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The influence of specialized cancer hospitals in Florida on mortality, length of stay, and charges of care

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Title:
The influence of specialized cancer hospitals in Florida on mortality, length of stay, and charges of care
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Book
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English
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Spencer, Patricia L
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University of South Florida
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Subjects / Keywords:
Cost effectiveness
Prostate neoplasm
Breast neoplasm
Health care evaluation mechanisms
Dissertations, Academic -- Health Policy and Management -- Masters -- USF   ( lcsh )
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non-fiction   ( marcgt )

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Summary:
ABSTRACT: This thesis analyzes the influence of specialized cancer hospitals in Florida on the outcomes of the mortality risk, length of stay, and charges of care among patients diagnosed with cancer, and performed a mastectomy, lumpectomy or radical prostatectomy, after controlling for age, gender, race, severity, type of hospital ownership, payment options, type of admission, and presence or absence of residency programs. The Florida Agency for Health Care Administration inpatient hospital discharge dataset of 2005 was used to extract data. Analysis of covariance was used to compute the differences on the three outcomes as a function of the specialization/volume of the treatment facility.The treatment facility categories were defined as (1) specialized cancer hospital; (2) general hospital with high volume (100 or more cancer treatment discharges per defined cancer); (3) general hospital with medium volume (50 to 99 cancer treatment discharges per defined cancer); (4) general hospital with low volume (25 to 49 cancer treatment discharges per defined cancer); and (5) general hospital with very low volume (less than 25 cancer treatment discharges per defined cancer). There were no deaths in any of the three procedures at specialized cancer hospitals. Being hospitalized at a specialty cancer hospital for a radical prostatectomy for prostate cancer was associated with 0.93 fewer days in mean length of stay (mean = 2.68 overall), but length of stay was not significantly different for mastectomy and lumpectomy (mean = 2.21 and 1.86 overall respectively) compared to general hospitals with very low volumes.Charges for care were not significantly different for lumpectomy and radical prostatectomy (mean = $22,097 and $25,220 overall respectively) for a specialty cancer hospital compared to general hospitals with very low volumes, where for mastectomies it was $4,850 on average lower (mean = $24,608 overall). In this study, patients managed at specialized cancer hospitals sometimes had better outcomes (i.e. shorter lengths of stay for radical prostatectomies and lower charges for mastectomies) compared to very low volume hospitals, while not having any significantly worse outcomes.
Thesis:
Thesis (M.S.P.H.)--University of South Florida, 2008.
Bibliography:
Includes bibliographical references.
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Mode of access: World Wide Web.
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System requirements: World Wide Web browser and PDF reader.
Statement of Responsibility:
by Patricia L. Spencer.
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Title from PDF of title page.
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Document formatted into pages; contains 29 pages.

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aleph - 002006364
oclc - 384434296
usfldc doi - E14-SFE0002725
usfldc handle - e14.2725
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ABSTRACT: This thesis analyzes the influence of specialized cancer hospitals in Florida on the outcomes of the mortality risk, length of stay, and charges of care among patients diagnosed with cancer, and performed a mastectomy, lumpectomy or radical prostatectomy, after controlling for age, gender, race, severity, type of hospital ownership, payment options, type of admission, and presence or absence of residency programs. The Florida Agency for Health Care Administration inpatient hospital discharge dataset of 2005 was used to extract data. Analysis of covariance was used to compute the differences on the three outcomes as a function of the specialization/volume of the treatment facility.The treatment facility categories were defined as (1) specialized cancer hospital; (2) general hospital with high volume (100 or more cancer treatment discharges per defined cancer); (3) general hospital with medium volume (50 to 99 cancer treatment discharges per defined cancer); (4) general hospital with low volume (25 to 49 cancer treatment discharges per defined cancer); and (5) general hospital with very low volume (less than 25 cancer treatment discharges per defined cancer). There were no deaths in any of the three procedures at specialized cancer hospitals. Being hospitalized at a specialty cancer hospital for a radical prostatectomy for prostate cancer was associated with 0.93 fewer days in mean length of stay (mean = 2.68 overall), but length of stay was not significantly different for mastectomy and lumpectomy (mean = 2.21 and 1.86 overall respectively) compared to general hospitals with very low volumes.Charges for care were not significantly different for lumpectomy and radical prostatectomy (mean = $22,097 and $25,220 overall respectively) for a specialty cancer hospital compared to general hospitals with very low volumes, where for mastectomies it was $4,850 on average lower (mean = $24,608 overall). In this study, patients managed at specialized cancer hospitals sometimes had better outcomes (i.e. shorter lengths of stay for radical prostatectomies and lower charges for mastectomies) compared to very low volume hospitals, while not having any significantly worse outcomes.
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Health care evaluation mechanisms
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PAGE 1

The Influence of Specialized Cancer Hospit als in Florida on Mortality, Length of Stay, and Charges of Care by Patricia L. Spencer A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Public Health Department of Health Policy and Management College of Public Health University of South Florida Major Professor: Laurence G. Branch, Ph.D. Barbara Langland-Orban, Ph.D. Etienne E. Pracht, Ph.D. Date of Approval: November 4, 2008 Keywords: cost effectiveness, prostate neoplasm, breast neoplasm, health care evaluation mechanisms Copyright 2008, Patricia L. Spencer

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Dedication To my dear children Diego, Matas, Valentina and Rafael, and my beloved husband Ral.

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Acknowledgments This thesis would not have been po ssible without the support of many people. Thanks to Dr. Laurence G. Branch for his outstanding mentorship, advice, support, and tireless editing that have been essential to the completion of this project. I would also like to gr atefully thank Dr. Barbara Orban for her wisdom and advice throughout the process, Dr. Etienne Pracht for his excellence and assistance, and especially Ms. Stephanie Gaskins for her warmth and generosity of spirit during this voyage.

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i Table of Contents List of Tables ii Abstract iii Introduction 1 Background 2 Specialized Cancer Hospitals 2 Cancer Types 2 Breast Cancer 2 Prostate Cancer 3 Outcomes 4 Data and Methods 5 Results 9 Discussion 18 References 23 Appendices 24 Appendix A: Florida Hospitals 25

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ii List of Tables Table 1 ICD9-CM Codes 6 Table 2 Categories of Florida Hospitals 9 Table 3 Sample Characteristics 11 Table 4 Summary of Outcomes for Breast Cancer 12 Table 5 Summary of Outcomes for Prostate Cancer 16

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iii The Influence of Specialized Cancer Hospit als in Florida on Mortality, Length of Stay, and Charges of Care Patricia L. Spencer, MD, MBA ABSTRACT This thesis analyzes the influence of specialized cancer hospitals in Florida on the outcomes of the mortality ri sk, length of stay, and charges of care among patients diagnosed with cancer and performed a mastectomy, lumpectomy or radical prostatectomy, after controlling for age, gender, race, severity, type of hospital ownership, payment options, type of admission, and presence or absence of residency programs. The Florida Agency for Health Care Administration inpatient hospital discharge dataset of 2005 was used to extr act data. Analysis of covariance was used to compute the differences on the three outcomes as a function of the specialization/volume of the treatment facility. The treatment facility categories were defined as (1) specialized cancer hospital; (2) general hospital with high volume (100 or more cancer treatment discharges per defined cancer); (3) general hospital with medium volume (50 to 99 cancer treatment discharges per defined cancer); (4) general hospital with lo w volume (25 to 49 cancer treatment

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iv discharges per defined cancer); and (5) general hospital with very low volume (less than 25 cancer treatment discharges per defined cancer). There were no deaths in any of the th ree procedures at specialized cancer hospitals. Being hospitalized at a specialty cancer hospital for a radical prostatectomy for prostate cancer was associated with 0.93 fewer days in mean length of stay (mean = 2.68 overall), but length of stay was not significantly different for mastectomy and lumpectomy (mean = 2.21 and 1.86 overall respectively) compared to general hospitals with very low volumes. Charges for care were not significantly different for lumpectomy and radical prostatectomy (mean = $22,097 and $25,220 overall respectively ) for a specialty cancer hospital compared to general hospitals with very low volumes, where for mastectomies it was $4,850 on average lower (mean = $24,608 overall). In this study, patients managed at specialized cancer hospitals sometimes had better outcomes (i.e. shorter lengths of stay for radical prostatectomies and lower charges for mastectomies) compared to very low volume hospitals, while not having any significantly worse outcomes.

