Achieving the High-Value Colectomy: Preventing Complications or Improving Efficiency

BACKGROUND: There is increased focus on the value of surgical care. Postoperative complications decrease value, but it is unknown whether high-value hospitals spend less than low-value hospitals in cases without complications. Previous studies have not evaluated both expenditures and validated outcomes in the same patients, limiting the understanding of interactions between clinical performance, efficient utilization of services, and costliness of surgical episodes. OBJECTIVE: This study aimed to identify payment differences between low-and high-value hospitals in colectomy cases without adverse outcomes using a linked data set of multipayer claims and validated clinical outcomes. DESIGN: This is a retrospective observational cohort study. We assigned each hospital a value score (ratio of cases without adverse outcome to mean episode payment). We stratified hospitals into tertiles by value and used analysis of variance tests to compare payments between low-and high-value hospitals, first for all cases, and then cases without adverse outcome. SETTING: January 2012 to December 2016, this investigation used clinical registry data from 56 hospitals participating in the Michigan Surgical Quality Collaborative, linked with 30-day episode payments from the Michigan Value Collaborative. PATIENTS: A total of 2947 patients undergoing elective colectomy were selected. MAIN OUTCOME MEASURES: The primary outcome measured was risk-Adjusted, price-standardized 30-day episode payments. RESULTS: The mean adjusted complication rate was 31% (±10.7%) at low-value hospitals and 14% (±4.6%) at high-value hospitals (p < 0.001). Low-value hospitals were paid $3807 (17%) more than high-value hospitals ($22,271 vs $18,464, p < 0.001). Among cases without adverse outcome, payments were still $2257 (11%) higher in low-value hospitals ($19,424 vs $17,167, p = 0.04). LIMITATIONS: This study focused on outcomes and did not consider processes of care as drivers of value. CONCLUSIONS: In elective colectomy, high-value hospitals achieve lower episode payments than low-value hospitals for cases without adverse outcome, indicating mechanisms for increasing value beyond reducing complications. Worthwhile targets to optimize value in elective colectomy may include enhanced recovery protocols or other interventions that increase efficiency in all phases of care. See Video Abstract at http://links.lww.com/DCR/B56.