Utilization of Procedures by Hospital Referral Region Presentation to Joint Hearing: House Committee on Public Health and Appropriations Subcommittee on General Government and Health and Human Services May 10, 2010 Sylvia Cook Center for Health Statistics Department of State Health Services

Health Care Data Collection “…shall develop a statewide health care data collection system to collect health care charges, utilization data, provider quality data, and outcome data to facilitate the promotion and accessibility of cost-effective, good quality health care” Section 108.006 (a), Texas Health and Safety Code May 10, 2010

Inpatient Discharge Data Collected from over 500 hospitals licensed or owned by the state Record of each hospital stay Released quarterly Available for 1999 through 1st quarter 2009 Exemptions from reporting Hospitals located in counties with population less than 35,000 Hospitals that do not seek reimbursement for providing medical services May 10, 2010

Map of hospitals This map shows the counties where hospitals are required to report data. Counties with no hospital had a total population of 498,164 in 2000. Counties where the hospitals are not required to report had a total population of over 1.2 million in 2000. A Critical Access Hospital (CAH) is a hospital that is certified to receive cost-based reimbursement from Medicare. May 10, 2010

Utilization Review Inpatient Procedures by Hospital Referral Region, 2007 Primary C-Section State of Texas 18.92 Abilene 18.51 Amarillo 16.94 Austin 18.25 Beaumont 29.13 Bryan 15.83 Corpus Christi 20.75 Dallas 18.73 East Texas 23.44 El Paso 23.06 Fort Worth 16.72 Harlingen 21.98 Houston 17.72 Longview 20.85 Lubbock 21.07 McAllen 23.40 Odessa 13.69 San Angelo 16.01 San Antonio 20.81 Temple 17.48 Texarkana 18.95 Tyler 16.07 Victoria 22.50 Waco 18.50 Wichita Falls 9.81 Seven inpatient procedures for which there is national concern about over-use, under-use or inappropriate use. Hospital service areas (HSAs) are local health care markets for hospital care. An HSA is a collection of ZIP codes whose residents receive most of their hospitalizations from the hospitals in that area. Hospital referral regions (HRRs) are regional market areas for tertiary medical care. Each HRR contains at least one hospital that performs major cardiovascular procedures and neurosurgery. Patients can receive very different care depending on where they live. Number of primary cesarean sections per 100 deliveries Cesarean section (C-section) is the birth of a baby through surgical incisions (cuts) made in the abdomen and uterus of the mother. C-section rates vary significantly from region to region. Institutions that serve as referral centers may experience larger numbers of high-risk deliveries which require C-section, but other less-well defined factors also produce variation in the utilization of this procedure. May 10, 2010

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Utilization Review Inpatient Procedures by Hospital Referral Region, 2007 Vaginal Birth After Previous Cesarean Section State of Texas 6.06 Abilene 1.77 Amarillo 7.59 Austin 10.25 Beaumont 0.98 Bryan 6.58 Corpus Christi 2.62 Dallas 5.95 East Texas 7.69 El Paso 7.22 Fort Worth 7.05 Harlingen 1.92 Houston 6.97 Longview 1.68 Lubbock 7.52 McAllen 3.18 Odessa 8.81 San Angelo 4.10 San Antonio 4.07 Temple 11.67 Texarkana 4.94 Tyler 6.04 Victoria 1.01 Waco 5.40 Wichita Falls 28.71 Seven inpatient procedures for which there is national concern about over-use, under-use or inappropriate use. There are wide regional variations in clinical practice for these procedures. 'Utilization' refers to the degree to which these procedures were performed: Hospital Referral Regions, defined by the Dartmouth Atlas of Healthcare. Hospital referral regions (HRRs) represent regional health care markets for tertiary medical care. Patients in these regions are typically referred to specialists in a central city in the region. May 10, 2010

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Utilization Review Inpatient Procedures by Hospital Referral Region, 2007 Incidental Appendectomy Among the Elderly State of Texas 1.70 Abilene 0.55 Amarillo 1.46 Austin 2.43 Beaumont 2.24 Bryan 1.78 Corpus Christi 3.14 Dallas 1.37 East Texas 0.00 El Paso 3.52 Fort Worth 1.20 Harlingen 2.64 Houston 1.61 Longview 0.74 Lubbock 1.17 McAllen 2.07 Odessa 1.33 San Angelo 0.93 San Antonio 1.87 Temple 2.15 Texarkana 0.00 Tyler 2.01 Victoria 2.59 Waco 0.54 Wichita Falls 3.74 Seven inpatient procedures for which there is national concern about over-use, under-use or inappropriate use. There are wide regional variations in clinical practice for these procedures. 'Utilization' refers to the degree to which these procedures were performed: Hospital Referral Regions, defined by the Dartmouth Atlas of Healthcare. Hospital referral regions (HRRs) represent regional health care markets for tertiary medical care. Patients in these regions are typically referred to specialists in a central city in the region. Number of incidental appendectomies per 100 discharges age 65 or older with an intra-abdominal procedure May 10, 2010