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1 Introduction Numerous studies have suggested that outcomes for surgical procedures are better if they are performed by high volume surgeons. Similar results have been found for prostate oncology.1 The majority of studies evaluate the influence of specific surgical procedures on the primary outcome of hospita l mortality. Considering in-hospital mortality as the outcome, there is strong evidence of association between volume of activity and outcome for surgery of prostate cancer. The evidence of association is weaker for breast, lung and gastric cancer. For surgery of colorectal cancer there may be no association2. The hypothesis of this study is w hether there is a positive association between receiving treatment from spec ialized cancer hospitals and higher volume treatment facilities in Florida on mortality risk, length of stay, and charges for care for breast and prostate cancer patients than in lower volume treatment facilities.

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2 Background Specialized Cancer Hospitals In the state of Florida there is onl y one hospital recognized by the National Cancer Institute as a Comprehensive C ancer Center the H.Lee Moffitt Cancer Center located in Tampa. It provides pat ient services; conducts basic, population sciences, and clinical research; and engages in outreach and education activities3. For the rest of the hospitals in Florida there is no formal accreditation process to provide cancer treatments. Cancer Types Breast Cancer : Breast cancer is a cancer that starts in the cells of the breast in women and men. Breast cancer screening is an attempt to find undiagnosed cancers. The most common screeni ng methods are self and clinical breast exams, x-ray mammography, and breast magnetic resonance imaging (MRI). Genetic testing may also be used. Breast cancer is staged according to the TNM (tumor/lymph node/metastasis) syst em. Prognosis is closely linked to results of staging, and staging is also used to allocate patients to treatments both in clinical trials and clinical practice. The mainstay of breast cancer treatment is surgery when the tumor is localized, with possible adjuvant hormonal therapy (with tamoxifen or an aromatase inhibitor ), chemotherapy and/or radiotherapy

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3 Surgical removal of the breast, or mast ectomy, is the most common procedure; in cases of early stages it is possible to perform a lumpectomy, which only removes a portion of the breast. Prostate Cancer : Prostate cancer is a disease in which cancer develops in the prostate a gland in the male reproductive system It is one of the most common types of cancer in men. Prostate cancer develops most frequently in men over fifty years old. However, many men who develop prostate cancer never have symptoms, undergo no therapy, and eventually die of other causes. Prostate cancer is most often discovered by PSA ( prostate specific antigen ) screening and less commonly by physical examination or by symptoms. Treatment options for prostate cancer with intent to cure are primarily surgery and radiation therapy Other treatments such as hormonal therapy, chemotherapy proton therapy cryosurgery, high intensity focused ultrasound (HIFU) also exist depending on the clinical scenario and desired outcome. Surgical removal of the prostate, or prostatectomy, is a common treatment either for early stage prostate cancer, or for cancer which has failed to respond to radiation therapy. The most common type is radical retropubic prostatectomy in which case the surgeon removes the prostate through an abdominal incision. Another type is radical perineal prostatectomy in which case the surgeon removes the prostate through an incision in the perineum the skin between the scrotum and anus Radical prostatectomy can also be performed laparoscopically, through a series of sm all (1cm) incisions in the abdomen, with or without the assistance of a surgical robot. Radical prostatectomy is effective

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4 for tumors which have not spread beyond the prostate. Outcomes Health services research has focused on the treatment of survival (mortality rate), length of stay in the tr eatment facility, charges for the treatment, and functional status contingent on survival. These analyses focus on the first three outcomes.

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5 Data and Methods The Florida Agency for Health Care Administration (AHCA) collects data on all admissions to Florida hospitals. Patient data include demographic and case-mix-related characteristics such as age, sex, race, up to ten diagnoses and procedures, length of stay, source and type of admission, charges, and discharge status of all pat ients admitted to the states community hospitals. Functional status is not available. This study extracted data from the Florida AHCA inpatient hospital discharge dataset of 2005. Florida had 278 hospitals in the 2005 AHCA dataset. The list of Florida hospitals ordered by name can be found in Appendix A along with the information of the county, city and number of beds. The hospitals were categorized as a function of the specialization/volume of the treatment facility. The rationale for this categorization is based on a lear ning curve experience where it can be considered that more than two procedures performed per week, equivalent to 100 or more procedures per year, allo ws a high degree of specialization and experience in any given technique. Continuing with this rationale, having on average one to two procedures done per week, equivalent to 50 to 99 procedures per year, allows enough exper ience, but then less than one per week, equivalent to 25 to 49 per year, and less than one per two weeks, the same as 1 to 24 per year, would be considered in both cases not sufficient. The

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treatment facility categories are thus defined in five categories as follows: (1) specialized cancer hospital, (2) general hospital with high volume (100 or more cancer treatment discharges per defi ned cancer), (3) general hospital with medium volume (50 to 99 cancer treatment discharges per defined cancer), (4) general hospital with low volume (25 to 49 cancer treatment discharges per defined cancer), and (5) general hospital with very low volume (less than 25 cancer treatment discharges per defined cancer). The principal diagnosis code was used to extract the cancer discharges from the AHCA dataset in accordance to the topography: breast or prostate. See Table 1 for details. Table 1. ICD9-CM Codes Codes Breast Cancer Prostate CancerPrincipal Diagnosis CPT 1740-1749; 2330 CPT 1850-1859; 2334 CPT 8541-8549 = mastectomy CPT 8520-8523 = lumpectomy CPT 851-859 not 852 nor 854 = other breast procedure CPT 600-609 not 605 = other prostate procedure CPT "" = none_procedure CPT "" = none_procedure CPT else = else_procedureCPT else = else_procedureICD9-CM International Classification of Diseases, Ninth Revision, Clinical Modification Procedures included CPT 605 = radical prostatectomy Procedures excluded The surgical procedure codes performed by each category of hospital were analyzed using the International Classification of Diseases, Nineth Revision, Clinical Modification (ICD9-CM) wh ich classifies 17 broad categories of diseases and injuries, one being cancer. For breast cancer, the treatments identified as mastectomies and lumpectomies were analyzed; other procedures such as biopsies or transfusions, among many others, for breast cancer pat ients were not counted as treatment procedures with curative intent. For prostate cancer, radical prostatectomy was 6

PAGE 14

7 considered the only cancer treatment; other procedures such as laser treatment, catheterization, biopsies or transfusi on, among others, for prostate cancer patients were not counted as treatment pr ocedures with intent to cure for the purpose of this study. See Table 1 for details for the procedure codes used for breast and prostate cancer. A one-way analysis of variance (ANOVA) was used to analyze the dependent continuous variables of charges and length of stay, with a categorical independent variable hospital category with more than 2 levels; in this case there were 5 levels. For the binary dependent variabl e of mortality, a multiple logistic regression model was used. A general linear model (glm) was used in all cases because of the existence of unbalanced ca tegories. The statistical analysis system software utilized was SAS version 9.2. Control variables were used to adjust the models using a variation of ANOVA analysis of covariance (ANCOVA) which combines features of ANOVA and regression. These contro l variables are grouped into four categories: (1) sociodemographic characte ristics such as age (exact age in years) and race [white (reference group), black non Hispanic, Hispanic, all others]; (2) a measure of severity [mild (reference group), moderate, severe, critical] and type of admission [elective (reference group), urgent, emergency] of the hospitalized patient; (3) monetary factors such as hospital type of ownership [non-for-profit, investor (reference gr oup), public] and insurance of patient [Medicare, Medicaid, commerce (reference group), all other]; (4) and lastly, a measure of provider of educational activities as per the presence or not of

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8 residents in the hospital [no residents (refe rence group), presence of residents]. The type of hospital such as general hospital, teaching hospital or specialty hospital was not used because it was highly correlated with the operational definition fo the independent variable. The measure of severity was calcul ated using the 3M Severity-adjustment Software Schematics (PC Grouper version 01. 2)4. This formula used secondary diagnoses to calculate the severity score and adjusted for age and operating room procedures.

