L. Kuo1, K. D. Simmons1, R. R. Kelz1 1Hospital Of The University Of Pennsylvania,Surgery,Philadelphia, PA, USA
Introduction: Minimally invasive surgery (MIS) is often associated with higher costs than open operations due to expensive equipment. Institutions that perform higher volumes of an operation are associated with improved clinical outcomes, such as shorter lengths of stay and fewer postoperative complications, over low-volume institutions, and these improved outcomes may translate into lower associated costs. We sought to examine if economies of scale existed in the provision of MIS surgery.
Methods: A unique inpatient database using discharge data from three high-volume surgical states (California, Florida and New York) over a five-year period was used. Four common general surgery operation groups, for which the MIS approach offers improved or equivalent outcomes to the open technique, were selected: cholecystectomy, appendectomy, bariatric, and antireflux. For each operation, the per-hospital number of MIS operations and the associated wage-adjusted cost was obtained. Hospitals were categorized as low-volume (lowest 20%), moderate, and high volume (highest 20%) for each of the five MIS operations. The median associated wage-adjusted cost was compared between low, moderate and high-volume categories for each operation using the Kruskal-Wallis. The Bonferroni correction was used to adjust for multiple comparisons.
Results: For cholecystectomy, appendectomy, and antireflux procedures, low-volume institutions had a significantly higher median cost than moderate- and high-volume institutions. For cholecystectomy and appendectomy, high-volume institutions had the lowest median cost. For antireflux operations, moderate-volume institutions had the lowest median cost, although the difference may not be clinically significant. For bariatric procedures, cost increased with volume. See Table 1.
Conclusion: Economies of scale exist between low- vs. moderate- and high-volume institutions for all operations studied except bariatric. The highest-volume institutions did not always have the lowest associated costs. Costs associated with bariatric operations increased with volume, which may be related to restrictions on where high-risk patients receive bariatric surgery.
