Cost variation in a laparoscopic cholecystectomy and the association with outcomes across a single health system: implications for standardization and improved resource utilization

Lack of Association of Pediatric Surgical Patient Outcomes With Increased Disposable Operating Room Supply Costs

INTRODUCTION

There is wide variation in the cost of disposable operating room supplies between surgeons performing the same operation at the same institution. The general relationship between variation in disposable supply cost and patient outcomes is unknown. We aimed to evaluate the relationship between disposable supply cost and patient outcomes for sixteen common operations.

METHODS

Cost data were reviewed for the most common procedures performed by five surgical divisions at a single children's hospital over a six-month period in 2021. For procedure, the median disposable OR costs were calculated. Each operation performed was categorized as low cost (below the group median) or high cost (above the group median. We compared the rates of adverse events (clinic visit within 5 days, 30-day emergency department visit, unplanned reoperation, unplanned readmission, anesthesia complications, prolonged hospital length of stay, need for blood product transfusion, or death) between procedures with low and high disposable supply costs.

RESULTS

1139 operations performed by 48 unique surgeons from five specialties were included; 596 (52%) were low-cost and 543 (48%) high-cost. The low and high-cost groups did not differ regarding most demographic characteristics. Overall, 21.9% of children suffered any adverse outcome; this rate did not differ between the low and high-cost groups when evaluated individually or in aggregate (20.5% vs 23.6%, p = 0.23).

CONCLUSION

Our data demonstrate that across a wide range of pediatric surgical procedures, the cost of disposable operating room supplies was not associated with the risk of adverse outcomes.

LEVEL OF EVIDENCE

Level 3.

Variation in cost of disposable operating room supplies at a children's hospital

BACKGROUND

Operating room (OR) costs account for 40% of hospital costs. Disposable supplies make up a portion of OR costs and are the only cost that is under control of the surgeon. There are little data to explain how surgeons select surgical supplies and what factors predict supply selection. Our goal with the current work was to assess variation in cost of disposable OR supplies at the surgeon level, hypothesizing high variability would be observed.

STUDY DESIGN

Cost data were reviewed for the most common procedures performed by five surgical divisions at a single children's hospital over a six-month period in 2021. For each procedure, the average disposable OR costs for each surgeon were tabulated and compared to the median supply cost for a given procedure at the group level.

RESULTS

For each procedure, the variation ranged from 149% (gastrostomy tube placement) to 758% (tonsillectomy and adenoidectomy). The median supply cost for an individual surgeon was not always above or below the median supply cost for that procedure for the group. No relationship was observed between whether the supply cost was above or below the median for a given case and a surgeon's case volume, years in practice, or operative length. There was also no relationship between surgeon volume and median cost, surgery length, and years of experience.

CONCLUSION

These data demonstrate variation in the cost of disposable OR supplies at the individual surgeon level at a single institution. This variation is not explained by case volume, years in practice, or operative length.

Post-cholecystectomy syndrome: a retrospective study analysing the associated demographics, aetiology, and healthcare utilization

Background

Post-cholecystectomy syndrome (PCS) is a group of heterogeneous signs and symptoms, predominately consisting of right upper quadrant abdominal pain, dyspepsia, and/or jaundice, manifesting after undergoing a cholecystectomy. According to some studies, as many as 40% of post-cholecystectomy patients are in fact, affected by this syndrome. This study aims to determine the demographics, aetiology, average length of hospital stay, and health care burden associated with PCS.

Methods

We queried the National Inpatient Sample (NIS) database to determine inpatient admissions of PCS between 2011 and 2014 using the ICD-9 primary diagnosis code 576.0.

Results

From 2011 to 2014, the number of inpatient admissions with a principal diagnosis of PCS totally 275. The average length of hospital stay was 4.28±4.28, 3.42±2.73, 3.74±1.84, and 3.79±2.78 days in 2011, 2012, 2013, and 2014, respectively. The total yearly charges were $32,079±$24,697, $27,019±$22,633, $34,898.21±$24,408, and $35,204±$32,951 in 2011, 2012, 2013, and 2014, respectively. Notably, the primary cause of PCS in our patient sample between the year 2011 and 2014, was biliary duct dysfunction, followed by Peptic ulcer disease.

