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Wide variation in cost of surgical care for parathyroidectomy: is there a need for standardization of practice?
ARTICLE IN PRESS Surgery ■■ (2017) ■■–■■
Contents lists available at ScienceDirect
Surgery j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y m s y
Central Surgical Association
Wide variation in cost of surgical care for parathyroidectomy: is there a need for standardization of practice? Samuel Jang a,b, Meagan Mandabach b, Zviadi Aburjania b, Courtney J. Balentine b, and Herbert Chen b,* a b
Howard Hughes Medical Institute, Birmingham, AL Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
A R T I C L E
I N F O
Article history: Accepted 21 October 2017
A B S T R A C T
Background. Identifying hospital and provider variation in surgical cost is a potent method for controlling rising healthcare expenditure and delivering cost-effective care. The purpose of this study was to examine the variation of hospital cost by providers for parathyroidectomy in a single academic institution. Methods. We retrospectively evaluated 894 consecutive parathyroidectomies under 8 surgeons in our institution between September 2011 and July 2016. Total duration of stay and cost were evaluated using nonparametric tests. Categorical variables were evaluated with χ2. Results. The median total hospital cost for parathyroidectomy was $4,863.28 (interquartile range: 4,196– 5,764), but the median costs per provider varied widely from $4,522.30 to $12,072.87. The median duration of stay was 0 days (IQR: 0–1) and demonstrated a wide variation among providers. Longer duration of practice was associated with lower cost. Despite the variation, only 2% was readmitted after discharge with no patient mortality. Conclusion. We found substantial variation in hospital cost among providers for parathyroidectomy despite practicing in the same academic institution, with some surgeons spending 4 time more for the same operation. Implementing institutional standards of practice could be a method to decrease variation and costs of surgical care. (Surgery 2017;160:XXX-XXX.) © 2017 Elsevier Inc. All rights reserved.
Containing the cost of patient care is becoming increasingly important as US health care spending climbed to $3.2 trillion in 2015, accounting for 17.8% of gross domestic product.1 Cost for providing surgical care is currently estimated to be $400 billion.2 As health care expenditure is being examined for inefficiencies, hospitals and lawmakers are interested in identifying areas where costs could be contained. Additionally, bundled payments, where a single reimbursement covers all services for a single episode of care, are being proposed as an alternative payment model to the prevalent fee-for-service model.3 A successful bundled payment program requires physicians and hospitals to understand the costs
S.J. was financially supported by the Howard Hughes Medical Research Fellows Program. Otherwise, this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Presented at the Central Surgical Association annual meeting, Chicago, July 30 to August 1, 2017. * Corresponding author. Department of Surgery, University of Alabama at Birmingham, 1808 7th Avenue, South Suite 502, Birmingham, AL 35233. E-mail address: [email protected] (H. Chen).
of providing services and the causes of variations in costs of hospitalization.3,4 It is now well known that there are geographic and hospital variations in cost of care,5,6 even for the same surgical procedures.4,7,8 Differences in payment models and regional variation in practice was thought to explain the geographic differences in costs; however, recent studies revealed that providers from even the same institution show significant differences in cost for the same surgical procedures.9,10 Thus, reducing ineffective medical practice has been identified as a potential strategy to reduce costs,11 including by addressing the variations in cost of care.5,12-14 Parathyroidectomy is mainstay for most parathyroid diseases including most commonly for primary hyperparthyroidism,15 and its incidence is rising.16 However, provider-level variation in costs of parathyroidectomy has not been well examined. With relatively clear indications and low rates of complications,17,18 parathyroidectomy is suitable for analyzing the differences in surgical care among providers. Costs differences can potentially be attributed to particular factors more accurately. The present study aimed to compare the cost of parathyroidectomy among providers in a single academic institution and identify factors associated with increased hospital costs.
https://doi.org/10.1016/j.surg.2017.10.046 0039-6060/© 2017 Elsevier Inc. All rights reserved.
Please cite this article in press as: Samuel Jang, Meagan Mandabach, Zviadi Aburjania, Courtney J. Balentine, and Herbert Chen, Wide variation in cost of surgical care for parathyroidectomy: is there a need for standardization of practice?, Surgery (2017), doi: 10.1016/j.surg.2017.10.046
ARTICLE IN PRESS S. Jang et al. / Surgery ■■ (2017) ■■–■■
2
Methods
Results
Patient selection and database review
Patient and provider characteristics
We retrospectively evaluated all parathyroidectomies coded as complete parathyroidectomy (06.81, n = 207), parathyroidectomy or exploration of parathyroid (60,500 and 60,502, n = 515), or other parathyroidectomy (06.89, n = 189) using International Classification of Diseases-9 and 10 procedural codes between September 2011 and July 2016 in University of Alabama at Birmingham (UAB) Hospital. Other procedural codes such as “resection of parathyroid gland, open approach” (n = 2) and “excision of left inferior parathyroid gland, open approach” (n = 1) were excluded because of their low frequencies and much higher costs on initial analysis. Cases performed by surgeons who operated <3 times during the inclusion window were excluded (15 cases by 10 providers). The nature of the single institution study sought to address the variations in cost across institutions and compare the providers practicing in the same institution. Total cost of hospitalization was the primary outcome of this study. UAB Hospital utilizes the Change Healthcare (formerly McKesson) Performance Analytics suite of products for our Cost Accounting and Decision Support functions. Additional information available from the database included fees to anesthesiology, radiology, heart center, and laboratory fees among other specific costs. Admission date, discharge date, demographics information, insurance provider, patient type (outpatient versus inpatient), readmission to UAB, and mortality status during hospitalization of each patient were available. Additionally, the surgeon who performed the parathyroidectomy, their surgical department, and years in practice were collected. Years in practice were determined by subtracting the year of training completion from 2016. All patient-related information was encrypted, deidentified, and compliant with the Health Insurance Portability, Affordability and Accountability regulations.
