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  • br Keywords Health care quality indicators Hospital emergenc


    Keywords: Health care quality indicators, Hospital emergency service, Renal-cell carcinoma
    1Department of Health Policy and Administration, Pennsylvania State University, University Park, PA
    2Penn State Cancer Institute, Hershey, PA 3Department of Public Health Sciences, Pennsylvania State University, Hershey, PA 4Division of Urology 5Department of Surgery, Penn State College of Medicine, Hershey, PA
    Address for correspondence: Joel E. Segel, PhD, Department of Health Policy and
    Administration, Pennsylvania State University, 504 S Ford Building, University Park,
    As the costs of cancer care, including those of kidney cancer, continues to increase,1-3 one area that has been targeted as a potential driver is the increase in emergency department (ED) utilization.4,5 For example, cancer patients have significantly higher rates of ED utilization with an average of 2 visits per year compared to the 0.17 average visits for patients without cancer.4,5 Furthermore, over 4% of all ED visits (or over 29 million visits) in the US between 2006 and 2012 were for cancer patients.6 In response to the escalating costs, payers have been increasingly turning to alternative payment models that emphasize paying for value rather than volume.7-9 While defi-nitions of value vary, the definitions broadly capture some measure of quality per dollar spent.7
    The importance of this Fer-1 shift towards value-based payment models has been highlighted by the Centers for Medicare and Medicaid Services (CMS) call for 90% of Medicare fee-for-service programs to be tied to quality or value by 2018.10 While this broad target has not been met, in the oncology field the CMS Oncology Care Model (OCM) was launched in 2016, with the goal of aligning provider incentives with oncology care quality improvement.11 More specifically, the OCM provides each pilot facility with a fixed per-beneficiary payment to coordinate all aspects
    of chemotherapy patient care as well as the possibility for additional payments if certain cost and quality targets are attained.12,13 One of
    the quality metrics included in the OCM is risk-adjusted ED visits, which is included specifically as a target by which more efficient care could potentially improve quality and lower costs.1,2,11,14
    While this is one of the first instances in which risk-adjusted ED visits has been included as a measure of quality or value in oncology care, several articles have highlighted that some cancer patients’ ED visits may be avoidable,15 especially for those receiving palliative or hospice care.15 While few studies directly address whether specific ED visits may be preventable,16 a systematic review found that the median rate of ED visits leading to admissions was 58%,17 suggesting many could potentially be addressed in an outpatient setting.
    With respect to kidney cancer, several studies have examined the costs associated with surgical management of pesticides disease. Recently, Jeong and colleagues showed that use of robotic technology for kidney cancer surgery was associated with greater cost but without improvement in perioperative outcomes.18 Furthermore, there is evidence suggesting an association of postoperative complications and associated costs, irrespective of surgical approach.19 However, this study focuses exclusively on events occurring in the inpatient setting without factoring in outpatient ED or clinic visits and associated readmissions.
    Despite the considerable work looking at quality of care among kidney cancer patients, there has been little work studying ED visits among kidney cancer patients undergoing surgery; and no study has estimated what a hospital’s risk-adjusted ED visit rate might capture relative to other metrics for kidney cancer patients. More specifically, the association between a hospital’s risk-adjusted ED rate for kidney cancer patients and other commonly reported quality measures (such as risk-adjusted mortality rates) or costs is not known. In this study we fill this gap with important implications for how patients, payers, and providers understand the newly incorporated risk-adjusted ED rate as a measure of quality for kidney cancer patients. Because surgery tends to be the primary, initial treatment for renal cell carcinoma,20 we focus on surgery as the index treatment rather than chemotherapy as in the OCM. However, given the increasing desire to expand bundled pay-ment models more fully across oncology care,21 this study presents an important test case of what a quality measure such as risk-adjusted ED visit rates may capture for renal cell carcinoma treatment providers.
    Patients and Methods
    We used 2007-2012 Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data. The data combine SEER cancer registry data from all newly diagnosed cancer patients in 12 geographically diverse states as well as Detroit and Seattle with Medicare claims data for Medicare-eligible patients. The merged