Conclusions

In conclusion, there is a strong need to examine for and treat the underlying aetiology when approaching a post-cholecystectomy patient. We found that longer hospital stays, were associated with a greater health care burden, and visa versa. Furthermore, our findings help identify at-risk populations which can contribute to improving surveillance of this costly disease.

Variation in Intraoperative and Postoperative Utilization for 3 Common General Surgery Procedures

OBJECTIVE

The aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures.

SUMMARY BACKGROUND DATA

Reducing surgical costs is paramount to the viability of hospitals.

METHODS

Retrospective analysis of electronic health record data for 7762 operations from 2 health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons.

RESULTS

The number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation (ρ = 0.49, P = 0.03) between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy.

CONCLUSIONS

Surgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.

Evaluating the impact of surgical supply cost variation during partial nephrectomy on patient outcomes

Background

Reducing surgical supply costs can help to lower hospital expenditures. We aimed to evaluate whether variation in supply costs between urologic surgeons performing both robotic or open partial nephrectomies is associated with differential patient outcomes.

Methods

In this retrospective cohort study, we reviewed 399 consecutive robotic (n=220) and open (n=179) partial nephrectomies performed at an academic center. Surgical supply costs were determined at the institution-negotiated rate. Through retrospective review, we identified factors related to case complexity, patient comorbidity, and perioperative outcomes. Two radiologists assigned nephrometry scores to grade tumor complexity. We created univariate and multivariable models for predictors of supply costs, length of stay, and change in serum creatinine.

Results

Median supply cost was $3,201 [interquartile range (IQR): $2,201–3,808] for robotic partial nephrectomy and $968 (IQR: $819–1,772) for open partial nephrectomy. Mean nephrometry score was 7.0 (SD =1.7) for robotic procedures and 8.2 (SD =1.6) for open procedures. In multivariable models, the surgeon was the primary significant predictor of variation in surgical supply costs for both procedure types. In multivariable mixed-effects analysis with surgeon as a random effect, supply cost was not a significant predictor of change in serum creatinine for robotic or open procedures. Supply cost was not a statistically significant predictor of length of stay for the open procedure. Supply cost was a significant predictor of longer length of stay for the robotic procedure, however it was not a clinically meaningful change in length of stay (0.02 days per $100 in supply costs).

Conclusions

Higher supply spending did not predict significantly improved patient outcomes. Variability in surgeon supply preference is the likely source of variability in supply cost. These data suggest that efforts to promote cost-effective utilization and standardization of supplies in partial nephrectomy could help reduce costs without harming patients.

Cost analysis of laparoscopic appendectomy in a large integrated healthcare system

INTRODUCTION

Healthcare expenditure is on the rise placing greater emphasis on operational excellence, cost containment, and high quality of care. Significant variation is seen in operating room (OR) costs with common surgical procedures such as laparoscopic appendectomy. Surgeons can influence cost through the selection of instrumentation for common surgical procedures such as laparoscopic appendectomy. We aimed to quantify the cost of laparoscopic appendectomy in our healthcare system and compare cost variations to operative times and outcomes.

METHODS AND PROCEDURES

We performed a retrospective review of laparoscopic appendectomies in a large regional healthcare system during one-year period (2018). Operating room supply costs and procedure durations were obtained for each hospital. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) outcomes and demographics were compared to the costs for each hospital.

RESULTS

A total of 4757 laparoscopic appendectomies were performed at 20 hospitals (27 to 522 per hospital) by 233 surgeons. The average supply cost per case ranged from $650 to $1067. Individual surgeon cost ranged from $197 to $1181. The average operative time was 41 min (range 33 to 60 min). There was no association between lower cost and longer operative time. The patient demographics and comorbidities were similar between sites. There were no significant differences in postoperative complications between high- and low-cost centers. The items with the greatest increase in cost were single-use energy devices (SUD) and endoscopic stapler. We estimate that a saving of over $417 per case is possible by avoiding the use of energy devices and may be as high as $ 984 by adding selective use of staplers. These modifications would result in an annual savings of $1 million for our health system and more than $ 125 million nationwide.

CONCLUSION

Performing laparoscopic appendectomy with reusable instruments and finding alternatives to expensive energy devices and staplers can significantly decrease costs and does not increase operative time or postoperative complications.