From September 2011 to July 2016, a total of 894 cases of parathyroidectomy performed by 8 UAB surgeons were analyzed in this study. The subspecialties of the surgeons included endocrine (n = 3, all fellowship trained), otolaryngology (n = 4), and cardiothoracic surgery (n = 1). Median patient age was 60 ± 0.42 years, and only 3 patients were under 18. As expected, 76% of the operations were done on female patients mostly in an outpatient setting (83%). About a third of all patients seen at UAB are African Americans; in a similar observation, 66% were Caucasians and 31% were African Americans. Only 3 (0.3%), 6 (0.7%), and 11 (1.2%) patients were Asian, Hispanic, and unreported, respectively. The most common payer type was Medicare (n = 398, 44.5%). The characteristics of the eight surgeons and their parathyroidectomy cases are described in Table 1 in a descending order of the surgeons’ median total hospital costs. Surgeons A, B, and C were designated as high-costs, D, E, and F as medium-costs, and G and H as lowcost, relative to their peers. The overall readmission rate was 2.2% (n = 20). There was no difference in readmission occurrence among subspecialties (P = .449). However, readmission was associated with previous longer hospitalization (1.4 days vs 0.6 days, P < .001), higher hospital cost ($6,905.67 vs $5,500.28, P < .001), and younger age (46.3 years vs 59.5 years, P < .001). There were no in-hospital mortality in this cohort.
Statistical analysis The data were analyzed using Excel (Microsoft, Redmond, WA) and SPSS statistical software 23 (IBM Corp, Armonk, NY). R software (R Core Team, 2015. R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria; https://www.R-project.org/) was used to create a dot plot. Mann-Whitney U tests and Kruskal-Wallis nonparametric tests were used to compare continuous variables where appropriate. SPSS medians test compared medians of independent samples. Categorical variables were analyzed with χ2 test. All error ranges in the text are reported with interquartile range (IQR) unless stated otherwise.
Total cost of parathyroidectomy and duration of stay of patients by provider The median total hospital cost for parathyroidectomy was $4,863.28 (IQR: 4,196–5,764), but the median costs per provider varied widely from $4,522.30 to $12,072.87 (P < .001). Individual surgeons’ median total cost of parathyroidectomy and the duration of stays of their patients are summarized in Table 2 in a descending order of the surgeons’ median total hospital costs. Furthermore, the cost of parathyroidectomy by individual surgeons varied widely. Provider H had the lowest absolute range of $2,967.01 and provider A had the highest with $37,955.61. The providers in the low-cost group showed the least variation in their costs. The distribution of the costs of individual parathyroidectomy cases are plotted in Figure. The median duration of stay was 0 day (IQR: 0–1) and also demonstrated a wide variation in median duration of stay among providers (0 to 5 days).
Table 1 Characteristics of surgeons performing parathyroidectomies and their patients. Surgeon
n
Years in practice
Readmission (%)
Mean patient age (SEM)
Caucasian patient (%)
Female patient (%)
Out-patient (%)
All A B C D E F G H P value
894 3 5 132 3 29 18 20 684 —
— 7 9 8 26 3 15 16 31 —
20 (2.2) 0 (0.0) 0 (0.0) 2 (1.5) 0 (0.0) 1 (3.4) 3 (16.7) 1 (5.0) 13 (1.9) .014*
59.2 (12.6) 59.3 (13.3) 66.6 (7.8) 58.4 (13.0) 63.3 (26.3) 53.7 (14.6) 57.7 (16.4) 56.3 (16.4) 59.6 (12.2) .233†
597 (66.8) 0 (0.0) 4 (80.0) 94 (71.2) 1 (33.3) 8 (27.6) 9 (50.0) 13 (6.5) 465 (68.0) <.001*
683 (76.4) 2 (66.7) 5 (100.0) 100 (75.8) 2 (66.7) 22 (75.9) 12 (66.7) 17 (85.0) 522 (76.3) <.001*
753 (84.2) 1 (33.3) 0 (0.0) 88 (66.7) 2 (66.7) 19 (65.5) 9 (50.0) 20 (100.0) 611 (89.3) <.001*
Dept, department. * χ2 test. † Kruskal-Wallis test.
Please cite this article in press as: Samuel Jang, Meagan Mandabach, Zviadi Aburjania, Courtney J. Balentine, and Herbert Chen, Wide variation in cost of surgical care for parathyroidectomy: is there a need for standardization of practice?, Surgery (2017), doi: 10.1016/j.surg.2017.10.046
ARTICLE IN PRESS S. Jang et al. / Surgery ■■ (2017) ■■–■■
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Table 2 Total cost of parathyroidectomy and duration of stay by provider. Surgeon
All A B C D E F G H P value
Total cost of parathyroidectomy
Patient duration of stay
Median
IQR
Cost >10,000 (%)
Median
IQR
Same day discharge (%)
≥3 days (%)
4,863.28 12,072.87 8,833.13 6,295.56 6,277.84 6,156.44 5,864.32 4,933.00 4,522.30 <.001‡
4,196–5,764 4,326–42,281* 7,437–10,328 5,762–7,598 3,984–24,201* 5,345–12,624 5,218–7,763 4,659–5,492 4,078–5,193 —
32 (3.6) 2 (66.7) 1 (20.0) 10 (7.6) 1 (33.3) 9 (31.0) 1 (5.6) 0 (0.0) 8 (1.2) <.001†
0 5 1 1 1 1 1 0 0 <.001‡
0–1 1–27* 1–2 1 1–18* 0–5 1–1 0–0 0–0 —
593 (66.3) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 14 (48.3) 0 (0.0) 19 (95.0) 557 (81.8) <.001†
39 (4.4) 2 (66.7) 1 (20.0) 7 (5.3) 1 (33.3) 9 (31.0) 2 (11.1) 0 (0.0) 17 (2.5) <.001†
IQR, interquartile range. * As IQR cannot be reported due to n = 3, full range denoted. † χ2 test. ‡ Median test.