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Results Breast Cancer: The ACHA dataset of 2005 had 3,756 mastectomy and 631 lumpectomy discharges for female breast cancer as the principal diagnosis. Only 186 of the 278 (67%) hospitals had at least one treatment discharge code for breast cancer (Table 2). Table 2. Categories of Florida HospitalsCategoryDescription (by defined cancer) N hospitals Total discharges N hospitals Total discharges 1specialized cancer hospital 1 225 1 156 2 100 cancer treatment discharges high 7 925 5 854 350 99 cancer treatment discharges medium12 832 13 837 425 49 cancer treatment discharges low 34 1,144 12 372 51-24 cancer treatment discharges very low132 1,261 151 949 Total186 4,387 182 3,168 Breast CancerProstate Cancer Within these treatment discharges t he hospitals were distributed in the different categories in accordance to the description given in the methods section. The distribution is shown in Table 2: (1) specialized cancer hospital (n=1 hospital; H. Lee Moffitt Cancer Center), (2) general hospital with high volume (n=7 hospitals; Orlando Regional Medical Center, Florida Hospital, Baptist Hospital of Miami, Jackson Memorial Hospital, Memorial Regional Hospital, Tallahasee Memorial Hospital and Boca Ra ton Community Hospital), (3) general hospital with medium volume (n=12 hospitals; among them Holmes Regional Medical Center, Mount Sinai Medical C enter, Shands Hospital, etc), (4) general 9

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10 hospital with low volume (n=34 hospitals), and (5) general hospital with very low volume (n=132 hospitals). The descriptive characteristics of the sample are provided in Table 3. Mortality Rates: Analyzing the in-hospital mortality for all Florida hospitals that performed at least one mastectomy per year, the probability of dying was 0.08% overall. There were three deaths, one at the category 3 hospitals (patient aged 51 years old, white, stayed 8 days in the hospital, and had a commercial insurance), and two at the category 5 hospitals (one patient aged 90 years old, white, with length of stay of 8 days, and the other patient was aged 83 years old, white, with 13 days in the hospital; both we re Medicare). For lumpectomies, the in-hospital probability of dying by the procedure in Florida hospitals was 0.16% overall. There was only one death reported for the category 4 hospitals (patient aged 61 years old, black, length of stay 10 days, and had commercial insurance). There were too few data to perform any si gnificant statistical test on mortality (Table 3). Length of Stay: The mean length of stay for all hospitals was 2.68 days for mastectomies, and 1.86 days for lumpectomies. The mean length of stay for mastectomies ranged from 2.09 days for category 1 hospital to 2.22 days for category 5 hospitals. After adjusting for the control variables, there was a significant increase of 0.15 days for cat egory 2 hospitals compared to category 5 hospitals. The mean length of stay for lumpectomies ranged from 1.36 days for category 1 hospital to 2.51 days for category 5 hospitals. When controlling for

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Table 3. Sample Characteristics%n%n%n Independent Variable Hospital Categories 16211214 5 156 22281617109 27 854 31868723145 26 837 42594931195 12 372 529109327168 30 949 Control Variables Age (mean years) 62 66 61 Gender M-100 3168 F1003756100631 Race White73275374467 72 2283 Black103911166 13 402 Hispanic124651384 11 359 Else5147214 4 124 Severity mild63238296609 74 2330 moderate351296210 24 756 severe272210 2 70 critical0602 0 12 Type of admission elective86323781511 93 2932 urgent 1244516100 7 227 emergency274320 0 9 Hospital ownership not-for profit60207952300 58 1627 investor2794135206 32 910 public134481375 10 274 missing8288850 11 357 Payer Medicare45167560380 35 1112 Medicaid5196533 1 34 commercial42157529178 57 1791 selfpay4141213 3 104 other4169427 4 127 Residents Yes40166733241 49 1730 missing8288850 11 357 Dependent Variables Length of Stay (mean) 2.21 days 1.86 days 2.68 days Charges (mean) $24,608 $22,097 $ 32,301 Mortality 0.0830.161 0.03 1Characteristic(n = 4,387)Breast Cancer Prostate Cancer MastectomyLumpectomyRadical Prostatectomy(n = 3,168) (n = 3,756) (n = 631)11

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12 Table 4. Summary of Outcomes for Breast Cancerestimate p r2estimate p r2Length of Stay (days) < 0.00010.285216 (days) < 0.00010.428711 category < 0.0001 0.2948 cat1 0.7637 0.7344 cat20.150.0024 0.2063 cat3 0.9354 -0.210.0275 cat4 0.5399 0.0909 age 0.6804 0.1385 black0.42< 0.0001 0.650.0349 hispanic 0.6921 0.680.0221 race other 0.6558 0.9748 moderate0.69< 0.0001 3.81< 0.0001 severe4.76< 0.0001 3.63< 0.0001 critical14.36< 0.0001 22.43< 0.0001 non-for-profit 0.4544 0.3291 public 0.9801 0.4139 medicare-0.260.0052 0.1101 medicaid 0.2488 0.930.0355 selfpay 0.1128 0.7496 other payer-0.390.0068 0.1229 urgent0.38< 0.0001 0.0859 emergency3.49< 0.0001 5.14< 0.0001 yes residents-0.170.0174 0.8362 Charges ($) < 0.00010.278316 ($) < 0.00010.521748 category < 0.0001 0.3018 cat1-4,850< 0.0001 0.5273 cat21,626< 0.0001 0.9255 cat35830.0067 0.3659 cat4 0.0691 0.6549 age-172< 0.0001 0.1600 black 0.9511 0.2456 hispanic5,877< 0.0001 7,1850.0011 race other 0.1391 0.8134 moderate5,863< 0.0001 15,1010.0047 severe26,616< 0.0001 19,6500.0003 critical100,388< 0.0001 263,321< 0.0001 non-for-profit-5,137< 0.0001 -5,4170.001 public-6,346< 0.0001 -6,1450.0237 medicare-4,067< 0.0001 0.3470 medicaid-5,138< 0.0001 0.3975 selfpay-3,3490.0085 0.6369 other payer-3,9530.0002 0.0652 urgent 0.5148 0.8142 emergency10,855< 0.0001 23,713< 0.0001 yes residents-1,0980.0376 0.3904Variables Mastectomy Lumpectomy

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13 other variables however, only the category 3 hospitals had a significant decrease of 0.21 days of stay (refer to Table 4 for more details). Charges for Care: The mean charges for all hospitals were $24,608 for mastectomies and $22,097 for lumpectomies. For mastectomies (86% of the treatment volume), the mean charges were $19,824, $26,857, $23,058, $25,444 and $23,913 from category 1 to category 5 hospitals respectively. There were significant differences among the category hospitals after adjusting for the control variables. The specialty cancer hospitals category charged on average $4,850 less per mastectomy compared to category 5 hospitals; category 2 and 3 hospitals charged $1,626 and $583 more respectively. As for lumpectomies (14% of the tr eatment volume), the mean charges for care were $14,879, $21,572, $17,710, $23,904, and $27,310 from category 1 through category 5 hospitals. There were no significant differences after adjusting for the control variables for the category hospitals. Control Variables: Among these the following findings are worthy of attention (see Table 4 for further details). The mean age for lumpectomies ranged from 56 years old for category 1 hospitals to 69 years old for category 5 hospitals; for mastectomies the mean age ranged from 53 years old for category 1 hospitals to 66 years old for category 5 hospitals. There were significant differences among race, where blacks compared to whites would stay on average 0.42 and 0.65 more days for mastectomy and lumpectomy procedures respectively; Hispanics would stay on average 0.68 more days when a mastectomy was performed, and were charged $5,877 and $7,185 more on

