Nationwide Variation in Surgical Quality and Cost in Laparoscopic Procedures

Ciara R Huntington, MD, Tiffany C Cox, MD, Laurel J Blair, MD, Amy E Lincourt, MBA, PhD, Vedra A Augenstein, MD, FACS, B Todd Heniford, MD, FACS. Carolinas Medical Center

Introduction: Healthcare systems and surgeons are under increasing pressure to provide high quality care for the lowest possible cost. This study utilizes national data to examine the outcomes and costs of common laparoscopic procedures based on hospital type, size, and location.

Methods: The National Inpatient Survey (NIS) was queried from 2008-2011 for five laparoscopic procedures: colectomy (LC), inguinal hernia repair (LIHR), ventral hernia repair (LVHR), Nissen fundoplication (NF), and cholecystectomy (LCh). Demographic, perioperative characteristics, and hospital charge data were collected. Outcomes were stratified by region and hospital type. Standard statistical analysis was performed.

Results: Total cases identified were as follows: 37,575 LC, 1554 LIHR, 15,582 LVHR, 15,582 NF, and 199,001 LCh.

Hospital type [nonfederal government(GH), nonprofit private(NPH), investor-owned private(IPH)] was examined for LC, LIHR, and LVHR; 77% of data was recorded from NPH. For LC, NPH and GH charged $33,666 and $35,173 respectively, while IPH charged $54,947(p<0.0001). LVHR charges varied by hospital type: $28,945 GH, $29,087 NPH, and $48,005 IPH(p<0.0001). Complication rate and mortality were equivalent for all hospital types for LC, LIHR, and LVHR(p>0.05). IPH compared to NPH had higher charges for each procedure; with a difference of $11,017 to $19,774(p<0.0001). Yet, IPH patients had the lowest Charlson comorbidity index(CCI) scores, significant for LC (p<0.0242) and LVHR(p<0.002) only.

The regions were divided into Northeast, Midwest, South, and West. The largest number of cases were reported in the South(36-44% of total), with the remainder divided between the Midwest(24-29%), Northeast(18-22%), and Western(9-18%) regions. For LC, the average CCI varied by region: 1.62 in the West, 1.64 Northwest, 1.67 Midwest, and 1.70 South(p<0.05). Minor postoperative complications varied from 12.7% in the Northeast to 20.4% in the West, while major complications ranged from 6.46% in the West to 7.69% in the Midwest. For LC, the median charges were $31,683 in the West, $34,775 in the Midwest, $35,309 in the Northeast, and $40,670 in the South(p<0.0001). Total hospital charges were significantly different between regions for each procedure; the South was most expensive for three of the five procedures(p<0.05) while the West showed wide variation in charges, being the least expensive for LC but most expensive for NF and LIHR(p<0.05). For the five procedures, only LCh had a significant difference in inpatient mortality(0.25% Northeast vs 0.53% South, p<0.05). For LVHR, minor postoperative complications(10.2%-13.3%, p<0.05) and major complications(6.9% vs 9.2%, p<0.05) varied between regions, though CCI was not different.

With regards to rural hospitals (RH) versus urban (UH), RH charged less than UH for all procedures, ($12,089-$30,506 vs $15,391-$37,047,p<0.0001). CCI and length of stay were inconsistent between RH and UH for the studied procedures. No differences in inpatient mortality was noted between RH and UH for all procedures (p>0.05).

Conclusions: There is wide variation in hospital charges and outcomes for laparoscopic surgery not fully explained by patient demographics. In general, investor-owned private hospitals charge more for common operations despite their patients appearing to be the healthiest. Surgeons need to champion efforts to standardize quality and eliminate excessive cost.

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