Provider factors associated with high costs Expectedly, the average value of the providers’ duration of stay of their patients was highly correlated with their respective total hospital costs (r2 = 0.94), where 1 more day cost an additional $1,224
on average. The 2 surgeons in the low-cost group had a median duration of stay of 0 days. Furthermore, in general, more years in practice was associated with lower costs. Three surgeons with the lowest costs all practiced >12 years while the 3 surgeons in the high cost group all practiced <10 years. The notable exceptions were providers D and E. We then analyzed whether the providers’ subspecialty was associated with higher cost of parathyroidectomy or a longer duration of stay. When the medians and means of each surgeon were compared, there were no significant differences in the total cost (P = .413 and mean: P = .227) and duration of stay (median: P = .547 and mean: P = .195) between surgeons in the different subspecialties. Analysis of specific costs of parathyroidectomy
Figure. Provider level variation of total cost of parathyroidectomy. Dot plots compare the total cost of parathyroidectomy among the 8 surgeons in this study. Black dots are the cost of individual parathyroidectomy cases, grey dots represent the mean with standard deviation as error bars, and the grey horizontal lines show the median.
Combinations of many components determine the total cost of parathyroidectomy. After determining that there are significant provider differences in cost of parathyroidectomy, we examined whether we could attribute some of the variation to specific costs. In the data provided by Change Healthcare Performance Analytics described in the Methods, there were 4 specific costs besides the operative cost that were a part of every case at our institution: cost of anesthesiology, radiology, heart center, and laboratory workups. The providers’ median costs attributed to these categories are summarized in Table 3. To compare the costs of specific areas relative to other providers in the institution, the median of the all the surgeons’ individual median costs were first calculated. Next, the areas of cost that are higher than the median cost of all the providers median are shaded as dark grey and areas that cost less than the median of all providers
Table 3 Selected specific costs involved in total cost of parathyroidectomy.
IQR, interquartile range. Dark shade: higher than the median cost of all providers. Light shade: lower than the median cost of all providers. * As IQR cannot be reported due to N = 3, full range denoted. † Median test.
Please cite this article in press as: Samuel Jang, Meagan Mandabach, Zviadi Aburjania, Courtney J. Balentine, and Herbert Chen, Wide variation in cost of surgical care for parathyroidectomy: is there a need for standardization of practice?, Surgery (2017), doi: 10.1016/j.surg.2017.10.046
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are shaded in light grey. The dark grey areas are potential specific costs that could have contributed to higher costs relative to others and light grey areas are fees that could have decreased the providers’ total cost. For example, provider G’s cost to anesthesiology was >2 times less than most of the providers, while provider A’s cost of laboratory workup was >3 times higher compared to all others. Discussion As the need for mitigating hospital costs becomes more crucial, hospitals have sought to identify areas where costs can be contained. To do this effectively, the healthcare industry must understand the costs of providing services and the causes of variations in care. Limited data exists that examines such factors associated with variations at the provider level. This study aims to examine these differences by identifying possible variances among providers in the costs of performing parathyroidectomies. Previous studies have alluded to cost differences associated with provider variance. Gani et al analyzed variations in hospital costs and found there were differences in the total cost of a many different surgical procedures between surgeons.9 This study examined several surgeries, including coronary artery bypass grafting, abdominal aortic aneurysm repair, laparoscopic cholecystectomy, colectomy, and pancreaticoduodenectomy; however, their study does not study variations associated parathyroidectomies, while our study focuses only on parathyroidectomies and examines a larger sample size of such operations. We have found that median cost of care varied by surgeon and that the cost of parathyroidectomies had broad variation within individual providers. Expectedly, duration of stay was found to play a role in overall costs. Our results found wide differences in patient’s median duration of stay, with one additional day having an extra cost per day of $1,224 on average, showing a high correlation between longer duration of stay and higher total costs. Surgeons in the low-cost group had a median duration of stay of zero days. Experience also has been found to be associated with lower hospital costs. The surgeons in the low-cost group had all practiced for >12 years, while the high-cost group had practiced for <10 years. Our study also examined surgical subspecialties as having an association with hospital costs; however, no difference was reported by our data. If the total cost of performing parathyroidectomies can vary by provider, it begs the question as to how such added costs could be accrued. Our study does not closely examine the role that surgeons’ volume could play in variation of cost among providers, because surgeons joining or leaving the institution during the study period affect their overall volume. Other studies have found that surgeons with higher patient volume are associated with lower hospital costs.19 The surgeon in our study with the highest volume also showed the lowest median cost; however, the physician, who had the second largest volume, accrued the third highest median cost. Since duration of stay plays a pivotal role in hospital costs, same day discharge is a possibility for assuaging such costs. Meltzer et al reported that discharging a patient after a parathyroidectomy is safe, with no statistically significant difference in hematoma rates between in-patients and out-patients.20 Another study corroborates these findings with no statistically significant differences in readmittance between same-day discharged patients and those that remained in the hospital for ≥1 days.21 Mazeh et al studied same-day discharge for thyroidectomies, a procedure most similar to parathyroidectomy, and reported that readmission was not necessary for any of their same-day patients, and that same-day thyroidectomies are safe if they are performed an experienced surgeon.22 Although an increased duration of stay does bolster the hospital costs accumulated by a patient, often same day discharge is not possible for a patient, who needs to be under close observation following surgery.
