Abstract 14264: National Comparison of Hospital Market Share for Out-of-Hospital Cardiac Arrest and Elective Cardiac Surgery

Introduction: Competition in the healthcare market is a theoretical driver of innovation, cost-savings, and improved quality. When patients are treated for certain emergent conditions, such as out-of-hospital cardiac arrest (OHCA), individuals have less choice in their treating hospital. For patients undergoing elective cardiac valve replacement surgery (EVRS), hospital choice may reflect distinct referral patterns and preferences. Our objective was to compare hospital market share for different cardiac services, thus allowing for better understanding of the care landscape and target interventions to improve outcomes. Methods: Using age-eligible Medicare fee-for-service institutional claims, an emergency department (ED) treated OHCA cohort was identified via ICD-9/10 diagnosis codes and ED charges. EVRS, an inpatient referral procedure, were identified from in-patient summary claims using procedure codes. Market shares were built for each hospital by sequential addition of ZIP-code areas and calculating the hospital’s cumulative market share. Geographic market share areas were defined for each hospital at 90%, 25% and 10% cut-offs if present. Correlation between corresponding market shares and patient counts were assessed using Pearson’s r. Results: Between 1/2013 and 12/2015, we identified 206,162 EVRS claims and 222,018 OHCA claims. Median age was similar (77 vs 78 yrs), as was percent of female patient (43% vs 44%). Very few beneficiaries (0.38%) appeared in both cohorts. Many more hospitals cared for OHCA than EVRS (4482 vs 1170). More OHCA treating hospitals achieved a 25% market share (68% vs 57%) however, EVRS hospital with a 25% market share covered more population (420,294 vs 66,394) and had a greater client radius (21 vs 15 miles). Among the hospitals providing care to both cohorts, the cumulative market share and patient counts were positively correlated (r = 0.49 and 0.46 respectively, p<0.001 for both). Conclusion: Despite many more hospitals providing care for OHCA, the market share for EVRS and OHCA trend together. This market trend, combined with the association of better outcomes with higher OHCA volume suggests that OHCA should be regionalized within markets to facilities that provide elective cardiac surgical procedures.

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Abstract 271: Care Patterns for Out Of Hospital Cardiac Arrest Differ From Other Emergency Care Sensitive Conditions

Circulation ◽

10.1161/circ.142.suppl_4.271 ◽

2020 ◽

Vol 142 (Suppl_4) ◽

Author(s):

David G Buckler ◽

Douglas Wiebe ◽

Sarah Sims ◽

Ronan Doorley ◽

Alexis Zebrowski ◽

...

Keyword(s):

Cardiac Arrest ◽

Emergency Care ◽

Systems Of Care ◽

Heart Association ◽

Care Utilization ◽

Fee For Service ◽

Care Patterns ◽

Utilization Patterns ◽

Hospital Cardiac Arrest ◽

Sensitive Conditions

Background: Understanding utilization patterns for out of hospital cardiac arrest (OHCA) is critical to organizing regional systems of care as recommended by the American Heart Association. We examined the agreement between regional utilization patterns for out-of-hospital cardiac arrest (OHCA) and other emergency care sensitive conditions (ECSCs). Methods: We used Medicare fee-for-service outpatient and inpatient claims from 2013-2014 to describe geographic utilization patterns for 5 emergency care conditions as has been done previously. We compared these regional clusters developed for OHCA to similarly created clusters for other emergency cardiovascular (ECV) conditions (by adding STEMI and stroke). Regional ZIP code attributions were compared using a modified Jaccard index, measuring the agreement between region membership. We also calculated patient-level risk-adjusted survival probabilities (controlling for patient age, sex, race and presenting condition) and summarized for each region as an observed-to-expected (O:E) ratio. O:E ratios higher than 1 indicate better than expected survival. Each region was ranked based on its O:E ratio and ranks between the two sets of conditions were compared. Results: The analysis included 3,279,013 ECSC claims containing 246,342 OHCA and 1,037,472 ECV claims grouped into 234 OHCA regions and 343 ECV regions. When comparing OHCA only to all ECV utilization (clusters), agreement was 64%. O:E survival to hospital discharge for OHCA regions showed greater variability compared to ECV regions (OHCA: 0.53-2.2 vs. ECV: 0.90 - 1.10). In comparing ranked O:E outcomes between OHCA and ECV regions, we found 72% discordance in quartile rankings (κ = 0.28). Conclusion: Care utilization pattern and risk-adjusted survival for OHCA in older adults vary greatly when compared to other emergency cardiovascular conditions and should be benchmarked separately. Further research is needed to understand the role strong regionalization of care policies could play in improving outcomes and streamlining care processes.

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Abstract 134: Survival After Out-of-hospital Cardiac Arrest: The Role of Urban-rural Residence and Demographic Factors

Circulation ◽

10.1161/circ.142.suppl_4.134 ◽

2020 ◽

Vol 142 (Suppl_4) ◽

Author(s):

Ethan E Abbott ◽

David G Buckler ◽

Alexis M Zebrowski ◽

Benjamin S Abella ◽

Brendan G Carr

Keyword(s):