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14 average for mastectomy and lumpectomy procedures respectively, the latter not being associated to a longer stay. Non-for profit and public hospitals compared to investor hospitals would charge on average less per mastectomy, $5,137 and $6,356 respectively; $5,417 and $6,145 less per lumpectomy respectively. For mastectomies length of stay and charges were significantly lower for type of health insurance (Medicare 0.26 days and $4,067; other payer 0.39 days and $3,953 respectively; only lower charges of care for Medicare $4,067 and selfpay $3,349, both not associated to lower l ength of stay) compared to commercial health insurance. As expected, there were significant increases on length of stay and charges for care associated to severity and type of admission. Overall, 29% of the variance in length of stay and 28% for charges for mastectomies were explained by the fully controlled model, and 43% of the variance in length of stay and 52% of charges for lumpectomies. Prostate Cancer: The ACHA dataset of 2005 had 3,168 radical prostatectomy discharges for prostate cancer as the principal diagnosis. Only 182 of the 278 (65%) hospitals had at least one treatment discharge code for prostate cancer. For these treatment discharges, the hospitals were distributed in the different categories in accordance to the descripti on given in the methods section. The distribution is shown in Table 2: (1) specialized cancer hospital (n=1 hospital; H. Lee Moffitt Cancer Center), (2) general hospi tal with high volume (n=5 hospitals; Florida Hospital, Cedars Medical Cent er, West Marion Community Hospital,

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15 Aventura Hospital and Medical Center, Sain t Lukes Hospital), (3) general hospital with medium volume (n=13 hospitals; among them, Jackson Memorial Hospital, Tallahasee Memorial Hospital, St. Josephs Hospital, Morton Plant Hospital, etc), (4) general hospital with low volume (n=12 hospitals), and (5) general hospital with very low volume (n=151 hospitals). The descriptive characteristics of the sample are described in Table 3. Mortality Rates: Analyzing the in-hospital mortality for all Florida hospitals that performed at least one radical pros tatectomy per year, the probability of dying was 0.03% overall. Only one death occured at the category 5 hospitals (patient was 70 years old, white, stay ed 7 days in the hospital, and had Medicare as health insurance). There were not enough end points to perform any significant statistical test on mortality (Table 3). Length of Stay: The mean length of stay for all hospitals was 2.68 days for radical prostatectomy. The mean l ength of stay for radical prostatectomy ranged from 2.46 days for category 1 hospitals to 3.40 days for category 5 hospitals. There was a positive linear re lation between category of hospitals and length of stay. Being hospitalized at a specialized cancer hospital was associated with 0.93 fewer days in length of stay, 0.73 fewer days for category 2 hospitals, and 0.26 fewer days for category 3 hospitals compared to category 5 hospitals. Further details are shown on Table 5. Charges for Care: The mean charges for care for all hospitals where a radical prostatectomy was performed wa s $32,301. The mean charges for care for each category were $25,220, $35,689, $28,711, $32,179, and $34,530 from

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category 1 through category 5 hospitals resepctively. Being hospitalized in a specialty cancer hospital was associat ed with a mean reduction of $9,301, while being in category 3 hospitals was associated with a $1,939 mean reduction compared to category 5 hospitals. However, after adjusting the model, only the category 3 hospitals mean charge of $774 le ss was statistically significant (see Table 5). Table 5. Summary of Outcomes for Prostate Cancerestimate p r2estimate p r2(days) < 0.00010.33869 ($) < 0.00010.317561 category < 0.0001 0.0002 cat1-0.93< 0.0001 0.1288 cat2-0.73< 0.0001 0.2019 cat3-0.26< 0.0001 -7740.0014 cat4 0.0638 0.1441 age 0.1112 0.9003 black0.74< 0.0001 2,0740.0099 hispanic0.47< 0.0001 4,912< 0.0001 race other0.510.0009 moderate0.89< 0.0001 3,922< 0.0001 severe3.31< 0.0001 26,373< 0.0001 critical11.83< 0.0001 110,048< 0.0001 non-for-profit0.170.0136 -9,236< 0.0001 public-0.350.0029 -11,820< 0.0001 medicare 0.6061 0.4564 medicaid 0.1374 0.1948 selfpay 0.3682 0.2400 other payer 0.1405 2,6750.0474 urgent 0.9619 0.0718 emergency 0.3342 0.7469 yes residents0.160.0339 -2,1680.0008Length of Stay Charges Variables Radical Prostatectomy Control Variables: Among the variables used to adjust the model the following were significant (see Table 5 for details). The mean age for radical prostatectomy ranged from 59 years old fo r category 1 hospitals to 62 years old for category 5 hospitals. There were si gnificant differences among race, where 16

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17 blacks and Hispanics compared to whites would stay on average 0.74 and 0.47 more days respectively for radical prostatectomy; both on average were charged more in the amounts of $2,074 and $4,912 respectively; the latter not being associated to a longer stay. Non-for-profit and public hospitals compared to investor hospitals would charge on av erage less per intervention, $9,236 and $11,820 respectively; the former would stay 0.17 more days, and the latter 0.35 less days on average. There were no signi ficant differences among the types of health insurance for length of stay, but other payers compared to commercial health insurance charged on average $2,675 more per procedure. These 127 patients of the other payer group were distributed as follows: 44 Champus, 2 Veterans Administration, 32 other (examp le county health program), 45 charity, and 4 other. If the radical prostatect omy was performed where there were residents, the length of stay was ex tended on averge in 0.16 days and charges were on average $2,168 less. As expected, there were significant increases on length of stay and charges for care associated with severity; for type of admission no significant differences were found. Overall, 34% of the variance in lengt h of stay and 32% of the variance in charges were explained by the fully controlled model.

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18 Discussion This study found that there were no in-hospital deaths in Florida for the year 2005 related to mastectomy, lumpectomy or radical prostatectomy interventions for hospitals with 100 or mo re treatment discharges per year or specialized cancer hospitals. Even though no statistical test was performed, a mortality pattern appeared when the three procedures were merged. One death occurred in a category 3 hospital, one in a category 4 hospital and three in a category 5 hospital. Deaths appeared inversely related to the volume of the procedures performed at the hospital. The age of the two patients who died consequent to a mastectomy at category 5 hospitals that resulted in death (83 and 90 years old) are also noteworthy. It invites the query of whether other options might have existed for these older pat ients. Also, the overall mortality for these procedures (0.03% for radical prostatectomy, 0.08% for mastectomy and 0.16% for lumpectomy) was inversely related to the complexity of the procedure. The length of stay after radical prostatectomy for prostate cancer was on average likely to be lower if performed at higher volume hospitals, and substantially so if performed at a spec ialized cancer hospital. There were no statistically significant findings that specialized cancer centers had different lengths of stay for mastectomy and lumpectomy procedures. Specialized cancer hospitals charged less for mastectomies. These findings are consistent with the