To alleviate the cost differences between providers and within the same provider, there is a need for surgeons to be educated and held accountable. Vigneswaran et al demonstrated that surgeons who were made aware of the costs of their surgical care reduced their spending by 8.6% and increased standardizations when providing treatment.23 Another study found similar results with a reduction in expenditures by 10% for laparoscopic cholecystectomies.24 UAB plans to provide information regarding the cost of parathyroidectomy for individual surgeons and their peers with the hope that our institution will experience a similar reduction of cost and heightened efficiency. One of the limitations affecting this study is that while the total number of parathyroidectomy in this study is 894, surgeon H is responsible for 684 cases, which could decrease the power of our findings. However, our study does qualitatively show that even the surgeon with a very few cases show a wide variation. Another limitation is that our database available through the Change Healthcare Performance Analytics does not include the type of hyperparathyroidism, clinical characteristics of individual patients, such as their histology, comorbidity, and postoperative complications. While it is possible that parathyroidectomies performed for different types of hyperparathyroidism may incur varying cost of surgical care, we wanted to address this limitation by including a relatively large number of sample for a surgical procedure with clear indications and low rates of complication. However, such complications and comorbidities do have the potential to drive up costs by increasing the duration of stay. A study examining hepatopancreatobiliary surgeries found that perioperative complications brought about a hospital charge almost double that of the normal cost.25 Additionally, surgical complications in hepatopancreatobiliary surgeries increased a patient’s hospital stay by 7 additional days on average, and our data found a high correlation between increased duration of stay and higher overall charges. Complications could also duration of a surgery, which would, in turn, drive up the cost of anesthesia, further increasing the overall cost of surgery. Additional research is needed to fully realize the extent of provider variations with a focus on patient’s preoperative conditions. We found substantial variation in hospital cost among providers for parathyroidectomy despite practicing in the same academic institution, with some surgeons spending 4 times more for the same operation. Implementing institutional standards of practice could be a method to decrease variation and the costs of surgical care. References 1. WHO. Health expenditure, total (% of GDP). http://data.worldbank.org/indicator/ sh.xpd.totl.zs. Accessed June 23, 2017. 2. Munoz E, Munoz W 3rd, Wise L. National and surgical health care expenditures, 2005–2025. Ann Surg 2010;251:195-200. 3. Murayama KM. Bundling our health care future. JAMA Surg 2015;150:1115-6. 4. Grenda TR, Pradarelli JC, Thumma JR, Dimick JB. Variation in hospital episode costs with bariatric surgery. JAMA Surg 2015;150:1109-15. 5. Zhang Y, Baik SH, Fendrick AM, Baicker K. Comparing local and regional variation in health care spending. N Engl J Med 2012;367:1724-31. 6. Hussey PS, Huckfeldt P, Hirshman S, Mehrotra A. Hospital and regional variation in Medicare payment for inpatient episodes of care. JAMA Intern Med 2015;175:1056-7. 7. Nelson-Williams H, Gani F, Kilic A, et al. Factors associated with interhospital variability in inpatient costs of liver and pancreatic resections. JAMA Surg 2016;151:155-63. 8. Reinke CE, Sonnenberg EM, Karakousis GC, Fraker DL, Kelz RR. Variation in cost of total thyroidectomy across the United States, 2007 to 2008. Am J Surg 2015;210:302-8. 9. Gani F, Hundt J, Daniel M, Efron JE, Makary MA, Pawlik TM. Variations in hospitals costs for surgical procedures: inefficient care or sick patients? Am J Surg 2017;213:1-9. 10. Sun GH, Auger KA, Aliu O, Patrick SW, DeMonner S, Davis MM. Variation in inpatient tonsillectomy costs within and between US hospitals attributable to postoperative complications. Med Care 2013;51:1048-54.
Please cite this article in press as: Samuel Jang, Meagan Mandabach, Zviadi Aburjania, Courtney J. Balentine, and Herbert Chen, Wide variation in cost of surgical care for parathyroidectomy: is there a need for standardization of practice?, Surgery (2017), doi: 10.1016/j.surg.2017.10.046
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11. Wennberg JE, Peters PG Jr. Unwarranted variations in the quality of health care: can the law help medicine provide a remedy/remedies? Spec Law Dig Health Care Law 2004;305:9-25. 12. Newhouse JP, Garber AM. Geographic variation in health care spending in the United States: insights from an Institute of Medicine report. JAMA 2013;310:1227-8. 13. Ginsburg PB. Wide variation in hospital and physician payment rates evidence of provider market power. Res Brief 2010;16:1-11. 14. Miller DC, Gust C, Dimick JB, Birkmeyer N, Skinner J, Birkmeyer JD. Large variations in Medicare payments for surgery highlight savings potential from bundled payment programs. Health Aff (Millwood) 2011;30:2107-15. 15. Madkhali T, Alhefdhi A, Chen H, Elfenbein D. Primary hyperparathyroidism. Ulus Cerrahi Derg 2016;32:58-66. 16. Yeh MW, Ituarte PH, Zhou HC, et al. Incidence and prevalence of primary hyperparathyroidism in a racially mixed population. J Clin Endocrinol Metab 2013;98:1122-9. 17. Campbell MJ. The definitive management of primary hyperparathyroidism: who needs an operation? JAMA 2017;317:1167-8. 18. Adler JT, Sippel RS, Chen H. The influence of surgical approach on quality of life after parathyroid surgery. Ann Surg Oncol 2008;15:1559-65.
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19. Jain NB, Kuye I, Higgins LD, Warner JJ. Surgeon volume is associated with cost and variation in surgical treatment of proximal humeral fractures. Clin Orthop Relat Res 2013;471:655-64. 20. Meltzer C, Klau M, Gurushanthaiah D, et al. Safety of outpatient thyroid and parathyroid surgery: a propensity score-matched study. Otolaryngol Head Neck Surg 2016;154:789-96. 21. Peel JK, Melck AL. Same-day discharge after unilateral parathyroidectomy is safe. Can J Surg 2016;59:242-6. 22. Mazeh H, Khan Q, Schneider DF, Schaefer S, Sippel RS, Chen H. Same-day thyroidectomy program: eligibility and safety evaluation. Surgery 2012;152: 1133-41. 23. Vigneswaran Y, Linn JG, Gitelis M, et al. Educating surgeons may allow for reduced intraoperative costs for inguinal herniorrhaphy. J Am Coll Surg 2015;220:1107-12. 24. Gitelis M, Vigneswaran Y, Ujiki MB, et al. Educating surgeons on intraoperative disposable supply costs during laparoscopic cholecystectomy: a regional health system’s experience. Am J Surg 2015;209:488-92. 25. Ejaz A, Kim Y, Spolverato G, Taylor R, Hundt J, Pawlik TM. Understanding drivers of hospital charge variation for episodes of care among patients undergoing hepatopancreatobiliary surgery. HPB (Oxford) 2015;17:955-63.
