Cost variation in a laparoscopic cholecystectomy and the association with outcomes across a single health system: implications for standardization and improved resource utilization

Abstract

Background: Payers and regulatory bodies are increasingly placing emphasis on cost containment, quality/outcome measurement and transparent reporting. Significant cost variation occurs in many operative procedures without a clear relationship with outcomes. Clear cost-benefit associations will be necessary to justify expenditures in the era of bundled payment structures.

Methods: All laparoscopic cholecystectomies (LCCKs) performed within a single health system over a 1-year period were analysed for operating room (OR) supply cost. The cost was correlated with American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) outcomes.

Results: From July 2013 to June 2014, 2178 LCCKs were performed by 55 surgeons at seven hospitals. The median case OR supply cost was $513 ± 156. There was variation in cost between individual surgeons and within an individual surgeon's practice. There was no correlation between cost and ACS NSQIP outcomes. The majority of cost variation was explained by selection of trocar and clip applier constructs.

Conclusions: Significant case OR cost variation is present in LCCK across a single health system, and there is no clear association between increased cost and NSQIP outcomes. Placed within the larger context of overall cost, the opportunity exists for improved resource utilization with no obvious risk for a reduction in the quality of care.

Figure 1

Intra-operative supply cost per case. The distribution of case costs for each of seven hospitals is outlined by row. Box plots depict 25th percentile, median and 75th percentile. Whiskers represent 1.5× interquartile (IQR), and dots represent high outliers. The system median cost of $513 is depicted as a dotted vertical line. Hospitals are sorted by case volume in the period as per the numbers in the first column. Investigation of high outlier cases identified the use of energy devices as a common cause of high case cost

Figure 2

Intra-operative supply cost variability among surgeons. Each dot represents one surgeon. Dot colour represents one specific hospital. Dot size corresponds to case volume per surgeon. Intra-operative supply cost varies across surgeons and within a single surgeon's practice (y-axis ‘standard deviation’) for both high- and low-volume surgeons

Figure 3

Surgeon-specific median expenditure versus any National Surgical Quality Improvement Program (NSQIP) adverse events. Surgeon expenditure is compared with the health system complication rate (‘average rate’ = 3%) and the national American College of Surgeons (ACS) NSQIP complication rate (‘NSQIP rate’ = 3.5%) during the study period. The area of circles represents surgeon case volume and colour represents hospital affiliation. There is no obvious negative or positive correlation between cost and outcomes