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19 literature that hospitals with higher vo lumes are generally associated with better outcomes compared to very low volume hospitals, and this study demonstrates that it is valid particularly if per formed by specialized cancer hospitals. Some have suggested that specialized cancer hospitals have higher mortality rates, higher length of stay, and higher charges for care because they might have a more severly ill patient population along with expensive equipment and treatments, and the cost of specializ ed staff. These data demonstrate that specialized cancer hospitals do not have excess deaths related to the procedures studied, and in fact have shorter lengths of stay for prostate cancer treatment after controlling some aspects of patient severity and other related characteristics, but not TNM. Furthe rmore, the specialized cancer hospitals category are not different in length of stay for lumpectomies and mastectomies when compared to the other hospitals, and, in fact, charges significantly less for mastectomies, whle not different for lum pectomy or radical prostatectomy. And all these findings are without controlling t he TNM staging. Why? One plausible explanation is that mortality rates are lower in specialized cancer hospitals because of high volume and specialization which impacts morbidity by fewer complications, along with the exclusive dedica tion of staff to cancer patients. This includes focused management to cancer without competing with other less deadly diagnosis, and staff not genuinely biased towards better survival diseases. Length of stay also is less, basically due to fewer complications thanks to dedicated staff and the concomitant specia lization. And charges for care, also are less, even though the specialized canc er hospitals have higher technology

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20 and updated equipment, perform the latest innov ation in cancer treatments, and their staff is specialized with higher st ipends associated, so, even though the fixed costs are in fact higher, with hi gh volumes on one side, but essentially a better performance by the staff at the end by less length of stay and less complications, allow these costs to be prorated and the variable costs to be lower. In regards to the control variables, even though there were no statistical differences for age, there was a pattern for the three procedures; all three had an increase on average age per category, with age lowest for category 1 hospitals and highest for category 5 hospitals. One question that arises from this observation is whether there were not other options to be offered to patients at the category 5 hospitals? Differences am ong race for length of stay and charges for care were not expected; these were found to be higher for Hispanics and blacks. Plausible explanations coul d be that these patients have more aggressive or advanced stages of cancer which is not controlled in this study, or more likely because of socioeconomic and language barriers that require more time of hospitalization to deliver the appr opriate care with the concomitant higher charges. As expected non-for-profit and public hospitals charged less on average compared to investor institutions. There were various findings for the variable type of payer or health insurance. One that was worth special attention was other payers that charged on average $2,675 more for radical prostatectomy compared to commercial health insurance; the majority of other payers are from charity, county health programs, and Champus payers. One

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21 possible explanation is that commercial health insurances reimbursed less on average than the other payer fee. As expected, Medicare and Medicaid for mastectomy procedures on average charged less. Other unexpected finding was that Medicaid lumpectomy patients st ayed on average almost a day more than their commercial health insurance counterpar ts. One plausible explanation is the use of a different payment method, fo r example by arranging fixed pricing regardless of length of stay which is an incentive to not extend the days of hospitalization; or as for the race vari able, is that this group delays medical attention with the concomitant major staging of their cancer, or also due to their economic situation, they are held at t he hospital for more time because they would not be able to have the appropriate care at home. And finally, hospitals having residents within their staff were found to charge less on average for mastectomy and radical prostatectomy procedures when it was expected the contrary due to higher length of stay to learn from the patients. The plausible explanation is that perhaps the majority of the residents belong to non-for-profit and public hospitals. The lack of further findings for lumpectomy could reside in the fact that the procedure was easy to perform, no special skills or equipment were required nor the existence of concomitant complications or necessary days of hospitalization, many being possible to be ambulatory; all th is said would not relate then to the volume of the hospital. Very similar rationale could apply to mastectomies which has been a procedure performed for many years yielding the learning curve to many physicians independent of which hospital is chosen.

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22 Other positive aspects of specialized cancer hospitals, along with having the same or better outcomes than general hospitals, whether high or very low volumes, is that generally they are associ ated with positive externalities, such as basic and clinical research, outreach and educational activities, playing a relevant role in prevention and early diagnosis with the ultimate goal of diminishing the mortality and morbidity of cancer as a whole. There were some methodological limitations of the study. First, this study focused on surgical treatment proc edures instead of the comprehensive treatment because radiotherapy and chemotherapy data are collected differently. Second, the TNM staging is not avail able which is a parameter related to survival and related to type of procedure done. Third, using mortality as an inhospital outcome is a rare event for mastectomy, lumpectomy and radical prostatectomy. Data should be pooled from several years in order to provide an insight for this easy measure. The intent of this study is to pursue this same analysis for other cancers such as colorectal, lung and gastric cancer in addition to measure the trends of the last five years. This is to fu rther add evidence that high cancer discharge volume hospitals, preferably specialized cancer hospitals, are a cost efficient model and deliver better outcomes to patients.

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23 References 1. Nuttall, M., van der Meulen, J., et al (2004). A systematic review and critique of the literature relating hospital or su rgeon volume to heatlh outcomes for 3 urological cancer procedures J Urol (6 Pt 1): 2145-52 2. Davoli, M., Amato, L (2005). Volume and heatlh outcomes: an overview of systematic reviews Epidemio Prev 29 (3-4 suppl): 3-63 3. https://cissecure.nci.nih.gov/factsheet/FactsheetSearch.aspx?FSType=1.2 NCI website for CCC 4. Revere, L, Large, J., et al. (2004). A comparison of inpatient severity, average length of stay, and costs for traditi onal fee-for-service Medicare and Medicare HMOs in Florida Health Care Management Review (29-4): 320328

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24 Appendices

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Appendix A: Florida Hospitals AHCA ID Name Hospital City CountyBeds 103000A G HOLLEY STATE HOSPITAL LANTANA PALM BEACH100 100250ALL CHILDREN'S HOSPITAL SAINT PETERSBURGPINELLAS216 100240ANNE BATES LEACH EYE HOSPITAL MIAMI DADE 100 120001ARNOLD PALMER HOSPITAL FOR CHILDREN & WOMEN ORLANDO ORANGE443 110068ATLANTIC SHORES HOSPITAL FORT LAUDERDALEBROWARD72 100131AVENTURA HOSPITAL AND MEDICAL CENTER AVENTURA DADE 407 100093BAPTIST HO SPITAL PENSACOLA ESCAMBIA492 100008BAPTIST HOSPITAL OF MIAMI MIAMI DADE 577 100088BAPTIST MEDICAL CENTER JACKSONVILLE DUVAL 579 100117BAPTIST MEDICAL CE NTER BEACHES JACKSONVILLE BEACHDUVAL 122 100140BAPTIST MEDICAL CE NTER NASSAU FERNANDINA BEACHNASSAU54 23960052BAPTIST MEDICAL CENTER SOUTH JACKSONVILLE DUVAL 96 100121BARTOW REGIONAL MEDICAL CENTER BARTOW POLK 56 110034BAY MEDICAL BEH AVIORAL HEALTH CENTER PANAMA CITY BAY 90 100026BAY MEDICAL CENTER PANAMA CITY BAY 323 100032BAYFRONT ME DICAL CENTER SAINT PETERSBURGPINELLAS502 100014BERT FISH ME DICAL CENTER NEW SMYRNA BEACHVOLUSIA112 100002BETHESDA MEMO RIAL HOSPITAL BOYNTON BEACHPALM BEACH390 100213BLAKE MEDICAL CENTER BRADENTON MANATEE383 100168BOCA RATON COMM UNITY HOSPITAL BOCA RATON PALM BEACH394 100243BRANDON REGIONAL HOSPITAL BRANDON HILLSBOROU327 100184BROOKS REHABILITATION HOSPITAL JACKSONVILLE DUVAL 143 100071BROOKSVILLE REGION AL HOSPITAL BROOKSVILLE HERNANDO120 100039BROWARD GENERAL MEDICAL CENTER FORT LAUDERDALEBROWARD716 100112CALHOUN-LIBERTY HOSPITAL BLOUNTSTOWN CALHOUN25 100138CAMPBELLTON-GRACEVILLE HO SPITAL GRACEVILLE JACKSON25 100177CAPE CAN AVERAL HOSPITAL COCOA BEACH BREVARD150 100244CAPE CORAL HOSPITAL CAPE CORAL LEE 281 100254CAPITAL REGIONAL MEDICAL CENTER TALLAHASSEE LEON 198 100009CEDARS MEDICAL CENTER MIAMI DADE 560 100161CENTRAL FLORIDA REGIONAL HOSPITAL SANFORD SEMINOLE226 100047CHARLOTTE REGIONAL MEDICAL CENTER PUNTA GORDA CHARLOTTE208 104024CIRCLES OF CARE, INC. MELBOURNE BREVARD52 100023CITRUS MEMORIAL HOSPITAL INVERNESS CITRUS198 100056CLEVELAND CLINIC HOSPITAL WESTON BROWARD150 100234COLUMBIA HO SPITAL WEST PALM BEACHPALM BEACH250 100191COMMUNITY HOSPITAL NEW PORT RICHEYPASCO 389 100183CORAL GABLES HOSPITAL CORAL GABLES DADE 256 110019CORAL SPRINGS MEDICAL CENTER CORAL SPRINGSBROWARD200 100258DELRAY ME DICAL CENTER DELRAY BEACH PALM BEACH403 100150DEPOO HOSPITAL KEY WEST MONROE49 100175DESOTO MEMORIAL HOSPITAL ARCADIA DESOTO49 110036DEVER EUX HOSPITAL & CHILDREN'S CENTER OF FLORIDA VIERA BREVARD100 100020DOCTORS HOSPITAL INC CORAL GABLES DADE 281 100166DOCTORS HOSPITAL OF SARASOTA SARASOTA SARASOTA168 100078DOCTORS MEMORIAL HOSPITAL BONIFAY HOLMES25 100106DOCTORS' MEMORIAL HOSPITAL, INC. PERRY TAYLOR48 100197DOUGLAS GARDENS HOSPITAL MIAMI DADE 32 110044EASTSIDE PSYCHIATRIC HOSPITAL TALLAHASSEE LEON 24 100134ED FRASER MEMORIAL HOSPITAL MACCLENNY BAKER 25 100239EDWARD WHITE HOSPITAL SAINT PETERSBURGPINELLAS167 110004ENGLEWOOD COMMUNITY HOSPITAL ENGLEWOOD SARASOTA100 110035FAMILY, THE SUNRISE BROWARD100 100236FAWCETT MEMORIAL HOSPITAL PORT CHARLOTTECHARLOTTE238 100024FISHERMEN'S HOSPITAL MARATHON MONROE58 100219FLAGLER HOSPITAL SAINT AUGUSTINEST. JOHNS316 100007FLORIDA HOSPITAL ORLANDO ORANGE892 100068FLORIDA HOSPITAL OCEANSIDE ORMOND BEACHVOLUSIA119 100169FLORIDA HOSPITAL ORMOND MEMORIAL ORMOND BEACHVOLUSIA205 120004FLORIDA HOSPITAL ALTAMONTE ALTAMONTE SPRINGSSEMINOLE258 120003FLORIDA HOSPITAL APOPKA APOPKA ORANGE50 23960017FLORIDA HOSPITAL CELEBRATION HEALTH CELEBRATION OSCEOLA112 25

