate goal. The day is fast approaching when payments will be bundled into a lump sum that will be given to the hospital to cover a patient’s hospitalization as
SC
well as the doctor’s professional fees. With increasing regularity, hospitals track the costs of care for various diagnostic related groups to see if savings can be derived from more efficient
M AN U
care since the only way to increase profits under such a system will be to decrease cost. In the current paper by Thomas et al, an attempt was made to discharge all pituitary patients on postoperative day 1. Such a strategy, if it has no impact on quality or safety, would undoubtedly render significant cost savings to the institution and, if pervasive, to the health care system.
TE D
However, as with most medico-economic issues, several critical issues are raised that require more discussion.
First of all, there are two classes of pituitary patients in whom early discharge could
EP
arguably create significant safety issues, namely patients with large macroadenomas and patients
AC C
with Cushing’s Disease. Patients with large macroadenomas tend to have more firm and vascular tumors. These tumors tend to invade the cavernous sinus and also markedly compress the pituitary gland. For this reason the incidence of delayed hematoma, pseudoaneurysm formation, cerebrospinal fluid leak and hypopituitarism is much higher than with smaller microadenomas. Some institutions will routinely place a lumbar drains in these patients, either to decrease the incidence of intra-operative CSF leak (2) or post-operative CSF leak (1, 4), which can result in spinal headaches if mobilization occurs too quickly. For this reason, I suspect the
ACCEPTED MANUSCRIPT
rate of re-admission would be higher in this population if a 24 hour discharge were applied routinely throughout the nation. Such readmissions will soon not be reimbursed and ultimately could result in substantial financial loss to hospitals. Likewise, a delayed hematoma, CSF leak or
RI PT
adrenal crisis could be life-threatening and result not only in a decrease in quality of care but also an increase in litigation.
SC
Cushing’s Disease, if treated appropriately, should result in a fairly rapid drop cortisol levels. However, if the tumor is not removed with an extra-capsular en bloc resection, these
M AN U
levels can drop more slowly over a few days (3). Although one strategy is to just place all patients on post-operative hormone replacement and have the endocrinologist sort it out as an outpatient, this strategy has drawbacks. First, the unnecessary administration of steroids to patients with Cushing’s Disease and second, the inability to quickly re-operate on patients who are not cured. Hence, many surgeons will withhold steroids and check an AM cortisol each
TE D
morning until cure or non-cure is determined, which if done on an outpatient basis can be risky since adrenal crisis may not be picked up in a sufficiently expedient fashion. Again, readmission rates, adverse outcomes and litigation may result. Finally, patients with significant co-
EP
morbidities or advanced age are also at higher risk and, to the authors credit, these patients were
AC C
not excluded from the study. As it turns out, the four patients who were not discharged on POD 1 indeed had either a large tumor, Cushing’s Disease or medical comorbidities. Nevertheless, the authors of this article should be commended for an outstanding and brave study. In fact, the real brilliance of this study and the key to their success, was to create the expectation in the patients pre-operatively, that they would be discharged on POD 1 and then to use patient education and physician extender outreach to ensure the safety of the policy. I suspect that the majority of non-Cushing’s adenomas < 2 cm in diameter without significant
ACCEPTED MANUSCRIPT
medical co-morbidities can be safely discharged on POD 1 and the authors have beautifully demonstrated how to accomplish this goal.
RI PT
However, by placing all pituitary glands in one basket, the authors have created a dangerous precedent. It would be more prudent, and I would recommend, that for a future study, the authors divide their patients into two groups. In one group, namely patients with non-
SC
Cushing’s adenomas < 2 cm in diameter without significant medical co-morbidities, the goal should be a discharge on POD 1. However, for the patients who do not fit into this category,
M AN U
early discharge may be counterproductive. It would be unfortunate if an insurance plan were to read this article and decide that all pituitary tumors should be discharged on POD 1 and penalize hospitals and surgeons for a longer length of stay. I am reminded of the book of Exodus where Pharoah spent a day working alongside the Hebrew slaves to motivate them to increase their productivity in building the pyramids. After toiling twice as hard for that unique day to please
punished for their efforts.
