Endocrine surgery as a model for value-based health care delivery

Abstract

Background: Experts advocate restructuring health care in the United States into a value-based system that maximizes positive health outcomes achieved per dollar spent. We describe how a value-based system implemented by the University of California, Los Angeles UCLA Section of Endocrine Surgery (SES) has optimized both quality and costs while increasing patient volume.

Methods: Two SES clinical pathways were studied, one allocating patients to the most appropriate surgical care setting based on clinical complexity, and another standardizing initial management of papillary thyroid carcinoma (PTC). The mean cost per endocrine case performed from 2005 to 2010 was determined at each of three care settings: A tertiary care inpatient facility, a community inpatient facility, and an ambulatory facility. Blood tumor marker levels (thyroglobulin, Tg) and reoperation rates were compared between PTC patients who underwent routine central neck dissection (CND) and those who did not. Surgical patient volume and regional market share were analyzed over time.

Results: The cost of care was substantially lower in both the community inpatient facility (14% cost savings) and the ambulatory facility (58% cost savings) in comparison with the tertiary care inpatient facility. Patients who underwent CND had lower Tg levels (6.6 vs 15.0 ng/mL; P = 0.024) and a reduced need for re-operation (1.5 vs 6.1%; P = 0.004) compared with those who did not undergo CND. UCLA maintained its position as the market leader in endocrine procedures while expanding its market share by 151% from 4.9% in 2003 to 7.4% in 2010.

Conclusions: A value-driven health care delivery system can deliver improved clinical outcomes while reducing costs within a subspecialty surgical service. Broader application of these principles may contribute to resolving current dilemmas in the provision of care nationally.

Keywords: Cost; electronic health record; endocrine surgery; patient value.

Figure 1

Growth in endocrine case volume in UCLA SES from 2009 to 2012

Figure 2

Relative mean cost per case in different UCLA SES facilities (2005-2010); ^*** P<0.0001

Figure 3

Influence of CND on Tg Levels and re-operation rates. ^*P<0.05. Adapted from: Popadich A, Levin O, Lee JC, Smooke-Praw S, Ro K, Fazel M, Arora A, Tolley NS, Palazzo F, Learoyd DL, Sidhu S, Delbridge L, Sywak M, Yeh MW. A multicenter cohort study of total thyroidectomy and routine central lymph node dissection for cN0 papillary thyroid cancer. Surgery. 2011 Dec;150(6):1048-57

Figure 4

Choropleth maps illustrating distribution of ZIP code of origin for UCLA SES patients in 2006 (a) and 2010 (b)

Figure 5

Distribution of market share for endocrine procedures, 8-county region (Los Angeles, Orange, Riverside, San Bernandino, Ventura, Santa Barbara, Kern, San Luis Obispo), fiscal years 2003-2010

Figure 6

The virtuous circle in health care delivery. Adapted from: Porter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Boston: Harvard Business School Press, 2006