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Appendix A: (Continued) AHCA ID Name Hospital City CountyBeds 100045FLORIDA HOSPITAL DELAND DELAND VOLUSIA156 100021FLORIDA HOSPITAL EAST ORLANDO ORLANDO ORANGE144 100072FLORIDA HOSPITAL FISH MEMORIAL ORANGE CITY VOLUSIA139 100118FLORIDA HOSPITAL FLAGLER PALM COAST FLAGLER81 100109FLORIDA HOSPITAL HEARTLAND MEDICAL CENTER SEBRING HIGHLANDS159 100089FLORIDA HOSPITAL KISSIMMEE KISSIMMEE OSCEOLA60 120013FLORIDA HOSPITAL LAKE PLACID LAKE PLACID HIGHLANDS50 100057FLORIDA HOSPITAL WATERMAN TAVARES LAKE 204 100282FLORIDA HOSPITAL WAUCHULA WAUCHULA HARDEE25 100046FLORIDA HOSPITAL ZEPHYRHILLS INC ZEPHYRHILLS PASCO 154 100210FLORIDA MEDICAL CENTER LAUDERDALE LAKESBROWARD459 104000FLORIDA STATE HOSPITAL CHATTAHOOCHEEGADSDEN2007 104026FORT LAUDERDALE HOSPITAL FORT LAUDERDALEBROWARD100 100223FORT WALTON BEACH MEDICAL CENTER FORT WALTON BEACHOKALOOSA247 100153GEORGE E. WEEMS MEMORIAL HOSPITAL APALACHICOLA FRANKLIN25 100130GLADES GENERAL HOSPITAL BELLE GLADE PALM BEACH73 110403GOOD SAMARITAN MEDICAL CE NTER WEST PALM BEACHPALM BEACH333 110003GULF BREEZE HOSPITAL GULF BREEZE SANTA ROSA65 111522GULF COAST HOSPITAL FORT MYERS LEE 120 100242GULF COAST MEDICAL CENTER PANAMA CITY BAY 176 111520GULF COAST TREATMENT CENTER FORT WALTON BEACHOKALOOSA24 110009H LEE MOFFITT CANCER CTR & RESEARCH INSTITUTE HOSPITALTAMPA HILLSBOROU162 100017HALIFAX MEDICAL CENTER DAYTONA BEACHVOLUSIA734 110016HALIFAX PSYCHI ATRIC CENTER-NORTH DAYTONA BEACHVOLUSIA30 100030HEALTH CENTRAL OCOEE ORANGE171 100081HEALTHMARK REGIONAL MEDICAL CENTER DEFUNIAK SPRINGSWALTON50 120005HEALTHPARK MEDICAL CENTER FORT MYERS LEE 362 23960013HEALTHSOUTH EMERALD COAST REHABILITATION HOSPITALPANAMA CITY BAY 75 103038HEALTHSOUTH REHAB HOSPITAL MIAMI DADE 60 110045HEALTHSOUTH REHABILITATION HOSPITAL LARGO PINELLAS70 110013HEALTHSOUTH REHABILITATION HOSPITAL OF SARASOTA SARASOTA SARASOTA76 23960042HEALTHSOUTH REHABILITATION HOSPITAL OF SPRING HILL BROOKSVILLE HERNANDO60 110021HEALTHSOUTH REHA BILITATION HOSPITAL OF TALLAHASSEETALLAHASSEE LEON 76 23960049HEALTHSOUTH RIDGELAKE HOSPITAL SARASOTA SARASOTA40 110027HEALTHSOUTH SEA PINES REHABILITATION HOSPITAL MELBOURNE BREVARD90 103028HEALTHSOUTH SUNRISE REHAB HOSPITAL SUNRISE BROWARD126 110017HEALTHSOUTH TREASURE COAST REHABILITATION HOSPITALVERO BEACH INDIAN RIV90 100137HEART OF FLORIDA REGIONAL MEDICAL CENTER DAVENPORT POLK 142 100055HELEN ELLIS MEMORIAL HOSPITAL TARPON SPRINGSPINELLAS168 100098HENDRY REGIONAL MEDICAL CENTER CLEWISTON HENDRY25 100053HIALEAH HOSPITAL HIALEAH DADE 378 100049HIGHLANDS REGIONAL MEDICAL CENTER SEBRING HIGHLANDS126 100225HOLLYWOOD MEDICAL CENTER HOLLYWOOD BROWARD324 104015HOLLYWOOD PAVILION HOLLYWOOD BROWARD46 100019HOLMES REGIONAL MEDICAL CENTER MELBOURNE BREVARD514 100073HOLY CROSS HOSPITAL, INC. FORT LAUDERDALEBROWARD571 100125HOMESTEAD HOSPITAL HOMESTEAD DADE 120 100200IMPERIAL POINT MEDICAL CENTER FORT LAUDERDALEBROWARD204 100105INDIAN RIVER MEMORIAL HOSPITAL VERO BEACH INDIAN RIV335 100142JACKSON HOSPITAL MARIANNA JACKSON100 100022JACKSON MEMORIAL HOSPITAL MIAMI DADE 1498 120008JACKSON MEMORIAL HOSPITAL-NORTH MIAMI DADE 60 100208JACKSON SOUTH COMMUNITY HOSPITAL MIAMI DADE 199 100048JAY HOSPITAL JAY SANTA ROSA55 100080JFK MEDICAL CENTER ATLANTIS PALM BEACH424 100253JUPITER MEDICAL CENT ER JUPITER PALM BEACH156 100209KENDALL REGIONAL MEDICAL CENTER MIAMI DADE 412 23960011KINDRED HOSP-BAY AREA-ST PETERSBURG SAINT PETERSBURGPINELLAS82 23960060KINDRED HOSPITAL OCALA OCALA MARION31 100152KINDRED HOSPITAL SOUTH FLORIDA CORAL GABLES CORAL GABLES DADE 53 26

