J. V. Vu1, J. LI3, D. S. LIKOSKY2, E. C. NORTON4,5, D. A. CAMPBELL1, S. E. REGENBOGEN1 1University Of Michigan,SURGERY,Ann Arbor, MI, USA 2University Of Michigan,CARDIAC SURGERY,Ann Arbor, MI, USA 3University Of Michigan,SCHOOL OF PUBLIC HEALTH,Ann Arbor, MI, USA 4University Of Michigan,ECONOMICS,Ann Arbor, MI, USA 5University Of Michigan,HEALTH MANAGEMENT AND POLICY,Ann Arbor, MI, USA
Introduction: As payers increasingly tie reimbursement to value, there is increased focus on both outcomes and expenditures for surgical care. One way of measuring hospital value is by comparing episode payments to adverse outcomes. While postoperative complications increase spending and decrease value, it is unknown whether hospitals that achieve highest value in major surgery also deliver efficient care beyond the prevention of complications. We aimed to identify the contributions of clinical quality and efficiency of perioperative care to high-value strategies for success in episode-based reimbursement for colectomy.
Methods: This was a retrospective observational cohort study of elective colectomy patients from 2012 to 2016, from 56 hospitals in the Michigan Surgical Quality Collaborative and Michigan Value Collaborative. Hospitals were assigned a value score (proportion of cases without adverse outcome divided by mean episode payment). Adverse outcomes included postoperative complications, reoperation, or death within 30 days of surgery. Risk-adjusted payments for total 30-day episode and components of care were compared using ANOVA between hospitals by value tertile.
Results: We matched 2,947 patients enrolled in both registries, 646 (22%) of which experienced adverse outcomes. Mean adjusted complication rate was 31% (+10.7%) at low-value hospitals and 14% (+4.6%) at high-value hospitals (p<0.001). Mean episode payments for all cases were $3,807 (17%) higher in low-value than high-value hospitals, ($22,271 vs. $18,464 p<0.001). Among cases without adverse outcomes only, payments were still $2,257 (11%) higher in low-value hospitals ($19,424 vs. $17,167, p=0.04).
Conclusion: In elective colectomy, high-value hospitals achieve lower episode payments than low-value hospitals for cases both with and without complications, indicating mechanisms for increasing value beyond reducing complications alone. High-value hospitals had two-fold lower complication rates, but also achieved 11% savings in uncomplicated cases. Worthwhile targets to optimize value in elective colectomy may include enhanced recovery protocols or other interventions that increase efficiency in all phases of care.
