Surgeon Experience and Medicare Expenditures for Laparoscopic Compared to Open Colectomy

Kyle H. Sheetz, MD, MS; Andrew M. Ibrahim, MD, MPH; Scott E. Regenbogen, MD, MPH; Justin B. Dimick, MD, MPH

Disclosures

Annals of Surgery. 2018;268(6):1036-1042. 

In This Article

Abstract and Introduction

Abstract

Objective: To quantify the extent to which payments for laparoscopic and open colectomy are influenced by a surgeon's experience with laparoscopy.

Background: Numerous studies suggest that healthcare costs for laparoscopic colectomy are lower than open surgery. None have assessed the importance of surgeon experience on the relative financial benefits of laparoscopy.

Methods: We conducted a study of 182,852 national Medicare beneficiaries undergoing laparoscopic or open colectomy between 2010 and 2012. Using instrumental variable methods to account for selection bias, we compared Medicare payments for laparoscopic and open colectomy. We stratified our analysis by surgeons' annual experience with laparoscopic colectomy to determine the influence of provider experience on payments.

Results: In the fully adjusted analysis, average episode payments per patient were $2640 [95% confidence interval (CI) −$4091 to −$1189] lower with the laparoscopic approach versus open. Surgeons in the highest quartile of laparoscopic experience demonstrated an average payment savings of $5456 per patient (CI −$7918 to −$2994) in their laparoscopic versus open cases. Among surgeons in the lowest quartile of laparoscopic experience, there was, however, no difference between laparoscopic and open cases (difference: $954, 95% CI −$731 to $2639). Differences in payments were explained by differences in complications rates. Both groups had similar rates of complications for open procedures (least experience, 21%, most experience, 21%; P = 0.45), but differed significantly on rates of complications for laparoscopic cases (least experience, 28%, most experience, 15%; P < 0.01).

Conclusions: This population-based study demonstrates that differences in payments between laparoscopic and open colectomy are influenced by surgeon experience. The laparoscopic approach does not reduce payments for patients whose surgeons have limited experience with the procedure.

Introduction

There is a considerable amount of research suggesting that laparoscopic operations have lower costs compared to traditional open surgery. Several studies focusing on colectomy, and other major abdominal operations, demonstrate a 20% to 50% reduction in costs with the laparoscopic versus open approach.[1–5] Lower costs are attributable to shorter lengths of stay and lower complication rates.[6,7] These studies contribute to perceptions that laparoscopic surgery is always less expensive, despite concerns about technology and equipment costs. There are growing efforts to reduce the costs of surgical hospitalizations, including numerous policies that use financial penalties to motivate change (eg, bundled payments or accountable care organizations).[8–10]

It is unclear whether all surgeons, particularly those with limited laparoscopic experience, attain the full financial benefits of the minimally invasive approach. In other domains, such as patient safety or readmissions, the importance of surgeon experience or proficiency has received significant attention.[11–14] Few studies have assessed the direct relationship between surgeon experience and the absolute or relative costs of laparoscopic and traditional open surgery. This information is important because the use of minimally invasive technologies may represent 1 leverage point through which surgeons can augment current practices to reduce the costs of care.

To address this question, we conducted a population-based study of Medicare beneficiaries undergoing laparoscopic or open colectomy. We used instrumental variable methods to account for selection bias between patients undergoing each approach. After grouping surgeons by their annual experience with laparoscopic colectomy, we assessed the differences in Medicare payments between laparoscopic versus open surgery. We then evaluated payments for complications, readmissions, and postacute care to determine the mechanisms of payment differences between approaches for surgeons with differing levels of experience.

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