Cardiac Arrest ◽

Community Health ◽

Census Data ◽

Racial Composition ◽

County Level ◽

Fee For Service ◽

Post Discharge ◽

Mixed Effect ◽

Urban Rural ◽

Hospital Cardiac Arrest

Introduction: Survival to discharge after out-of-hospital cardiac arrest (OHCA) exhibits significant regional variability across communities in the US with differences in outcomes following arrest between rural, suburban, and urban communities. We examined the relationship between urban-rural residential county classification and survival following OHCA to determine if racial composition of a county and community health indicators contribute to improved outcomes following OHCA. Methods: Utilizing age-eligible Medicare fee-for-service claims data from January 2013 - December 2014, we identified OHCA patients by ICD-9-CM diagnosis code 427.5 and determined survival to discharge and at 30 days. Additional data sources included the 2013 National Center for Health Statistics (NCHS) urban-rural classification, US Census data, and County Health Rankings. Mixed effect logistic regression was used to determine the association of OHCA outcomes and NCHS classified residence, when accounting for individual age, sex, and race, county-level racial composition, poverty status, and community health measures. Results: 256,107 cases of OHCA were identified with a mean age of age of 78.7 (SD 8.5) years, 22.8% nonwhite, 47.5% female. Overall survival to discharge was 21.8% and survival at 30 days was 15.1%. Patients living in the most rural counties had increased likelihood of initial survival (aOR1.1, CI 1.0-1.1), but were associated with lower survival at 30 days (aOR 0.9, CI 0.8-0.9). Nonwhite patient race and residing in a majority nonwhite county were associated with significant decreases in the likelihood of survival to discharge and at 30 days (7% and 11%, respectively). Conclusions: Among Medicare beneficiaries, survival to discharge after OHCA was higher if residing in a non-urban community but did not persist at 30 days. OHCA patients residing in majority non-white counties were significantly less likely to survive the initial hospitalization and to 30-days post discharge. More study is needed to elucidate these disparities and determine if modifiable county level health factors exist that could contribute to improvements in OHCA survival.

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Abstract 11759: Survival Among Medicare Beneficiaries After Out-of-Hospital Cardiac Arrest Undergoing Interhospital Transfer

Circulation ◽

10.1161/circ.144.suppl_2.11759 ◽

2021 ◽

Vol 144 (Suppl_2) ◽

Author(s):

Ethan Abbott ◽

David Buckler ◽

alexis zebrowski ◽

Benjamin Abella ◽

Brendan G Carr

Keyword(s):

Cardiac Arrest ◽

Index Volume ◽

Statistical Significance ◽

Fee For Service ◽

Medicare Beneficiaries ◽

Interhospital Transfer ◽

Diagnosis Codes ◽

Comorbidity Index ◽

Index Hospital ◽

Hospital Cardiac Arrest

Intro: Among individuals treated for out-of-hospital cardiac arrest (OHCA), there is hospital-level variability in mortality, but the relationship between interhospital transfer (IHT) OHCA volume and survival remain unclear. We sought to examine the association of OHCA volume and survival for individuals undergoing IHT. Methods: Utilizing age-eligible Medicare fee-for-service claims, we identified an emergency department treated OHCA cohort using ICD-9/10 diagnosis codes. Hospital OHCA volume was defined as the total number of index (first-treated) OHCA claims during the study period and were binned into quartiles. Each claim was assigned the OHCA volume quartile of the index hospital and the index volume of the receiving hospital. Multiple logistic regression was conducted to assess the association between initial and receiving hospital volume categories and survival to 30 days among IHT patients while controlling for patient-level characteristics (age, sex, race), comorbidity index, urbanicity of index hospital and days to transfer. Results: We identified a cohort of 222,018 claims at 4,461 hospitals between 1/2013-12/2015. Median age was 78 years (IQR 71-85); 44% were female; 11% of the cohort was alive at 30 days. IHT occurred in 12,245 cases (5.5%) and 59% of transfers occurred on the day of admission or day 1. Transfers originated from 3411 index hospitals and 1566 receiving hospitals. Median OHCA hospital index volume was 25 [IQR 9, 67]. Adjusted odds of survival at 30 days was significantly lower at index hospitals with lower OHCA volumes compared to the highest volume category (aOR [95%CI] Q2: 0.71 [0.6, 0.83] p<0.001). Additionally, odds of survival at 30 days was significantly lower at low volume receiving hospitals (aOR [95%CI] Q1: 0.73 [0.55, 0.99] p<0.001), and increased for higher OHCA volume receiving hospitals, but these groups did not achieve statistical significance. Conclusion: For Medicare beneficiaries who suffer an OHCA and undergo IHT, lower index and receiving hospital OHCA volume was significantly associated with decreased adjusted odds of 30-day survival. Further exploration of hospital characteristics, timing, and transfer patterns is needed to understand differences in benefit for OHCA patients undergoing IHT.

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Audit Firm Industry Specialization as a Differentiation Strategy: Evidence from Fees Charged to Firms Going Public

Auditing A Journal of Practice & Theory ◽

10.2308/aud.2003.22.2.33 ◽

2003 ◽

Vol 22 (2) ◽

pp. 33-52 ◽

Cited By ~ 189

Author(s):

Brian W. Mayhew ◽

Michael S. Wilkins

Keyword(s):

Market Share ◽

Cost Savings ◽

Audit Fees ◽

Industry Specialization ◽

Audit Firm ◽

Differentiation Strategy ◽

Market Shares ◽

Audit Firms ◽

Bargaining Position ◽

The Impact

This paper examines IPO audit fees to assess the use of industry specialization as a differentiation strategy by audit firms. We extend existing theory on the impact of industry specialization on audit fees by incorporating Porter's (1985) theory of competition and differentiation. We suggest that market share enables audit firms to gain competitive advantages in terms of cost and service. However, the impact of such advantages on fees depends on whether the audit firm has successfully differentiated itself from competitors within client industries. Our results indicate that as audit firm industry market share increases without a differentiation in market share, the audit fee charged for a given IPO decreases. In the context of Porter (1985), this result suggests that the client is able to bargain for a portion of the auditor's cost savings because the audit firm has not successfully differentiated itself from competitors. In contrast, we show that audit firms that possess significantly higher market shares than their industry competitors earn fee premiums, suggesting that audit firms that have successfully differentiated themselves retain a stronger bargaining position with their clients.

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