Aristithes Doumouras, MD, MPH1, Fady Saleh, MD, MPH2, Scott Gmora, MD1, Mehran Anvari, MD, PhD1, Dennis Hong, MD, MSc1. 1McMaster University, 2William Osler Healthcare
Background: Gastric bypass is an important public health procedure with economic benefit to society. Understanding system factors, including the individual surgeon cost efficiencies, is vital to ensuring optimal economic benefit. Therefore, this study sought to determine the effect of system factors including cumulative volume on cost efficiencies.
Methods: This was a population-based longitudinal study of 29 surgeons during the first 6 years of performing bariatric surgery in a high volume, regionalized center of excellence system. Cumulative volume was determined using date and time of the procedure. These are the only centers sanctioned to performed bariatric surgery in the province. The main predictor was surgeon cumulative volume was analyzed in blocks of 25 cases for the first 100 and each 100 thereafter. Secondary predictors included patient demographics, comorbidities, complications, surgeon annual volume, hospital annual volume and hospital cumulative volume. The main outcome of interest was cost of the index admission in inflation adjusted Canadian dollars. Secondary outcome was the variation across surgeons. Bayesian hierarchal linear regression models accounting for year, hospital, surgeons were utilized for the analysis.
Results: Overall, 11,684 gastric bypasses were performed by 29 surgeons at 9 centers of excellence. The unadjusted average cost was $7868 (SD±14535). Compared to the first 25 cases, all-cause morbidity for the next 25 cases was not significantly different (-$686; 95%CI -$2205 – $-794 p=0.19). After the 50th case, the adjusted costs dropped by $2507 (95%CI -$4066 – -$933 p=0.002) . Overall, index admission costs plateaued after approximately 50 cases and this effect was maintained throughout the first 300 cases (-$1929 95% -$3657 – $-206 p=0.03). Complications ($9052 95% $8191 – $9918 p<0.001) and patients with severe diabetes ($4400 95% $2782 – $6068 p<0.001) had substantial impact on increased costs. Hospital and surgeon annual volumes as well as hospital cumulative volume had no effect on costs. Variation across surgeons was minimal.
Conclusion: This study demonstrated the clear, substantial influence of surgeon cumulative volume on improved cost efficiencies. As no other system factors had a significant impact on costs, this finding emphasizes role of the individual surgeon experience in decreasing inpatient costs and that it takes about 50 cases for surgeons to reach cost efficiencies. This effect is maintained through their first 300 cases.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86427
Program Number: S112
Presentation Session: Residents/Fellows Session
Presentation Type: ResFel