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Appendix A: (Continued) AHCA ID Name Hospital City CountyBeds 100115KINDRED HOSPITAL-BAY AREA-TAMPA TAMPA HILLSBOROU73 100143KINDRED HOSPITAL-CENTRAL TAMPA TAMPA HILLSBOROU102 100016KINDRED HOSPITAL-NORTH FLORIDA GREEN COVE SPRINGSCLAY 60 100120KINDRED HOSP-SO.FLA-FT LAUDERDALE FORT LAUDERDALEBROWARD70 100042KINDRED HOSP-SOUTH FLORIDA-HOLLYWOOD HOLLYWOOD BROWARD124 110051LA AMISTAD RESIDENTIAL TREATMENT CENTER MAITLAND ORANGE40 100241LAKE BUTL ER HOSPITAL HAND SURGERY CENTER LAKE BUTLER UNION 25 100156LAKE CITY MEDI CAL CENTER LAKE CITY COLUMBIA67 100099LAKE WALES MEDICAL CENTER LAKE WALES POLK 154 100157LAKELAND REGIONAL MEDICAL CENTER LAKELAND POLK 851 100129LAKESIDE BEHAVIORAL HEALTHCARE, INC ORLANDO ORANGE56 111526LAKEVIEW CE NTER IRTP (MERIDIAN) PENSACOLA ESCAMBIA16 23960046LAKEWOOD RANCH MEDICAL CENTER BRADENTON MANATEE120 100248LARGO MEDICAL CENTER LARGO PINELLAS256 100181LARKIN COMMUNITY HOSPITAL SOUTH MIAMI DADE 130 100246LAWNWOOD REGIONAL MEDICAL CENTER & HEART INSTITUTEFORT PIERCE ST. LUCIE341 100012LEE MEMORIAL HOSPITAL FORT MYERS LEE 427 100084LEESBURG REGIONAL MEDI CAL CENTER LEESBURG LAKE 294 100214LEESBURG REGIONAL MEDICAL CENTER-NORTH LEESBURG LAKE 15 100107LEHIGH REGIONAL MEDICAL CENTER LEHIGH ACRES LEE 88 104018LIFESTREAM BEHAVIORAL CENTER LEESBURG LAKE 40 100195LOWER KEYS MEDI CAL CENTER KEY WEST MONROE118 100004MADISON COUNTY MEMORIAL HOSPITAL MADISON MADISON25 110028MANATEE GLENS HOSPITAL BRADENTON MANATEE27 100035MANATEE MEMORIAL HOSPITAL BRADENTON MANATEE319 110049MANATEE PALMS YOUTH SERVICES BRADENTON MANATEE60 100160MARINERS HOSPITAL TAVERNIER MONROE42 120009MARTIN MEMORIAL HOSPITAL SOUTH STUART MARTIN100 100044MARTIN MEMORIAL MEDICAL CENTER STUART MARTIN244 110001MEASE COUNTR YSIDE HOSPITAL SAFETY HARBORPINELLAS300 100043MEASE DUN EDIN HOSPITAL DUNEDIN PINELLAS173 100179MEMORIAL HOSPITAL JACKSONVILLE JACKSONVILLE DUVAL 353 23960050MEMORIAL HOSPITAL MIRAMAR MIRAMAR BROWARD128 100206MEMORIAL HOSPITAL OF TAMPA TAMPA HILLSBOROU180 100230MEMORIAL HOSPITAL PEMBROKE PEMBROKE PINESBROWARD301 111527MEMORIAL HOSPITAL WEST PEMBROKE PINESBROWARD299 100038MEMORIAL REGIONAL HOSPITAL HOLLYWOOD BROWARD690 100061MERCY HOSPITAL INC. MIAMI DADE 483 110199MIAMI CHILDREN'S HOSPITAL MIAMI DADE 275 100127MORTON PLANT HOSPITAL CLEARWATER PINELLAS687 100063MORTON PLANT NORT H BAY HOSPITAL NEW PORT RICHEYPASCO 122 100034MOUNT SINAI MEDICAL CENTER MIAMI BEACH DADE 955 100062MUNROE REGIONAL MEDICAL CENTER OCALA MARION421 100018NAPLES COMMUNITY HOSPITAL NAPLES COLLIER420 100139NATURE COAST REGIONAL HOSPITAL WILLISTON LEVY 40 100086NORTH BROWARD MEDICAL CENTER POMPANO BEACHBROWARD409 120006NORTH COLLIER HOSPITAL NAPLES COLLIER128 100204NORTH FLORIDA REGIONAL MEDICAL CENTER GAINESVILLE ALACHUA278 100122NORTH OKALOOSA MEDICAL CENTER CRESTVIEW OKALOOSA110 100237NORTH RIDGE MEDICAL CENTER FORT LAUDERDALEBROWARD332 100029NORTH SHORE MEDICAL CENTER MIAMI DADE 357 104007NORTHEAST FLORID A STATE HOSPITAL MACCLENNY BAKER1138 100238NORTHSIDE HOSPITAL SAINT PETERSBURGPINELLAS288 100147NORTHWEST FLORIDA COMMUNITY HOSPITAL CHIPLEY WASHINGTON59 100189NORTHWEST MEDICAL CENTER MARGATE BROWARD215 100264OAK HILL HOSPITAL BROOKSVILLE HERNANDO204 104008OAKWOOD CENT ER OF THE PALM BEACHES, INC. WEST PALM BEACHPALM BEACH44 100212OCALA REGIONAL MEDICAL CENTER OCALA MARION200 100226ORANGE PARK MEDICAL CENTER ORANGE PARK CLAY 230 100221ORLANDO REGIONAL LUCERNE HOSPITAL ORLANDO ORANGE209 100006ORLANDO REGIONAL MEDICAL CENTER ORLANDO ORANGE581 120002ORLANDO REGIONAL SAND LAKE HOSPITAL ORLANDO ORANGE153 27

