S. Mallick1,2, S. Sakowitz1,2, T. Coaston1,2, S. Bakhtiyar3, A. Khan4, H. Lee5, P. Benharash1,2 1University Of California – Los Angeles, Center For Advanced Surgical & Interventional Technology (CASIT), Department Of Surgery, Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles, Cardiovascular Outcomes Research Laboratories (CORELAB), Department Of Surgery, Los Angeles, CA, USA 3University of Colorado Anschutz Medical Campus, Department Of Surgery, Aurora, CO, USA 4Vanderbilt University Medical Center, Department Of Surgery, Nashville, TN, USA 5Los Angeles County Harbor-UCLA Medical Center, Department Of Surgery, Los Angeles, CA, USA
Introduction:
With the substantial rise in healthcare expenditures across the US, efforts to mitigate cost while ensuring high quality of care are essential. Despite well-recognized variation in fees, quality, and value in colorectal surgery across institutions, the exact cost buckets driving these differences have not previously been elucidated.
Methods:
Adults with a diagnosis of colon or rectal cancer undergoing elective colorectal resection were identified in the 2019 Arizona, Massachusetts, Maryland, and New York State Inpatient Databases. Multilevel mixed-effects models were used to identify patient and hospital characteristics associated with hospitalization costs. The random intercept for each hospital was generated and considered as the baseline cost attributable to care at each center. Hospitals within the highest quartile of baseline, risk-adjusted, and reliability-adjusted costs were classified as high-cost hospitals (HCH), while all others were classified as low-cost hospitals (LCH). Revenue codes were used to identify the charges of care associated with specific hospital. We subsequently applied multivariable regression models to examine the association of HCH status with specific drivers of hospitalization costs.
Results:
Of 6,138 patients meeting study criteria, 88.4% underwent colectomy and 11.4% underwent rectal resection. Variation in hospital-level costs was evident, with median center-level charges of $58,640 (interquartile range (IQR), 35,010-91,897). Upon multi-level modelling, 68.2% of variation in charges was attributable to the hospital, independent of patient-level characteristics (Figure 1A). Significant variation in fees associated with hospital services was also noted, with operating room costs displaying the highest difference in unadjusted costs (Figure 1B).
Upon multivariable analysis, significant incremental cost differences were noted in risk-adjusted charges of all hospital services studied (p<0.001). The three main services driving the financial differences were operating room charges (β: +$23,104 (IQR, 21,973-24,236)), medical/surgical supplies fees (β: $6,527 (IQR, 6,085-6,970)), followed by room/boarding charges (β: $6,369 (IQR, 5,259-7,479)) (all p<0.001, Ref:LCH). Notably, patients at HCH (AOR: 0.94, 95%CI: 0.56-1.45, p=0.83) had similar risk-adjusted odds of major complications relative to LCH.
Conclusion:
Operating room, medical/surgical device, and room costs appear to drive the significant variation seen in colorectal surgical expenditures. With HCH portending similar outcomes to their lower-cost counterparts, implementation of interventions designed to tackle the source of the observed variation are necessary to optimize outcomes while limiting healthcare expenditures.