Study Finds Wide Variation in Hepatopancreatobiliary Surgery Charges

A research team from Johns Hopkins Hospital in Baltimore, MD, set out to identify factors associated with variation in hospital hepatopancreatobiliary surgery charges.

The costs associated with surgical procedures can vary considerably between hospitals, this despite the fact that a uniform set of charges for each procedure exists. The differences have seemed to be related to each hospital’s unique approach to care and each individual patient's needs. A research team from Johns Hopkins Hospital in Baltimore, MD, set out to identify factors associated with variation in hospital hepatopancreatobiliary (HPB) surgery charges. Their study, published in the journal HPB, is important because few other studies have looked at this specific procedure. Their findings may help increase savings.

These investigators enrolled patients (n=2545) who underwent an HPB procedure—either a pancreas (66.8%) or liver/biliary (33.2%) resection—between 2009—2013. They assessed a full array of possible total hospital charges including room and board, surgical/anesthesia services, medications, laboratory/radiology services and other miscellaneous charges.

The average charges were $42,357 + $33,745, indicating that variation is indeed enormous for this procedure at this facility. The investigators note that extended length of stay was the most significant cost driver with each additional day increasing costs by about $4,000. Some factors were related to providers’ characteristics, however.

The investigators looked at actual length of stay (LOS) and compared it to expected LOS, calculated using individual Medicare severity diagnosis-related group. Surgeons within the lowest quartile of observed:expected LOS had lower total charges ($33,879) compared to those in the highest quartile ($49,498). These differences persisted even when differences in LOS and morbidity were accounted for.

Morbidity ranged from 7% to 9%. Peri-operative complications increased charges by about $40,000 on average. The investigators note that charges varied significantly even among patients who did not experience complications.

High observed:expected LOS was also linked to high across-the-board charges.

The investigators note that several centers now use enhanced recovery protocols for patients undergoing HPB surgery. The protocols include interventions that minimize patients’ stress, decrease opioid use, avoid blood loss and transfusion when possible, and reduce perioperative fasting. They recommend implementing these protocol at all hospitals, and suggest that hospitals would be well-advised to analyze surgeon-specific charges after surgery routinely.