Reducing cost and waste in pediatric laparoscopic procedures

BACKGROUND

In 2017 the healthcare cost in the United States accounted for 17.9% of the Gross Domestic Product (GDP). Furthermore, healthcare facilities produce more than 4 billion pounds of waste annually. Interhospital and intersurgeon variabilities in surgical procedures are some of the drivers of high healthcare cost and waste. We sought to determine the effect of a monthly surgeon report card detailing the utilization and cost of disposable and reusable surgical supplies on cost and waste reduction for pediatric laparoscopic procedures.

METHODS

Starting in July 2017, surgeons were provided with an individual report with supply cost per case, high cost, and disposable supply utilization, and clinical outcomes. Cost, utilization, and clinical outcomes six quarters before and after the intervention were compared.

RESULTS

A total of 998 pediatric laparoscopic procedures were analyzed. We reduced the median supply cost per case by 43% after the intervention with total cost savings of $71,035 for the first four quarters. We also reduced the use of disposable trocars by 56% and the use of disposable harmonics and staplers by 33%.

CONCLUSIONS

Using a periodic surgeon report card, we significantly reduced supply cost and utilization of disposable items for all pediatric laparoscopic procedures performed at the University of Wisconsin American Family Children's Hospital.

TYPE OF STUDY

Cost effectiveness study.

LEVEL OF EVIDENCE

Level III.

Surgeon Variability Impacts Costs in Laparoscopic Cholecystectomy: the Volume-Cost Relationship

BACKGROUND

Physician variation in adherence to best practices contributes to the high costs of health care. Understanding surgeon-specific cost variation in common surgical procedures may inform strategies to improve the value of surgical care.

METHODS

Laparoscopic cholecystectomies at a single institution were identified over a 5-year period and linked to an institutional cost database. Multiple linear regression was used to control for patient-, case-, and hospital-specific factors while assessing the impact of surgeon variability on cost.

RESULTS

The final dataset contained 1686 patients. Higher surgeon volume (reported in tertiles) was associated with decreased costs ($5354 vs. $6301 vs. $7156, p < 0.01) and OR times (66 min vs. 85 min vs. 95 min, p < 0.01). After controlling for patient-, case-, and hospital-specific factors, non-MIS fellowship training type (p < 0.01) and low surgeon volume (p < 0.01) were associated with increased costs, while time in practice did not contribute to cost variation (p = NS).

CONCLUSIONS

Surgeon variability contributes to costs in laparoscopic cholecystectomy. Some of this variability is associated with operative volume and fellowship training. Collaboration to limit this cost variability may reduce surgical resource utilization.

Patient Factors Lead to Extensive Variation in Outcomes and Cost From Cholecystectomy

BACKGROUND

Cholecystectomy is a common procedure with significantly varied outcomes. We analyzed differences in comorbidities, outcomes, and cost of cholecystectomy by acute care surgery (ACS) versus hepatopancreaticobiliary (HPB) surgery.

STUDY DESIGN

Patients were retrospectively identified between 2008 and 2015. Exclusion criteria included the following: (1) part of another procedure; (2) abdominal trauma; (3) ICU admission; vasopressors.

RESULTS

One hundred and twenty-six ACS and 122 HPB patients were analyzed. The HPB subset had higher burden of comorbid disease and significantly lower projected 10-year survival (87.4% ACS vs 68.5% HPB, P < .0001). Median lengths of stay were longer in HPB patients (2 vs 5 days, P < .0001) as were readmission rates (30-day 5.6% vs 13.1%, P = .040; 90-day 7.9% vs 20.5%, P = .005). Median cost was higher including operative supply cost ($969.42 vs $1920.66, P < .0001) and total cost of care ($7340.66 vs $19 338.05, P < .0001). A predictive scoring system for difficult gallbladders was constructed and a phone application was created.

CONCLUSION

Cholecystectomy in a complicated patient can be difficult with longer hospital stays and higher costs. The utilization of procedure codes to explain disparities is not sufficient. Incorporation of comorbidities needs to be addressed for planning and reimbursement.