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Utilization Review Inpatient Procedures by Hospital Referral Region, 2007 Hysterectomy State of Texas 2.94 Abilene 2.87 Amarillo 3.33 Austin 2.65 Beaumont 2.26 Bryan 3.50 Corpus Christi 3.18 Dallas 3.19 East Texas 2.70 El Paso 2.74 Fort Worth 3.19 Harlingen 2.74 Houston 2.83 Longview 3.21 Lubbock 3.42 McAllen 2.23 Odessa 3.60 San Angelo 3.11 San Antonio 2.91 Temple 2.54 Texarkana 2.83 Tyler 2.55 Victoria 3.47 Waco 3.29 Wichita Falls 1.62 Number of hysterectomies per 100 female discharges age 18 or older Hysterectomy is the surgical removal of the uterus in women. It is a common surgical procedure performed for a great variety of indications, not all of which are agreed upon by practitioners, leading to substantial regional and interfacility variation in rates. As in other therapies for which evidence is less than compelling, rates of this procedure may depend upon traditional practice, rather than agreed-upon indications. This table excludes hysterectomies with diagnoses of genital cancer and pelvic or lower abdominal trauma. Inpatient discharges related to pregnancy and childbirth (maternal discharges) are also excluded from the table. May 10, 2010

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Utilization Review Inpatient Procedures by Hospital Referral Region, 2007 Laminectomy and/or Spinal Fusion State of Texas 2.00 Abilene 1.94 Amarillo 3.34 Austin 1.88 Beaumont 2.36 Bryan 2.89 Corpus Christi 1.74 Dallas 2.18 East Texas 0.00 El Paso 1.55 Fort Worth 2.09 Harlingen 1.33 Houston 1.86 Longview 2.66 Lubbock 1.94 McAllen 0.91 Odessa 2.35 San Angelo 3.37 San Antonio 2.05 Temple 0.80 Texarkana 3.25 Tyler 2.58 Victoria 1.35 Waco 2.73 Wichita Falls 0.61 Number of laminectomies or spinal fusions per 100 discharges age 18 or older Laminectomy (removal of a portion of vertebra) and spinal fusion (stabilization of a part of the spine by fusing vertebrae together) are commonly performed for chronic back pain. Utilization of these procedures vary substantially by source of insurance, type of facility (teaching vs. nonteaching), and other nonclinical demographics. There is some evidence to suggest that nonsurgical treatment may produce similar outcomes, and few evidence-based studies exist comparing one form of therapy to another. Inpatient discharges related to pregnancy and childbirth (maternal discharges) are excluded from the table. May 10, 2010

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Utilization Review Inpatient Procedures by Hospital Referral Region, 2007 Coronary Artery Bypass Graft State of Texas 1.27 Abilene 1.53 Amarillo 1.39 Austin 1.43 Beaumont 1.17 Bryan 2.21 Corpus Christi 1.21 Dallas 1.19 East Texas 0.00 El Paso 0.90 Fort Worth 1.14 Harlingen 1.37 Houston 1.05 Longview 1.32 Lubbock 1.71 McAllen 2.35 Odessa 1.13 San Angelo 1.62 San Antonio 1.47 Temple 1.11 Texarkana 1.55 Tyler 1.60 Victoria 0.63 Waco 1.69 Wichita Falls 0.99 Number of coronary artery bypass grafts per 100 discharges age 40 or older Coronary artery bypass graft (CABG) is the surgical restoration of blood flow to the vessels serving the heart. It is a commonly used approach for those with obstructions of the heart vessels. Substantial variations in the rate at which this procedure is performed have been noted, and may reflect the availability of other revascularization techniques, the availability of surgeons and other skilled personnel, or variations in the way patients are chosen for the procedure. There is evidence to suggest that those facilities and surgeons that perform a larger number of such procedures may have better results. Inpatient discharges related to pregnancy and childbirth (maternal discharges) are excluded from the table. May 10, 2010

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Utilization Review Inpatient Procedures by Hospital Referral Region, 2007 Percutaneous Transluminal Coronary Angioplasty State of Texas 3.09 Abilene 6.67 Amarillo 6.24 Austin 3.46 Beaumont 3.39 Bryan 3.20 Corpus Christi 2.12 Dallas 2.67 East Texas 0.00 El Paso 2.29 Fort Worth 3.19 Harlingen 1.85 Houston 2.87 Longview 2.94 Lubbock 5.34 McAllen 3.28 Odessa 3.48 San Angelo 4.26 San Antonio 3.08 Temple 3.19 Texarkana 2.61 Tyler 2.62 Victoria 2.93 Waco 3.82 Wichita Falls 2.67 Number of percutaneous transluminal coronary angioplasties per 100 discharges age 40 or older Percutaneous transluminal coronary angioplasty (PTCA) is performed on patients with coronary artery disease by threading a slender balloon-tipped tube to a trouble spot in an artery of the heart. The balloon is then inflated so that blood can flow more easily. Often an expandable metal stent, a wire mesh tube, is inserted to prop open arteries after PTCA. PTCA is a potentially overused procedure, and rates vary widely and systematically between areas. Patient and physician preferences may play a role in this variation. PTCA may be more appropriate in areas with an older population or with higher rates of smoking or other risk factors for cardiovascular disease. May 10, 2010

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Why might there be variation? Clinical factors Patient or physician preference Local practice patterns Type of insurance Availability of alternative treatment or specialized care May 10, 2010