Worse Outcomes After Esophagectomy at Private Equity-Owned Hospitals

Esophagectomy outcomes trended in the wrong direction at hospitals owned by private-equity companies, a review of more than 9,000 cases showed.

Statistically significant differences existed for 30-day mortality, any complication, serious complications, and failure to rescue, all favoring non-equity hospitals. Private-equity ownership was associated with lower procedural volume, although only 5.5% of all cases came from private-equity hospitals.

Additional studies are required to identify drivers of the outcome disparities, improve performance, and inform policy decisions involving allocation of care for select surgical procedures, reported Jonathan Williams, MD, of the University of Michigan in Ann Arbor, and co-authors in JAMA Surgery.

“These findings suggest that poorer postoperative outcomes at private equity-acquired health centers may be attributed to characteristic structural differences associated with private equity acquisition,” the authors stated.

“Our sensitivity analysis, which analyzed comparative outcomes for similarly low-volume non-acquired and private equity-acquired health centers, showed a persistence in worse 30-day mortality and any complication rates for patients undergoing esophagectomy at private equity-acquired centers,” they added. “This finding suggests that there are additional contributing institutional factors at play at private equity-acquired health centers than simply a volume-outcome association for esophagectomy care.”

Structural elements potentially contributing to the outcome disparities might include intensive care unit organization and multidisciplinary care teams, which have been linked to fewer adverse events, as well as failure to rescue, nurse-to-patient ratio, and teaching hospital status.

Failure to rescue has received increased attention in surgical outcomes research, particularly for high-complexity procedures, Williams and colleagues noted. The outcome is based on the theory that the incidence of complications is not the primary driver of postoperative mortality, but instead delays or omissions in recognition and treatment of complications.

“The results of this study both confirm this association and show an association between hospital acquisition status and failure to rescue,” the authors stated.

The study was limited to Medicare patients, and older patients have an increased risk of complications, noted Aaron R. Dezube, MD, and Virginia Litle, MD, both of St. Elizabeth’s Medical Center in Brighton, Massachusetts, in an accompanying commentary. Additionally, the complication rates were low. As such, the findings might have limited generalizability to younger patients and high-volume academic centers.

Despite the limitations, the sensitivity analysis showed that non-acquired hospitals outperformed private equity-acquired facilities.

“The message from this article is the necessity to keep an eye not only on esophagectomy outcomes, but also on all complex surgical procedures among hospital types, and to raise the alarm if needed,” Dezube and Litle wrote. “Either private equity-acquired hospitals need to invest in quality databases, hire more staff, and educate staff on perioperative care, or they need to recognize the private inequity they are providing for complex cases.”

Private equity acquisition of health systems has increased involvement in the management of acute-care hospitals, Williams and co-authors noted in their introduction.

“The impetus of private equity acquisition of a healthcare institution is to directly manage and modify care delivery operations with a central goal of maximizing profit and limiting costly inefficiencies,” they continued. “As private equity acquisition of health systems has become more prevalent, both professional physician societies and governmental agencies have called for further investigation of the association of these practices with care quality.”

MedPage Today took a closer look at some of the concerns about private-equity ownership in a recent end-of-year review of the topic.

Growing involvement of private-equity interests in hospital management has created a need to examine associations between private-equity acquisition and the quality of care for complex surgical procedures, such as esophagectomy.

Toward that end, the authors analyzed data from the Medicare Provider Analysis and Review to identify beneficiaries 65 or older who underwent elective esophagectomy from January 2016 through December 2020. They searched the Agency for Healthcare Research and Quality (AHRQ) Compendium of U.S. Health Systems to identify centers acquired by a private-equity entity. Finally, they linked the American Hospital Association Annual Survey to the AHRQ compendium by means of facilities’ unique CMS Certification Number.

During the study period, 954 centers performed esophagectomy, consisting of 132 private equity-acquired and 822 non-acquired centers. The number of hospitals performing esophagectomy declined over the study period. As compared with non-acquired centers, private equity-acquired hospitals had a lower annual esophagectomy case volume (2 vs 7, PPPP

The analysis included 9,462 esophagectomy procedures, 517 (5.5%) of which were performed at private equity-acquired hospitals. Comparison of outcomes for non-acquired versus private equity-acquired hospitals produced the following results:

• 30-day mortality: 4.9% vs 8.1%, OR 1.82, P=0.002
• Serious complication: 14.3% vs 17.5%, OR 1.35, P=0.03
• Any complication: 30.1% vs 36.6%, OR 1.46, P=0.001
• Failure to rescue: 3.4% vs 5.9%, OR 1.86, P=0.004
• Readmission: 19.2% vs 21.1%, OR 1.13, P=0.28

“Our findings suggest that center-level factors outside of case volume alone may influence outcomes for patients undergoing high-complexity operations, which may better inform center designations by advocacy groups who have historically been focused on case volume alone,” the authors stated in their conclusions. “Further investigations into structural drivers of outcome differences at private equity-acquired health centers are necessary to inform potential regulations for esophagectomy care and other similar high-complexity surgical conditions.”

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