TE D
their Pharoah, the Israelites were told that such productivity was expected every day and thus
EP
As with Pharoah, it is not clear that the motivations of the government and the insurance companies can be completely trusted to have as their goal the maintenance of quality while
AC C
reducing costs. Several examples of this abound. For example, the recent emphasis on patient satisfaction as a metric of quality appears motivated by profit hungry companies such as Press Gainey that serve to benefit economically from the hospitals use of their surveys. Indeed, good medicine often results in unsatisfied patients who must swallow a metaphorical “bitter pill” to achieve better health. Studies correlating worse outcome with higher patient satisfaction scores support this skepticism.
ACCEPTED MANUSCRIPT
Likewise, the Centers for Medicare and Medicaid have ironically instituted a “two-night” rule. This rule mandates that if a patient does not stay 2 nights in the hospital, then they are not sick enough to be considered an inpatient and should be considered in “observation” status, in
RI PT
which case only part B and not Part A is used. Ultimately, hospital reimbursements will go down with only one night stay and while it is not clear how this impacts surgical patients, it is
conceivable that a 24 hour pituitary stay will result in markedly lower hospital reimbursement for
SC
the same treatment. While one could argue that such a policy may be appropriate for certain pituitary tumors, the risk is that Pharoah may require a 24 hour stay for all pituitary tumors
M AN U
otherwise payments will be diminished. Ironically, such a rule might result in hospital pressure to physicians to keep their patients a second night even if that second night is not medically necessary.
All in all, I think it is more important for us as physicians to be less concerned with how
TE D
quickly we can discharge our patients or how cheaply we can care for our patients than in identifying those situations in which tests are ordered unnecessarily or patients are needlessly kept in the hospital. However, global rules based on diagnosis are potentially dangerous in
AC C
medical care.
EP
making physicians slaves to administrators who do not understand the nuances and art of good
ACCEPTED MANUSCRIPT
References 1.
Jakimovski D, Bonci G, Attia M, Shao H, Hofstetter C, Tsiouris AJ, Anand VK,
RI PT
Schwartz TH: Incidence and significance of intraoperative cerebrospinal fluid leak in endoscopic pituitary surgery using intrathecal fluorescein. World Neurosurgery S18788750(13)00924-8. 10.1016/j.wneu.2013.07.110., 2013.
Mehta GU, Oldfield EH: Prevention of intraoperative cerebrospinal fluid leaks by lumbar
SC
2.
cerebrospinal fluid drainage during surgery for pituitary macroadenomas. Journal of
3.
M AN U
Neurosurgery 116:1299-1303, 2012.
Monteith SJ, Starke RM, Jane JAJ, Oldfield EH: Use of the histological pseudocapsule in surgery for Cushing disease: rapid postoperative cortisol decline predicting complete tumor resection. Journal of Neurosurgery 116:721-727, 2012 Patel KS, Komotar RJ, Szentirmai O, Moussazadeh N, Raper DS, Starke RM, Anand VK,
TE D
Schwartz TH: Case-specific protocol to reduce CSF leakage after endonasal endsocopic
EP
surgery. Journal of Neurosurgery 119:661-668, 2013.
AC C
4.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S1878-8750(14)00216-2
DOI:
10.1016/j.wneu.2014.03.003
Reference:
WNEU 2291
To appear in:
World Neurosurgery
Received Date: 20 November 2013 Accepted Date: 4 March 2014
Please cite this article as: Schwartz TH, The shifting economic demands in health care. What is a pituitary surgeon to do?, World Neurosurgery (2014), doi: 10.1016/j.wneu.2014.03.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
The shifting economic demands in health care. What is a pituitary surgeon to do?
RI PT
Theodore H. Schwartz MD
Department of Neurological Surgery, Neurology, Otolaryngology, Weill Cornell Medical
SC
College, New York Presbyterian Hospital, New York, N.Y.