Please cite this article in press as: Samuel Jang, Meagan Mandabach, Zviadi Aburjania, Courtney J. Balentine, and Herbert Chen, Wide variation in cost of surgical care for parathyroidectomy: is there a need for standardization of practice?, Surgery (2017), doi: 10.1016/j.surg.2017.10.046
Contents lists available at ScienceDirect
Surgery j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y m s y
Central Surgical Association
Wide variation in cost of surgical care for parathyroidectomy: is there a need for standardization of practice? Samuel Jang a,b, Meagan Mandabach b, Zviadi Aburjania b, Courtney J. Balentine b, and Herbert Chen b,* a b
Howard Hughes Medical Institute, Birmingham, AL Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
A R T I C L E
I N F O
Article history: Accepted 21 October 2017
A B S T R A C T
Background. Identifying hospital and provider variation in surgical cost is a potent method for controlling rising healthcare expenditure and delivering cost-effective care. The purpose of this study was to examine the variation of hospital cost by providers for parathyroidectomy in a single academic institution. Methods. We retrospectively evaluated 894 consecutive parathyroidectomies under 8 surgeons in our institution between September 2011 and July 2016. Total duration of stay and cost were evaluated using nonparametric tests. Categorical variables were evaluated with χ2. Results. The median total hospital cost for parathyroidectomy was $4,863.28 (interquartile range: 4,196– 5,764), but the median costs per provider varied widely from $4,522.30 to $12,072.87. The median duration of stay was 0 days (IQR: 0–1) and demonstrated a wide variation among providers. Longer duration of practice was associated with lower cost. Despite the variation, only 2% was readmitted after discharge with no patient mortality. Conclusion. We found substantial variation in hospital cost among providers for parathyroidectomy despite practicing in the same academic institution, with some surgeons spending 4 time more for the same operation. Implementing institutional standards of practice could be a method to decrease variation and costs of surgical care. (Surgery 2017;160:XXX-XXX.) © 2017 Elsevier Inc. All rights reserved.
Containing the cost of patient care is becoming increasingly important as US health care spending climbed to $3.2 trillion in 2015, accounting for 17.8% of gross domestic product.1 Cost for providing surgical care is currently estimated to be $400 billion.2 As health care expenditure is being examined for inefficiencies, hospitals and lawmakers are interested in identifying areas where costs could be contained. Additionally, bundled payments, where a single reimbursement covers all services for a single episode of care, are being proposed as an alternative payment model to the prevalent fee-for-service model.3 A successful bundled payment program requires physicians and hospitals to understand the costs
S.J. was financially supported by the Howard Hughes Medical Research Fellows Program. Otherwise, this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Presented at the Central Surgical Association annual meeting, Chicago, July 30 to August 1, 2017. * Corresponding author. Department of Surgery, University of Alabama at Birmingham, 1808 7th Avenue, South Suite 502, Birmingham, AL 35233. E-mail address: [email protected] (H. Chen).
of providing services and the causes of variations in costs of hospitalization.3,4 It is now well known that there are geographic and hospital variations in cost of care,5,6 even for the same surgical procedures.4,7,8 Differences in payment models and regional variation in practice was thought to explain the geographic differences in costs; however, recent studies revealed that providers from even the same institution show significant differences in cost for the same surgical procedures.9,10 Thus, reducing ineffective medical practice has been identified as a potential strategy to reduce costs,11 including by addressing the variations in cost of care.5,12-14 Parathyroidectomy is mainstay for most parathyroid diseases including most commonly for primary hyperparthyroidism,15 and its incidence is rising.16 However, provider-level variation in costs of parathyroidectomy has not been well examined. With relatively clear indications and low rates of complications,17,18 parathyroidectomy is suitable for analyzing the differences in surgical care among providers. Costs differences can potentially be attributed to particular factors more accurately. The present study aimed to compare the cost of parathyroidectomy among providers in a single academic institution and identify factors associated with increased hospital costs.
https://doi.org/10.1016/j.surg.2017.10.046 0039-6060/© 2017 Elsevier Inc. All rights reserved.
Please cite this article in press as: Samuel Jang, Meagan Mandabach, Zviadi Aburjania, Courtney J. Balentine, and Herbert Chen, Wide variation in cost of surgical care for parathyroidectomy: is there a need for standardization of practice?, Surgery (2017), doi: 10.1016/j.surg.2017.10.046
ARTICLE IN PRESS S. Jang et al. / Surgery ■■ (2017) ■■–■■
2
Methods
Results
Patient selection and database review
Patient and provider characteristics
We retrospectively evaluated all parathyroidectomies coded as complete parathyroidectomy (06.81, n = 207), parathyroidectomy or exploration of parathyroid (60,500 and 60,502, n = 515), or other parathyroidectomy (06.89, n = 189) using International Classification of Diseases-9 and 10 procedural codes between September 2011 and July 2016 in University of Alabama at Birmingham (UAB) Hospital. Other procedural codes such as “resection of parathyroid gland, open approach” (n = 2) and “excision of left inferior parathyroid gland, open approach” (n = 1) were excluded because of their low frequencies and much higher costs on initial analysis. Cases performed by surgeons who operated <3 times during the inclusion window were excluded (15 cases by 10 providers). The nature of the single institution study sought to address the variations in cost across institutions and compare the providers practicing in the same institution. Total cost of hospitalization was the primary outcome of this study. UAB Hospital utilizes the Change Healthcare (formerly McKesson) Performance Analytics suite of products for our Cost Accounting and Decision Support functions. Additional information available from the database included fees to anesthesiology, radiology, heart center, and laboratory fees among other specific costs. Admission date, discharge date, demographics information, insurance provider, patient type (outpatient versus inpatient), readmission to UAB, and mortality status during hospitalization of each patient were available. Additionally, the surgeon who performed the parathyroidectomy, their surgical department, and years in practice were collected. Years in practice were determined by subtracting the year of training completion from 2016. All patient-related information was encrypted, deidentified, and compliant with the Health Insurance Portability, Affordability and Accountability regulations.