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Appendix A: (Continued) AHCA ID Name Hospital City CountyBeds 100263ORLANDO REGIONAL SOUTH SEMINOLE HOSPITAL LONGWOOD SEMINOLE206 100110OSCEOLA REGIONAL MEDICAL CENTER KISSIMMEE OSCEOLA235 120007PALM BAY COMMUN ITY HOSPITAL MELBOURNE BREVARD60 100176PALM BEACH GARD ENS MEDICAL CENTER PALM BEACH GARDENSPALM BEACH199 100050PALM SPRINGS GENERAL HOSPITAL HIALEAH DADE 247 100187PALMETTO GENERAL HOSPITAL HIALEAH DADE 360 100126PALMS OF PASADENA HOSPITAL SAINT PETERSBURGPINELLAS307 110006PALMS WEST HOSPITAL LOXAHATCHEE PALM BEACH175 100076PAN AMERICAN HOSPITAL MIAMI DADE 146 100114PARKW AY REGIONAL MEDICAL CENTER NORTH MIAMI BEACHDADE 382 100028PARRISH MEDICAL CENTER TITUSVILLE BREVARD210 100211PASCO REGIONAL MEDICAL CENTER DADE CITY PASCO 120 100077PEACE RIVER REGIONAL MEDICAL CENTER PORT CHARLOTTECHARLOTTE212 23960025PHYSICIANS REGIONAL MEDICAL CENTER NAPLES COLLIER83 110014PINECREST REHABILITATION HO SPITAL DELRAY BEACH PALM BEACH90 100167PLANTATION GENERAL HOSPITAL PLANTATION BROWARD264 110022PORT SAINT LUCIE HOSPITAL PORT SAINT LUCIEST. LUCIE75 100232PUTNAM COMMUNITY MEDICAL CENTER PALATKA PUTNAM141 100252RAULERSON HO SPITAL OKEECHOBEE OKEECHOBEE100 110183RECEPTION AND MEDICAL CENTER HOSPITAL LAKE BUTLER UNION 153 120010REGENCY MEDICAL CENTER WINTER HAVEN POLK 61 100256REGIONAL MEDICAL CENTER BAYONET POINT HUDSON PASCO 290 100025SACRED HEART HOSPITAL PENSACOLA ESCAMBIA449 23960041SACRED HEART HOSPITAL ON THE EMERALD COAST DESTIN WALTON50 100067SAINT ANTHONY'S HOSPITAL SAINT PETERSBURGPINELLAS395 100260SAINT LUCIE MEDICAL CENTER PORT SAINT LUCIEST. LUCIE194 100151SAINT LUKE'S HOSPITAL JACKSONVILLE DUVAL 313 100010SAINT MARY'S MEDICAL CENT ER WEST PALM BEACHPALM BEACH460 100040SAINT VINCENT'S MEDICAL CENTER JACKSONVILLE DUVAL 528 110055SANDYPINE S TEQUESTA PALM BEACH80 100124SANTA ROSA MEDICAL CENTER MILTON SANTA ROSA129 100087SARASOTA MEMORIAL HOSPITAL SARASOTA SARASOTA826 100217SEBASTIAN RI VER MEDICAL CENTER SEBASTIAN INDIAN RIV129 23960043SELECT SPEC IALTY HOSPITALORLANDO INC ORLANDO ORANGE35 23960045SELECT SPECIALT Y HOSPITALPANAMA CITY, INC. PANAMA CITY BAY 30 23960028SELECT SPECIALT Y HOSPITAL-MIAMI, INC MIAMI DADE 40 100249SEVEN RIVERS REGIONAL MEDICAL CENTER CRYSTAL RIVERCITRUS128 100082SHANDS AT AGH GAINESVILLE ALACHUA367 100102SHANDS AT LAKE SHORE LAKE CITY COLUMBIA99 100146SHANDS AT LIVE OAK LIVE OAK SUWANNEE15 100103SHANDS AT STARKE STARKE BRADFORD25 120011SHANDS AT VISTA GAINESVILLE ALACHUA81 100113SHANDS HOSPITAL AT THE UNIV. OF FLORIDA GAINESVILLE ALACHUA632 100001SHANDS JACKSONVILLE MEDICAL CENTER JACKSONVILLE DUVAL 696 110025SHANDS REHAB HOSPITAL GAINESVILLE ALACHUA40 110012SHRINERS HOSPITAL FOR CHILDREN-TAMPA UNIT TAMPA HILLSBOROU60 23960044SISTER EMMANUEL HOSPITAL FOR CONTINUING CARE MIAMI DADE 29 100259SOUTH BAY HO SPITAL SUN CITY CENTERHILLSBOROU112 100172SOUTH BEAC H COMMUNITY HOSPITAL MIAMI BEACH DADE 196 100132SOUTH FLORIDA BAPTIST HOSPITAL PLANT CITY HILLSBOROU147 120014SOUTH FLORIDA EVALUATION AND TREATMENT CENTER MIAMI DADE 200 104001SOUTH FLORIDA STATE HOSPITAL PEMBROKE PINESBROWARD350 100051SOUTH LAKE HOSPITAL CLERMONT LAKE 104 100154SOUTH MIAMI HOSPITAL SOUTH MIAMI DADE 445 110040SOUTHERN WINDS HOSPITAL HIALEAH DADE 72 100220SOUTHWEST FLORIDA REGIONAL MEDICAL CENTER FORT MYERS LEE 400 100196SPECIALTY HOSPITAL JACKSONVILLE JACKSONVILLE DUVAL 107 111525SPRING HILL REGIONAL HOSPITAL SPRING HILL HERNANDO124 110054SPRINGBROOK HOSPITAL BROOKSVILLE HERNANDO60 103027ST ANTHONY'S REHABILITATION HOSPITAL FORT LAUDERDALEBROWARD26 28

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Appendix A: (Continued) AHCA ID Name Hospital City CountyBeds 103004ST CATHERINE'S REHABILITATION HOSPITAL NORTH MIAMI DADE 60 100074ST CLOUD REGIONAL MEDICAL CENTER SAINT CLOUD OSCEOLA84 100075ST JOSEPH'S HO SPITAL, INC. TAMPA HILLSBOROU883 100180ST PETERSBURG GENERAL HOSPITAL SAINT PETERSBURGPINELLAS219 100015SUN COAST HOSPITAL LARGO PINELLAS200 100135TALLAH ASSEE MEMORIAL HOSPITAL TALLAHASSEE LEON 770 100128TAMPA GENERAL HOSPITAL TAMPA HILLSBOROU877 104016TEN BROECK HOSPITAL JACKSONVILLE DUVAL 99 23960047THE CENTERS INC OCALA MARION15 100255TOWN & COUNTRY HOSPITAL TAMPA HILLSBOROU201 100108TRINITY COMM UNITY HOSPITAL JASPER HAMILTON42 100054TWIN CITIES HOSPITAL NICEVILLE OKALOOSA65 110047UNIVERSITY BEHAVIORAL CENTER ORLANDO ORANGE104 100173UNIVERSITY COMMUNITY HOSPITAL TAMPA HILLSBOROU465 100069UNIVERSITY COMMUNITY HOSPITAL AT CARROLLWOOD TAMPA HILLSBOROU120 100224UNIVERSITY HOSPITAL AND MEDICAL CENTER TAMARAC BROWARD317 100079UNIVERSITY OF MIAMI HOSPITAL AND CLINICS MIAMI DADE 40 100070VENICE REGIONAL MEDICAL CENTER VENICE SARASOTA312 23960032VILLAGES REGIONAL HOSPITAL, THE THE VILLAGES SUMTER60 23960061WEKIVA SPRINGS CENTER FOR WOMEN JACKSONVILLE DUVAL 20 110010WELLINGTON REGIONAL MEDICAL CENTER WEST PALM BEACHPALM BEACH143 110008WEST BO CA MEDICAL CENTER BOCA RATON PALM BEACH185 104027WEST FLORIDA COMMUNITY CARE CENTER MILTON SANTA ROSA100 100231WEST FLORIDA HOSPITAL PENSACOLA ESCAMBIA531 110041WEST GABLES REHABILITATION HOSPITAL MIAMI DADE 60 23960039WEST MARION COMMUNITY HOSPITAL OCALA MARION70 100165WESTCHESTER GENERAL HOSPITAL MIAMI DADE 125 100228WESTSIDE REGIONAL MEDICAL CENTER PLANTATION BROWARD224 110043WILLOUGH AT NAPLES, THE NAPLES COLLIER42 104017WINDMOOR HEALTHCARE OF CLEARWATER CLEARWATER PINELLAS100 100052WINTER HAVEN HOSPITAL WINTER HAVEN POLK 466 100162WINTER PARK MEMORIAL HOSPITAL WINTER PARK ORANGE297 23960034WUESTHOFF MEDICA L CENTER MELBOURNE MELBOURNE BREVARD115 100092WUESTHOFF MEDICAL CENTER-ROCKLEDGE ROCKLEDGE BREVARD267 29