Harnessing Behavioral Economics Principles to Promote Better Surgeon Accountability for Operating Room Cost: A Prospective Study

BACKGROUND

Operating room (OR) cost accounts for a significant portion of inpatient spending, but most surgeons are unaware of the costs of OR implants and supplies. We leveraged behavioral economics principles and a cost transparency tool to have an impact on discretionary OR spending (disposable supplies).

STUDY DESIGN

We performed a single-institution, prospective study, from January to December 2018, across 3 departments: urology, thoracic, and endocrine. Two self-selected procedures per department were subjected to intraoperative supply cost (ISC) feedback via a custom dashboard and monthly email reports. Behavioral economics principles like choice overload, social ranking, and threshold effects were leveraged during study design. The primary outcome of percentage change in the department-level mean ISC, as determined via an interrupted time-series mixed effects model, was compared between the intervention year (2018) and "pre-baseline" (2016) and "baseline" (2017) years.

RESULTS

A total of 2,853 procedures and 26 surgeons comprised our analytical sample. Costs decreased in 5 of the 6 procedures in 2018. On average, there was a significant monthly decrease in costs of approximately 0.5% over the study period (p = 0.0004). Post-intervention, there was a nonsignificant additional decrease of 0.6% in monthly cost (p = 0.0648). Overall cost significantly decreased by 20% due to the intervention (p < 0.0001). Similar results were noted on sensitivity analysis. There were no significant changes in the incidence of postoperative complication due to our intervention.

CONCLUSIONS

Deployment of a cost feedback tool using behavioral economics principles resulted in a significant decrease in OR spending without negatively affecting complication rate.

Cost containment: an experience with surgeon education and universal preference cards at two institutions

BACKGROUND

As the cost of health care increases in the US, focus has been placed upon efficiency, cost reduction, and containment of spending. Operating room costs play a significant role in this spending. We investigated whether surgeon education and universal preference cards can have an impact on reducing the disposable supply costs for common laparoscopic general surgery procedures.

METHODS

General surgeons at two institutions participated in an educational session about the costs of the operative supplies used to perform laparoscopic appendectomies and cholecystectomies. All the surgeons at one institution agreed upon a universal preference card, with other supplies opened only by request. At the other, no universal preference cards were created, and surgeons were free to modify their own existing preference cards. Case cost data for these procedures were collected for each institution pre- (July 2014-December 2014) and post-intervention (February 2015-November 2017).

RESULTS

At the institution with an education only program, there was no statistically significant change in supply costs after the intervention. At the institution that intervened with the combined education and universal preference card program, there was a statistically significant supply cost decrease for these common laparoscopic procedures combined. This significant cost decrease persisted for each appendectomies and cholecystectomies when analyzed independently as well (p = 0.001 and p < 0.001 respectively).

CONCLUSIONS

In this study, surgeon education alone was not effective in reducing operating room disposable supply costs. Surgeon education, combined with the implementation of universal preference cards, significantly maintains reductions in operating room supply costs. As health care costs continue to increase in the US and internationally, universal preference cards can be an effective tool to contain cost for common laparoscopic general surgery procedures.

Evaluating Surgeons on Intraoperative Disposable Supply Costs: Details Matter

BACKGROUND

Cost report cards have demonstrated variation in intraoperative supply costs and may allow comparisons between surgeons. However, cost data are complex and, if not properly vetted, may be inaccurate.

METHODS

A retrospective assessment of intraoperative supply costs for consecutive laparoscopic cholecystectomies (2013-2017) at a 4-facility academic center was performed. Using unadjusted data (akin to an auto-generated report card), surgeons were ranked and highest to lowest-cost ratios were calculated. Then, four stepwise adjustments were performed: (1) excluded non-comparable operations and low volume (< 10 cases) surgeons, (2) eliminated outlier cases based on instrument profiles, (3) stratified by facility, and (4) adjusted prices (assigned one price; corrected aberrant/missing prices). Surgeon rank and highest to lowest-cost ratios were then re-calculated.

RESULTS

The unadjusted data identified 1392 cases for 33 surgeons (range, 1-317 cases). The ratio between the highest cost and lowest cost surgeon was 4.13. Steps 1 and 2 excluded 272 cases and 15 surgeons. Facility sample sizes ranged from 144 to 621 (step 3). Adjusting prices (step 4) required manual review of 472 unique items: 45% had > 1 price and 16 had missing prices. After all adjustments, surgeons had different rankings and highest to lowest-cost ratios within sites were smaller (ratio range, 1.17-2.10).