From September 2011 to July 2016, a total of 894 cases of parathyroidectomy performed by 8 UAB surgeons were analyzed in this study. The subspecialties of the surgeons included endocrine (n = 3, all fellowship trained), otolaryngology (n = 4), and cardiothoracic surgery (n = 1). Median patient age was 60 ± 0.42 years, and only 3 patients were under 18. As expected, 76% of the operations were done on female patients mostly in an outpatient setting (83%). About a third of all patients seen at UAB are African Americans; in a similar observation, 66% were Caucasians and 31% were African Americans. Only 3 (0.3%), 6 (0.7%), and 11 (1.2%) patients were Asian, Hispanic, and unreported, respectively. The most common payer type was Medicare (n = 398, 44.5%). The characteristics of the eight surgeons and their parathyroidectomy cases are described in Table 1 in a descending order of the surgeons’ median total hospital costs. Surgeons A, B, and C were designated as high-costs, D, E, and F as medium-costs, and G and H as lowcost, relative to their peers. The overall readmission rate was 2.2% (n = 20). There was no difference in readmission occurrence among subspecialties (P = .449). However, readmission was associated with previous longer hospitalization (1.4 days vs 0.6 days, P < .001), higher hospital cost ($6,905.67 vs $5,500.28, P < .001), and younger age (46.3 years vs 59.5 years, P < .001). There were no in-hospital mortality in this cohort.
Statistical analysis The data were analyzed using Excel (Microsoft, Redmond, WA) and SPSS statistical software 23 (IBM Corp, Armonk, NY). R software (R Core Team, 2015. R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria; https://www.R-project.org/) was used to create a dot plot. Mann-Whitney U tests and Kruskal-Wallis nonparametric tests were used to compare continuous variables where appropriate. SPSS medians test compared medians of independent samples. Categorical variables were analyzed with χ2 test. All error ranges in the text are reported with interquartile range (IQR) unless stated otherwise.
Total cost of parathyroidectomy and duration of stay of patients by provider The median total hospital cost for parathyroidectomy was $4,863.28 (IQR: 4,196–5,764), but the median costs per provider varied widely from $4,522.30 to $12,072.87 (P < .001). Individual surgeons’ median total cost of parathyroidectomy and the duration of stays of their patients are summarized in Table 2 in a descending order of the surgeons’ median total hospital costs. Furthermore, the cost of parathyroidectomy by individual surgeons varied widely. Provider H had the lowest absolute range of $2,967.01 and provider A had the highest with $37,955.61. The providers in the low-cost group showed the least variation in their costs. The distribution of the costs of individual parathyroidectomy cases are plotted in Figure. The median duration of stay was 0 day (IQR: 0–1) and also demonstrated a wide variation in median duration of stay among providers (0 to 5 days).
Table 1 Characteristics of surgeons performing parathyroidectomies and their patients. Surgeon
n
Years in practice
Readmission (%)
Mean patient age (SEM)
Caucasian patient (%)
Female patient (%)
Out-patient (%)
All A B C D E F G H P value
894 3 5 132 3 29 18 20 684 —
— 7 9 8 26 3 15 16 31 —
20 (2.2) 0 (0.0) 0 (0.0) 2 (1.5) 0 (0.0) 1 (3.4) 3 (16.7) 1 (5.0) 13 (1.9) .014*
59.2 (12.6) 59.3 (13.3) 66.6 (7.8) 58.4 (13.0) 63.3 (26.3) 53.7 (14.6) 57.7 (16.4) 56.3 (16.4) 59.6 (12.2) .233†
597 (66.8) 0 (0.0) 4 (80.0) 94 (71.2) 1 (33.3) 8 (27.6) 9 (50.0) 13 (6.5) 465 (68.0) <.001*
683 (76.4) 2 (66.7) 5 (100.0) 100 (75.8) 2 (66.7) 22 (75.9) 12 (66.7) 17 (85.0) 522 (76.3) <.001*
753 (84.2) 1 (33.3) 0 (0.0) 88 (66.7) 2 (66.7) 19 (65.5) 9 (50.0) 20 (100.0) 611 (89.3) <.001*
Dept, department. * χ2 test. † Kruskal-Wallis test.
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Table 2 Total cost of parathyroidectomy and duration of stay by provider. Surgeon
All A B C D E F G H P value
Total cost of parathyroidectomy
Patient duration of stay
Median
IQR
Cost >10,000 (%)
Median
IQR
Same day discharge (%)
≥3 days (%)
4,863.28 12,072.87 8,833.13 6,295.56 6,277.84 6,156.44 5,864.32 4,933.00 4,522.30 <.001‡
4,196–5,764 4,326–42,281* 7,437–10,328 5,762–7,598 3,984–24,201* 5,345–12,624 5,218–7,763 4,659–5,492 4,078–5,193 —
32 (3.6) 2 (66.7) 1 (20.0) 10 (7.6) 1 (33.3) 9 (31.0) 1 (5.6) 0 (0.0) 8 (1.2) <.001†
0 5 1 1 1 1 1 0 0 <.001‡
0–1 1–27* 1–2 1 1–18* 0–5 1–1 0–0 0–0 —
593 (66.3) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 14 (48.3) 0 (0.0) 19 (95.0) 557 (81.8) <.001†
39 (4.4) 2 (66.7) 1 (20.0) 7 (5.3) 1 (33.3) 9 (31.0) 2 (11.1) 0 (0.0) 17 (2.5) <.001†
IQR, interquartile range. * As IQR cannot be reported due to n = 3, full range denoted. † χ2 test. ‡ Median test.
