Putting the value framework to work in surgery

Health policy experts have proposed a framework defining value as outcomes achieved per dollar spent on health care. However, few institutions quantify their delivery of care along these dimensions. Our objective was to measure the value of our surgical services over time.

We reviewed the data of patients undergoing general and vascular surgery from 2002 through 2012 at a tertiary care university hospital as abstracted by the American College of Surgeons NSQIP. Morbidity and mortality data from the American College of Surgeons NSQIP database were risk adjusted to calculate observed-to-expected ratios, which were then inverted into a numerator as a surrogate for quality. Costs, the denominator of the value equation, were determined for each patient's hospitalization. The ratio was then transformed by a constant and analyzed with linear regression to analyze and compare values from 2002 through 2012.

A total of 25,453 patients met criteria for inclusion. Overall, the value of surgical services increased from 2002 through 2012. The observed increase in value was greater in general surgery than in vascular surgery, and value actually decreased in vascular procedures. Although there was a similar increase in outcomes in vascular surgery compared with general surgery, costs rose significantly higher ($474/year vs -$302/year; p < 0.001). These increased costs were mostly observed from 2006 through 2010 with the adoption of endovascular technology.

Despite the challenges posed by current information systems, calculating risk-adjusted value in surgical services represents a critical first step for providers seeking to improve outcomes, avoid ill-advised cost containment, and determine the costs of innovation.