CONCLUSIONS

Evaluating surgeons based on intraoperative supply costs is sensitive to analytic methods. Surgeons who were initially considered cost outliers became the least expensive within a given site. Auto-generated cost report cards may require additional analyses to produce accurate comparative assessments.

Cost Analysis and Supply Utilization of Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy (LC) is one of the highest volume surgeries performed annually. We hypothesized that there is a statistically significant intradepartmental cost variance with supply utilization variability amongst surgeons of different subspecialty. This study sought to describe laparoscopic cholecystectomy cost of care among three subspecialties of surgeons. This retrospective observational cohort study captured 372 laparoscopic cholecystectomy cases performed between June 2015 and June 2016 by 12 surgeons divided into three subspecialties: 2 in bariatric surgery (BS), 5 in acute care surgery (ACS), and 5 in general surgery (GS). The study utilized a third-party software, Surgical Profitability Compass Procedure Cost Manager and Crimson System (SPCMCS) (The Advisory Board Company, Washington, DC), to stratify case volume, supply cost, case duration, case severity level, and patient length of stay intradepartmentally. Statistical methods included the Kruskal-Wallis test. Average composite supply cost per case was $569 and median supply cost per case was $554. The case volume was 133 (BS), 109 (ACS), and 130 (GS). The median intradepartmental total supply cost was $674.5 (BS), $534 (ACS), and $564 (GS) (P<0.005). ACS and GS presented with a higher standard deviation of cost, $98 (ACS) and $110 (GS) versus $26 (BS). The median case duration was 70 min (BS), 107 min (ACS), and 78 min (GS) (P<0.02). The average patient length of stay was 1.15 (BS), 3.10 (ACS), and 1.17 (GS) (P<0.005). Overall, there was a statistically significant difference in median supply cost (highest in BS; lowest in ACS and GS). However, the higher supply costs may be attenuated by decreased operative time and patient length of stay. Strategies to reduce total supply cost per case include mandating exchange of expensive items, standardization of supply sets, increased price transparency, and education to surgeons.

Improving the value of care for appendectomy through an individual surgeon-specific approach

PURPOSE

Standardized care via a unified surgeon preference card for pediatric appendectomy can result in significant cost reduction. The purpose of this study was to evaluate the impact of cost and outcome feedback to surgeons on value of care in an environment reluctant to adopt a standardized surgeon preference card.

METHODS

Prospective observational study comparing operating room (OR) supply costs and patient outcomes for appendectomy in children with 6-month observation periods both before and after intervention. The intervention was real-time feedback of OR supply cost data to individual surgeons via automated dashboards and monthly reports.

RESULTS

Two hundred sixteen children underwent laparoscopic appendectomy for non-perforated appendicitis (110 pre-intervention and 106 post-intervention). Median supply cost significantly decreased after intervention: $884 (IQR $705-$1025) to $388 (IQR $182-$776), p<0.001. No significant change was detected in median OR duration (47min [IQR 36-63] to 50min [IQR 38-64], p=0.520) or adverse events (1 [0.9%] to 6 [4.7%], p=0.062). OR supply costs for individual surgeons significantly decreased during the intervention period for 6 of 8 surgeons (87.5%).

CONCLUSION

Approaching value measurement with a surgeon-specific (rather than group-wide) approach can reduce OR supply costs while maintaining excellent clinical outcomes.

LEVEL OF EVIDENCE

Level II.

Surgeon Variation in Intraoperative Supply Cost for Pancreaticoduodenectomy: Is Intraoperative Supply Cost Associated with Outcomes?

BACKGROUND

With increased scrutiny on the quality and cost of health care, surgeons must be mindful of their outcomes and resource use. We evaluated surgeon-specific intraoperative supply cost (ISC) for pancreaticoduodenectomy and examined whether ISC was associated with patient outcomes.

STUDY DESIGN

Patients undergoing open pancreaticoduodenectomy between January 2012 and March 2015 were included. Outcomes were tracked prospectively through postoperative day 90, and ISC was defined as the facility cost of single-use surgical items and instruments, plus facility charges for multiuse equipment. Multivariate logistic regression was used to test associations between ISC and patient outcomes using repeated measures at the surgeon level.