Provider factors associated with high costs Expectedly, the average value of the providers’ duration of stay of their patients was highly correlated with their respective total hospital costs (r2 = 0.94), where 1 more day cost an additional $1,224
on average. The 2 surgeons in the low-cost group had a median duration of stay of 0 days. Furthermore, in general, more years in practice was associated with lower costs. Three surgeons with the lowest costs all practiced >12 years while the 3 surgeons in the high cost group all practiced <10 years. The notable exceptions were providers D and E. We then analyzed whether the providers’ subspecialty was associated with higher cost of parathyroidectomy or a longer duration of stay. When the medians and means of each surgeon were compared, there were no significant differences in the total cost (P = .413 and mean: P = .227) and duration of stay (median: P = .547 and mean: P = .195) between surgeons in the different subspecialties. Analysis of specific costs of parathyroidectomy
Figure. Provider level variation of total cost of parathyroidectomy. Dot plots compare the total cost of parathyroidectomy among the 8 surgeons in this study. Black dots are the cost of individual parathyroidectomy cases, grey dots represent the mean with standard deviation as error bars, and the grey horizontal lines show the median.
Combinations of many components determine the total cost of parathyroidectomy. After determining that there are significant provider differences in cost of parathyroidectomy, we examined whether we could attribute some of the variation to specific costs. In the data provided by Change Healthcare Performance Analytics described in the Methods, there were 4 specific costs besides the operative cost that were a part of every case at our institution: cost of anesthesiology, radiology, heart center, and laboratory workups. The providers’ median costs attributed to these categories are summarized in Table 3. To compare the costs of specific areas relative to other providers in the institution, the median of the all the surgeons’ individual median costs were first calculated. Next, the areas of cost that are higher than the median cost of all the providers median are shaded as dark grey and areas that cost less than the median of all providers
Table 3 Selected specific costs involved in total cost of parathyroidectomy.
IQR, interquartile range. Dark shade: higher than the median cost of all providers. Light shade: lower than the median cost of all providers. * As IQR cannot be reported due to N = 3, full range denoted. † Median test.
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are shaded in light grey. The dark grey areas are potential specific costs that could have contributed to higher costs relative to others and light grey areas are fees that could have decreased the providers’ total cost. For example, provider G’s cost to anesthesiology was >2 times less than most of the providers, while provider A’s cost of laboratory workup was >3 times higher compared to all others. Discussion As the need for mitigating hospital costs becomes more crucial, hospitals have sought to identify areas where costs can be contained. To do this effectively, the healthcare industry must understand the costs of providing services and the causes of variations in care. Limited data exists that examines such factors associated with variations at the provider level. This study aims to examine these differences by identifying possible variances among providers in the costs of performing parathyroidectomies. Previous studies have alluded to cost differences associated with provider variance. Gani et al analyzed variations in hospital costs and found there were differences in the total cost of a many different surgical procedures between surgeons.9 This study examined several surgeries, including coronary artery bypass grafting, abdominal aortic aneurysm repair, laparoscopic cholecystectomy, colectomy, and pancreaticoduodenectomy; however, their study does not study variations associated parathyroidectomies, while our study focuses only on parathyroidectomies and examines a larger sample size of such operations. We have found that median cost of care varied by surgeon and that the cost of parathyroidectomies had broad variation within individual providers. Expectedly, duration of stay was found to play a role in overall costs. Our results found wide differences in patient’s median duration of stay, with one additional day having an extra cost per day of $1,224 on average, showing a high correlation between longer duration of stay and higher total costs. Surgeons in the low-cost group had a median duration of stay of zero days. Experience also has been found to be associated with lower hospital costs. The surgeons in the low-cost group had all practiced for >12 years, while the high-cost group had practiced for <10 years. Our study also examined surgical subspecialties as having an association with hospital costs; however, no difference was reported by our data. If the total cost of performing parathyroidectomies can vary by provider, it begs the question as to how such added costs could be accrued. Our study does not closely examine the role that surgeons’ volume could play in variation of cost among providers, because surgeons joining or leaving the institution during the study period affect their overall volume. Other studies have found that surgeons with higher patient volume are associated with lower hospital costs.19 The surgeon in our study with the highest volume also showed the lowest median cost; however, the physician, who had the second largest volume, accrued the third highest median cost. Since duration of stay plays a pivotal role in hospital costs, same day discharge is a possibility for assuaging such costs. Meltzer et al reported that discharging a patient after a parathyroidectomy is safe, with no statistically significant difference in hematoma rates between in-patients and out-patients.20 Another study corroborates these findings with no statistically significant differences in readmittance between same-day discharged patients and those that remained in the hospital for ≥1 days.21 Mazeh et al studied same-day discharge for thyroidectomies, a procedure most similar to parathyroidectomy, and reported that readmission was not necessary for any of their same-day patients, and that same-day thyroidectomies are safe if they are performed an experienced surgeon.22 Although an increased duration of stay does bolster the hospital costs accumulated by a patient, often same day discharge is not possible for a patient, who needs to be under close observation following surgery.
