Work relative value units and the association with operative time and surgical complexity: A pediatric NSQIP analysis

In the United States, physician compensation for surgical procedures is largely based on Current Procedural Terminology (CPT)-specific work Relative Value Units (wRVUs), which are meant to reflect operative time, technical skill and effort, mental effort and judgement, and stress. We sought to determine if operative time and case complexity are appropriately compensated for in pediatric surgical procedures.

The ACS Pediatric NSQIP database was surveyed for procedures that individually accounted for at least 0.1 % of the database in the year 2022. The median operative time and complication rates for these procedures from 2018 to 2022 were calculated. Major complications were defined as those causing significant deviation from the typical clinical course for the index procedure, as determined by the authors. Complications defined as minor were those that were judged to have little effect on a patient's expected clinical course or outcome. These were utilized as a surrogate for case complexity. 2022 wRVU and median operative time were used to calculate wRVU per hour of operative time (wRVU/h). Linear regression analysis was utilized to investigate the relationship between operative time and wRVU, operative time and wRVU/h, and complication rate and wRVU/h.

Linear regression analysis demonstrated a moderate positive association between median operative time and wRVU (R² = 0.2259, p < 0.0001). For every additional hour of operative time, however, there was an associated decrease in wRVU/h by 2.01 (or 0.33 for every 10 min, R² = 0.05568, p = 0.0012). Both major and minor complications are both associated with wRVU but neither are significantly associated with wRVU/h.

Compensation is positively correlated with operative time for pediatric surgical procedures. However, the current wRVU system significantly favors shorter procedures. Case complexity is only weakly correlated with wRVU/h, and below the threshold of statistical significance, which suggests that the wRVU system may not adequately compensate pediatric surgeons for performing lengthy and complex procedures.