Theodore H. Schwartz MD Department of Neurological Surgery Weill Cornell Medical College New York Presbyterian Hospital
New York, N.Y. 10065 [email protected]
AC C
EP
212-746-5620
TE D
525 East 68th St., Box #99
M AN U
Corresponding Author:
ACCEPTED MANUSCRIPT
As all Americans know, health care costs in the United States form an inordinately large percentage of gross domestic product. The growth of these costs, we are told, are unsustainable and have led to a close scrutiny of health care spending and methods to control cost. Hospitals
RI PT
pressure doctors to find new ways to decrease spending and increase savings, all the time careful to emphasize “quality” as the ultimate goal. The day is fast approaching when payments will be bundled into a lump sum that will be given to the hospital to cover a patient’s hospitalization as
SC
well as the doctor’s professional fees. With increasing regularity, hospitals track the costs of care for various diagnostic related groups to see if savings can be derived from more efficient
M AN U
care since the only way to increase profits under such a system will be to decrease cost. In the current paper by Thomas et al, an attempt was made to discharge all pituitary patients on postoperative day 1. Such a strategy, if it has no impact on quality or safety, would undoubtedly render significant cost savings to the institution and, if pervasive, to the health care system.
TE D
However, as with most medico-economic issues, several critical issues are raised that require more discussion.
First of all, there are two classes of pituitary patients in whom early discharge could
EP
arguably create significant safety issues, namely patients with large macroadenomas and patients
AC C
with Cushing’s Disease. Patients with large macroadenomas tend to have more firm and vascular tumors. These tumors tend to invade the cavernous sinus and also markedly compress the pituitary gland. For this reason the incidence of delayed hematoma, pseudoaneurysm formation, cerebrospinal fluid leak and hypopituitarism is much higher than with smaller microadenomas. Some institutions will routinely place a lumbar drains in these patients, either to decrease the incidence of intra-operative CSF leak (2) or post-operative CSF leak (1, 4), which can result in spinal headaches if mobilization occurs too quickly. For this reason, I suspect the
ACCEPTED MANUSCRIPT
rate of re-admission would be higher in this population if a 24 hour discharge were applied routinely throughout the nation. Such readmissions will soon not be reimbursed and ultimately could result in substantial financial loss to hospitals. Likewise, a delayed hematoma, CSF leak or
RI PT
adrenal crisis could be life-threatening and result not only in a decrease in quality of care but also an increase in litigation.
SC
Cushing’s Disease, if treated appropriately, should result in a fairly rapid drop cortisol levels. However, if the tumor is not removed with an extra-capsular en bloc resection, these
M AN U
levels can drop more slowly over a few days (3). Although one strategy is to just place all patients on post-operative hormone replacement and have the endocrinologist sort it out as an outpatient, this strategy has drawbacks. First, the unnecessary administration of steroids to patients with Cushing’s Disease and second, the inability to quickly re-operate on patients who are not cured. Hence, many surgeons will withhold steroids and check an AM cortisol each
TE D
morning until cure or non-cure is determined, which if done on an outpatient basis can be risky since adrenal crisis may not be picked up in a sufficiently expedient fashion. Again, readmission rates, adverse outcomes and litigation may result. Finally, patients with significant co-
EP
morbidities or advanced age are also at higher risk and, to the authors credit, these patients were
AC C
not excluded from the study. As it turns out, the four patients who were not discharged on POD 1 indeed had either a large tumor, Cushing’s Disease or medical comorbidities. Nevertheless, the authors of this article should be commended for an outstanding and brave study. In fact, the real brilliance of this study and the key to their success, was to create the expectation in the patients pre-operatively, that they would be discharged on POD 1 and then to use patient education and physician extender outreach to ensure the safety of the policy. I suspect that the majority of non-Cushing’s adenomas < 2 cm in diameter without significant
ACCEPTED MANUSCRIPT
medical co-morbidities can be safely discharged on POD 1 and the authors have beautifully demonstrated how to accomplish this goal.
