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Measuring risk-adjusted value using Medicare and ACS-NSQIP: is high-quality, low-cost surgical care achievable
Elise H Lawson1, David S Zingmond, Anne M Stey
1*Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles †VA Greater Los Angeles Healthcare System, Los Angeles, CA ‡Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL §Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles ¶Icahn School of Medicine at Mount Sinai Medical Center, NY ‖Department of Surgery, St Louis School of Medicine and Barnes Jewish Hospital, Washington University, St Louis, MO **Saint Louis Veterans Affairs Medical Center, St Louis, MO; and ††Center for Health Policy and Olin Business School, Washington University in Saint Louis, St Louis, MO.
Objective:
To evaluate the relationship between risk-adjusted cost and quality for colectomy procedures and to identify characteristics of "high value" hospitals (high quality, low cost).
Background:
Policymakers are currently focused on rewarding high-value health care. Hospitals will increasingly be held accountable for both quality and cost.
Methods:
Records (2005-2008) for all patients undergoing colectomy procedures in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Cost was derived from hospital payments by Medicare. Quality was derived from the occurrence of 30-day postoperative major complications and/or death as recorded in ACS-NSQIP. Risk-adjusted cost and quality metrics were developed using hierarchical multivariable modeling, consistent with a National Quality Forum-endorsed colectomy measure.
Results:
The study population included 14,745 colectomy patients in 169 hospitals. Average hospitalization cost was $21,350 (SD $20,773, median $16,092, interquartile range $14,341-$24,598). Thirty-four percent of patients had a postoperative complication and/or death. Higher hospital quality was significantly correlated with lower cost (correlation coefficient 0.38, P < 0.001). Among hospitals classified as high quality, 52% were found to be low cost (representing highest value hospitals) whereas 14% were high cost (P = 0.001). Forty-one percent of low-quality hospitals were high cost. Highest "value" hospitals represented a mix of teaching/nonteaching affiliation, small/large bed sizes, and regional locations.
Conclusions:
Using national ACS-NSQIP and Medicare data, this study reports an association between higher quality and lower cost surgical care. These results suggest that high-value surgical care is being delivered in a wide spectrum of hospitals and hospital types.
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