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Measuring Risk-adjusted Value Using Medicare and ACS-NSQIP: Is High Quality, Low Cost Surgical Care Achievable Everywhere?
Elise H Lawson*, David S. Zingmond*, Anne Stey*, Bruce Lee Hall*, Clifford Y Ko
UCLA School of Medicine, Los Angeles, CA
OBJECTIVE(S):
Policymakers are currently focused on rewarding high value healthcare. Hospitals will increasingly be held accountable for both quality and cost. Our objective was to develop a risk-adjusted measure of “value” in surgery and to determine if cost and quality are associated.
METHODS:
Records (2005-2008) for all patients undergoing colectomy 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 National Quality Forum endorsed measures.
RESULTS:
The study population included 14,401 colectomy patients in 166 hospitals. Average hospitalization cost was $21,435 (median $16,092, interquartile-range $15,118-$24,597). 27% of patients had a major complication and/or death. Among hospitals classified as high quality, 47% were found to be low cost (representing highest “value” hospitals) while 19% were high cost (p=0.020). Almost 40% of low quality hospitals were high cost. Highest “value” hospitals were a mix of teaching/non-teaching, small/large bedsize, and rural/urban location.
CONCLUSIONS:
Using national ACS-NSQIP and Medicare data, this study reports an association between high quality and low 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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