To alleviate the cost differences between providers and within the same provider, there is a need for surgeons to be educated and held accountable. Vigneswaran et al demonstrated that surgeons who were made aware of the costs of their surgical care reduced their spending by 8.6% and increased standardizations when providing treatment.23 Another study found similar results with a reduction in expenditures by 10% for laparoscopic cholecystectomies.24 UAB plans to provide information regarding the cost of parathyroidectomy for individual surgeons and their peers with the hope that our institution will experience a similar reduction of cost and heightened efficiency. One of the limitations affecting this study is that while the total number of parathyroidectomy in this study is 894, surgeon H is responsible for 684 cases, which could decrease the power of our findings. However, our study does qualitatively show that even the surgeon with a very few cases show a wide variation. Another limitation is that our database available through the Change Healthcare Performance Analytics does not include the type of hyperparathyroidism, clinical characteristics of individual patients, such as their histology, comorbidity, and postoperative complications. While it is possible that parathyroidectomies performed for different types of hyperparathyroidism may incur varying cost of surgical care, we wanted to address this limitation by including a relatively large number of sample for a surgical procedure with clear indications and low rates of complication. However, such complications and comorbidities do have the potential to drive up costs by increasing the duration of stay. A study examining hepatopancreatobiliary surgeries found that perioperative complications brought about a hospital charge almost double that of the normal cost.25 Additionally, surgical complications in hepatopancreatobiliary surgeries increased a patient’s hospital stay by 7 additional days on average, and our data found a high correlation between increased duration of stay and higher overall charges. Complications could also duration of a surgery, which would, in turn, drive up the cost of anesthesia, further increasing the overall cost of surgery. Additional research is needed to fully realize the extent of provider variations with a focus on patient’s preoperative conditions. We found substantial variation in hospital cost among providers for parathyroidectomy despite practicing in the same academic institution, with some surgeons spending 4 times more for the same operation. Implementing institutional standards of practice could be a method to decrease variation and the costs of surgical care. References 1. WHO. Health expenditure, total (% of GDP). http://data.worldbank.org/indicator/ sh.xpd.totl.zs. Accessed June 23, 2017. 2. Munoz E, Munoz W 3rd, Wise L. National and surgical health care expenditures, 2005–2025. Ann Surg 2010;251:195-200. 3. Murayama KM. Bundling our health care future. JAMA Surg 2015;150:1115-6. 4. Grenda TR, Pradarelli JC, Thumma JR, Dimick JB. Variation in hospital episode costs with bariatric surgery. JAMA Surg 2015;150:1109-15. 5. Zhang Y, Baik SH, Fendrick AM, Baicker K. Comparing local and regional variation in health care spending. N Engl J Med 2012;367:1724-31. 6. Hussey PS, Huckfeldt P, Hirshman S, Mehrotra A. Hospital and regional variation in Medicare payment for inpatient episodes of care. JAMA Intern Med 2015;175:1056-7. 7. Nelson-Williams H, Gani F, Kilic A, et al. Factors associated with interhospital variability in inpatient costs of liver and pancreatic resections. JAMA Surg 2016;151:155-63. 8. Reinke CE, Sonnenberg EM, Karakousis GC, Fraker DL, Kelz RR. Variation in cost of total thyroidectomy across the United States, 2007 to 2008. Am J Surg 2015;210:302-8. 9. Gani F, Hundt J, Daniel M, Efron JE, Makary MA, Pawlik TM. Variations in hospitals costs for surgical procedures: inefficient care or sick patients? Am J Surg 2017;213:1-9. 10. Sun GH, Auger KA, Aliu O, Patrick SW, DeMonner S, Davis MM. Variation in inpatient tonsillectomy costs within and between US hospitals attributable to postoperative complications. Med Care 2013;51:1048-54.
Please cite this article in press as: Samuel Jang, Meagan Mandabach, Zviadi Aburjania, Courtney J. Balentine, and Herbert Chen, Wide variation in cost of surgical care for parathyroidectomy: is there a need for standardization of practice?, Surgery (2017), doi: 10.1016/j.surg.2017.10.046
ARTICLE IN PRESS S. Jang et al. / Surgery ■■ (2017) ■■–■■
11. Wennberg JE, Peters PG Jr. Unwarranted variations in the quality of health care: can the law help medicine provide a remedy/remedies? Spec Law Dig Health Care Law 2004;305:9-25. 12. Newhouse JP, Garber AM. Geographic variation in health care spending in the United States: insights from an Institute of Medicine report. JAMA 2013;310:1227-8. 13. Ginsburg PB. Wide variation in hospital and physician payment rates evidence of provider market power. Res Brief 2010;16:1-11. 14. Miller DC, Gust C, Dimick JB, Birkmeyer N, Skinner J, Birkmeyer JD. Large variations in Medicare payments for surgery highlight savings potential from bundled payment programs. Health Aff (Millwood) 2011;30:2107-15. 15. Madkhali T, Alhefdhi A, Chen H, Elfenbein D. Primary hyperparathyroidism. Ulus Cerrahi Derg 2016;32:58-66. 16. Yeh MW, Ituarte PH, Zhou HC, et al. Incidence and prevalence of primary hyperparathyroidism in a racially mixed population. J Clin Endocrinol Metab 2013;98:1122-9. 17. Campbell MJ. The definitive management of primary hyperparathyroidism: who needs an operation? JAMA 2017;317:1167-8. 18. Adler JT, Sippel RS, Chen H. The influence of surgical approach on quality of life after parathyroid surgery. Ann Surg Oncol 2008;15:1559-65.
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19. Jain NB, Kuye I, Higgins LD, Warner JJ. Surgeon volume is associated with cost and variation in surgical treatment of proximal humeral fractures. Clin Orthop Relat Res 2013;471:655-64. 20. Meltzer C, Klau M, Gurushanthaiah D, et al. Safety of outpatient thyroid and parathyroid surgery: a propensity score-matched study. Otolaryngol Head Neck Surg 2016;154:789-96. 21. Peel JK, Melck AL. Same-day discharge after unilateral parathyroidectomy is safe. Can J Surg 2016;59:242-6. 22. Mazeh H, Khan Q, Schneider DF, Schaefer S, Sippel RS, Chen H. Same-day thyroidectomy program: eligibility and safety evaluation. Surgery 2012;152: 1133-41. 23. Vigneswaran Y, Linn JG, Gitelis M, et al. Educating surgeons may allow for reduced intraoperative costs for inguinal herniorrhaphy. J Am Coll Surg 2015;220:1107-12. 24. Gitelis M, Vigneswaran Y, Ujiki MB, et al. Educating surgeons on intraoperative disposable supply costs during laparoscopic cholecystectomy: a regional health system’s experience. Am J Surg 2015;209:488-92. 25. Ejaz A, Kim Y, Spolverato G, Taylor R, Hundt J, Pawlik TM. Understanding drivers of hospital charge variation for episodes of care among patients undergoing hepatopancreatobiliary surgery. HPB (Oxford) 2015;17:955-63.
Please cite this article in press as: Samuel Jang, Meagan Mandabach, Zviadi Aburjania, Courtney J. Balentine, and Herbert Chen, Wide variation in cost of surgical care for parathyroidectomy: is there a need for standardization of practice?, Surgery (2017), doi: 10.1016/j.surg.2017.10.046