RI PT
However, by placing all pituitary glands in one basket, the authors have created a dangerous precedent. It would be more prudent, and I would recommend, that for a future study, the authors divide their patients into two groups. In one group, namely patients with non-
SC
Cushing’s adenomas < 2 cm in diameter without significant medical co-morbidities, the goal should be a discharge on POD 1. However, for the patients who do not fit into this category,
M AN U
early discharge may be counterproductive. It would be unfortunate if an insurance plan were to read this article and decide that all pituitary tumors should be discharged on POD 1 and penalize hospitals and surgeons for a longer length of stay. I am reminded of the book of Exodus where Pharoah spent a day working alongside the Hebrew slaves to motivate them to increase their productivity in building the pyramids. After toiling twice as hard for that unique day to please
punished for their efforts.
TE D
their Pharoah, the Israelites were told that such productivity was expected every day and thus
EP
As with Pharoah, it is not clear that the motivations of the government and the insurance companies can be completely trusted to have as their goal the maintenance of quality while
AC C
reducing costs. Several examples of this abound. For example, the recent emphasis on patient satisfaction as a metric of quality appears motivated by profit hungry companies such as Press Gainey that serve to benefit economically from the hospitals use of their surveys. Indeed, good medicine often results in unsatisfied patients who must swallow a metaphorical “bitter pill” to achieve better health. Studies correlating worse outcome with higher patient satisfaction scores support this skepticism.
ACCEPTED MANUSCRIPT
Likewise, the Centers for Medicare and Medicaid have ironically instituted a “two-night” rule. This rule mandates that if a patient does not stay 2 nights in the hospital, then they are not sick enough to be considered an inpatient and should be considered in “observation” status, in
RI PT
which case only part B and not Part A is used. Ultimately, hospital reimbursements will go down with only one night stay and while it is not clear how this impacts surgical patients, it is
conceivable that a 24 hour pituitary stay will result in markedly lower hospital reimbursement for
SC
the same treatment. While one could argue that such a policy may be appropriate for certain pituitary tumors, the risk is that Pharoah may require a 24 hour stay for all pituitary tumors
M AN U
otherwise payments will be diminished. Ironically, such a rule might result in hospital pressure to physicians to keep their patients a second night even if that second night is not medically necessary.
All in all, I think it is more important for us as physicians to be less concerned with how
TE D
quickly we can discharge our patients or how cheaply we can care for our patients than in identifying those situations in which tests are ordered unnecessarily or patients are needlessly kept in the hospital. However, global rules based on diagnosis are potentially dangerous in
AC C
medical care.
EP
making physicians slaves to administrators who do not understand the nuances and art of good
ACCEPTED MANUSCRIPT
References 1.
Jakimovski D, Bonci G, Attia M, Shao H, Hofstetter C, Tsiouris AJ, Anand VK,
RI PT
Schwartz TH: Incidence and significance of intraoperative cerebrospinal fluid leak in endoscopic pituitary surgery using intrathecal fluorescein. World Neurosurgery S18788750(13)00924-8. 10.1016/j.wneu.2013.07.110., 2013.
Mehta GU, Oldfield EH: Prevention of intraoperative cerebrospinal fluid leaks by lumbar
SC
2.
cerebrospinal fluid drainage during surgery for pituitary macroadenomas. Journal of
3.
M AN U
Neurosurgery 116:1299-1303, 2012.
Monteith SJ, Starke RM, Jane JAJ, Oldfield EH: Use of the histological pseudocapsule in surgery for Cushing disease: rapid postoperative cortisol decline predicting complete tumor resection. Journal of Neurosurgery 116:721-727, 2012 Patel KS, Komotar RJ, Szentirmai O, Moussazadeh N, Raper DS, Starke RM, Anand VK,
TE D
Schwartz TH: Case-specific protocol to reduce CSF leakage after endonasal endsocopic
EP
surgery. Journal of Neurosurgery 119:661-668, 2013.
AC C
4.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