RESULTS

There were 249 patients who met inclusion criteria. Median ISC was $1,882 (interquartile range [IQR] $1,497 to $2,281). Case volume for 6 surgeons ranged from 18 to 66. Median surgeon-specific ISC ranged from $1,496 to $2,371. Greater case volume was associated with decreased ISC (p < 0.001). Overall, ISC was not predictive of postoperative complications (p = 0.702) or total hospitalization expenditures (p = 0.195). At the surgeon level, surgeon-specific ISC was not associated with the surgeon-specific incidence of severe complication or any wound infection (p > 0.227 for both), but was associated with delayed gastric emptying (p = 0.004) and postoperative pancreatic fistula (p < 0.001).

CONCLUSIONS

In a single-institution cohort of 249 pancreaticoduodenectomies, high-volume surgeons tended to be low-cost surgeons. Across the cohort, ISC was not associated with outcomes. At the surgeon level, associations were noted between ISC and complications, but these may be attributable to unmeasured differences in the postoperative management of patients. These findings suggest that quality improvement efforts to restructure resource use toward more cost-effective practice may not affect patient outcomes, although prospective monitoring of safety and effectiveness must be of the utmost concern.

Cost variation and opportunities for cost reduction for laparoscopic cholecystectomy

BACKGROUND

We performed 163 laparoscopic cholecystectomies at our institution during the third quarter of 2016. Direct supply cost per case varied from $524 to $1,022 among 14 surgeons. The purpose of this study was to determine the reasons for cost variation between high- and low-cost surgeons and identify opportunities for cost reduction.

METHODS

Average cost of supplies per case was examined for laparoscopic cholecystectomy during a 6-month period. Two groups were created, with the 4 highest-cost surgeons comprising group A and the 2 lowest-cost surgeons comprising group B. The cost for each item was identified, and utilization was compared between groups.

RESULTS

The average supply cost per case in group A was significantly greater than group B ($930 vs. $518). The difference persisted in subgroup analyses of both inpatients and patients with high American Society of Anesthesiologists scores. Compared with group A, surgeons in group B used reusable instruments more often and tended to choose lower-cost disposables.

CONCLUSIONS

Significant variation in direct cost exists between surgeons performing laparoscopic cholecystectomy. Much of the cost difference can be accounted for by a relatively small number of high-cost instruments. We identified areas for cost savings by substituting lesser cost alternatives without compromising the quality of patient care.

Targeting Value-Driven Quality Improvement for Laparoscopic Cholecystectomy in Michigan

OBJECTIVE

The purpose of this study was to evaluate complete episode expenditures for laparoscopic cholecystectomy, a common and lower-risk operation, to characterize novel targets for value-based quality improvement.

SUMMARY BACKGROUND DATA

Despite enthusiasm for improving the overall value of surgical care, most efforts have focused on high-risk inpatient surgery.

METHODS

We identified 19,213 patients undergoing elective laparoscopic cholecystectomy from 2012 to 2015 using data from Medicare and a large private payer. We calculated price-standardized payments for the entire surgical episode of care and stratified patients by surgeon. We used linear regression to risk- and reliability-adjusted expenditures for patient characteristics, diagnoses, and the use of additional procedures.

RESULTS

Fully adjusted total episode costs varied 2.4-fold across surgeons ($7922-$17,500). After grouping surgeons by adjusted total episode payments, each component of the total episode was more expensive for patients treated by the most expensive versus the least expensive quartile of surgeons. For example, payments for physician services were higher for the most expensive surgeons [$1932, 95% confidence interval (CI) $1844-$2021] compared to least expensive surgeons ($1592, 95% CI $1450-$1701, P < 0.01). Overall differences were driven by higher rates of complications (10% vs. 5%) and readmissions (14% vs. 8%), and lower rates of ambulatory procedures (77% vs. 56%) for surgeons with the highest versus lowest expenditures. Projections showed that a 10% increase ambulatory operations would yield $3.6 million in annual savings for beneficiaries.

CONCLUSIONS

Episode payments for laparoscopic cholecystectomy vary widely across surgeons. Although improvements in several domains would reduce expenditures, efforts to expand ambulatory surgical practices may result in the largest savings to beneficiaries in Michigan.