Acute care surgery practice model: Targeted growth for fiscal success

Acute care surgery (ACS) remains in its infancy as a defined surgical specialty within hospital systems. Little has been published regarding the financial impact of this method of care delivery to hospital systems and departments when combining trauma, surgical critical care, emergent, and elective general surgery into a single practice model. We sought to compare hospital net income and divisional clinical productivity measures of a newly formed, university division of ACS based on patient type-trauma, emergency general surgery, and elective surgery-to determine the best avenues by which to focus on programmatic growth.

Single calendar year, retrospective review of hospital system income and divisional fiscal productivity of specific patient visits by patient type (trauma, emergent, or elective) admitted to or discharged by the acute care surgeons. Demographic data, payor mix, patient volumes, and operative rates were determined for each patient type. Fiscal contribution by patient type to both hospital and clinical productivity were measured by hospital net income and divisional work relative value units (wRVU) production respectively. The Chi-square test for independence compared payor mix and analysis of variance was used for comparison of fiscal performance between patient types.

We included 1,492 patients in the analysis of calendar year 2010; 1,056 trauma (67% male; mean age, 41.9; range, 0-102), 346 emergent (53% male; mean age, 44.6; range, 15-91), and 90 elective (51% male; mean age, 46; range, 16-87) patient encounters met criteria for analysis. There were no differences in payor mix between patient types. Significant differences were seen in average per patient encounter hospital net income, divisional wRVU production and duration of stay. The ACS team (n = 3) operated on 12% of trauma patients compared with 52% of emergent and 100% of elective surgery encounters. Hospital net income per patient was greatest for trauma encounters, whereas divisional clinical productivity per patient encounter was greatest for emergent patients. Elective encounters contributed negatively to hospital margins.

Per-patient hospital system income and a majority of clinical wRVU productivity remains greatest for the care of injured patients in our ACS practice model; emergent general surgical encounters demonstrate the greatest per-patient rates of divisional clinical productivity.