Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles.
Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles.
JAMA Surg. 2019 Oct 1;154(10):915-921. doi: 10.1001/jamasurg.2019.2295.
The primary data sources used to generate and update work relative value units (RVUs) are surveys of small groups of specialists who are asked to estimate the time and intensity needed to perform surgical procedures. Because these surveys are conducted by specialty societies and rely on subjective data, these sources have been challenged as potentially biased.
To assess whether objective work measures are associated with a surgical procedure's assigned work RVUs and whether differences exist by surgical specialty.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study obtained data from the 2016 and 2017 participant use files of the American College of Surgeons National Surgical Quality Improvement Program. The 2017 physician fee schedule of the Centers for Medicare & Medicaid Services was a secondary data source. Procedures were included if they had at least 100 patient-level observations over the 2-year period. Data were analyzed from August 29, 2018, to April 2, 2019.
The dependent variable was a procedure's assigned work RVU. Independent variables of work RVUs were 4 procedure-level work measures (median operative time, median postoperative length of stay, all-cause 30-day readmission rate, and all-cause 30-day reoperation rate) and surgeon specialty (10-level category using general surgery as the reference).
The data set included 628 unique Current Procedural Terminology (CPT) codes and 726 CPT-specialty combinations from 1 239 991 patient observations. Statistically significant associations were found between each work measure and assigned work RVU, as follows: median operative time (R2 = 0.74; 95% CI, 0.71-0.78), postoperative length of stay (R2 = 0.42; 95% CI, 0.36-0.48), rate of readmission (R2 = 0.18; 95% CI, 0.13-0.23), and rate of reoperation (R2 = 0.15; 95% CI, 0.10-0.20). Including all 4 measures explained 80.2% (95% CI, 77.3%-83.1%) of the variation. Adding the surgical specialty improved the overall fit of the model (likelihood ratio test χ2 = 231.27; P < .001). Cardiac (7.78; 95% CI, 4.25-11.31; P < .001) and neurosurgery (2.46; 95% CI, 1.08-3.83; P < .001) had higher work RVUs compared with general surgery, whereas orthopedics (-1.53; 95% CI, -2.48 to -0.59; P = .002), urology (-1.58; 95% CI, -2.88 to -0.29; P = .02), plastics (-2.70; 95% CI, -4.39 to -1.01; P = .002), and otolaryngology (-3.05; 95% CI, -4.69 to -1.42; P < .001) had lower work RVUs compared with general surgery.
Objective work measures appeared to be associated with assigned work RVUs, predominantly with operative time; registry data can be used to augment and inform the generation and updating processes of the work RVUs.
生成和更新工作相对价值单位 (RVU) 的主要数据来源是对一小部分专家进行的调查，这些专家被要求估计执行手术程序所需的时间和强度。由于这些调查是由专业协会进行的，并依赖于主观数据，因此这些来源被认为可能存在偏差。
评估客观工作指标是否与手术程序的分配工作 RVU 相关，以及是否存在手术专业之间的差异。
设计、地点和参与者：这项横断面研究从美国外科医师学院国家手术质量改进计划的 2016 年和 2017 年参与者使用文件中获取数据。医疗保险和医疗补助服务中心的 2017 年医师费用表是次要数据来源。如果在 2 年期间有至少 100 个患者水平的观察值，则包含该程序。数据分析于 2018 年 8 月 29 日至 2019 年 4 月 2 日进行。
因变量是程序的分配工作 RVU。工作 RVU 的独立变量是 4 个程序级别的工作指标（中位数手术时间、中位数术后住院时间、所有原因 30 天再入院率和所有原因 30 天再次手术率）和外科医生专业（使用普通外科作为参考的 10 级类别）。
数据集包括 628 个独特的当前程序术语 (CPT) 代码和 726 个 CPT-专业组合，来自 123991 名患者的观察结果。发现每个工作指标与分配工作 RVU 之间存在统计学上的显著关联，如下所示：中位数手术时间（R2=0.74；95%CI，0.71-0.78）、术后住院时间（R2=0.42；95%CI，0.36-0.48）、再入院率（R2=0.18；95%CI，0.13-0.23）和再次手术率（R2=0.15；95%CI，0.10-0.20）。包括所有 4 个指标解释了 80.2%（95%CI，77.3%-83.1%）的变化。增加手术专业提高了模型的整体拟合度（似然比检验 χ2=231.27；P<.001）。心脏外科（7.78；95%CI，4.25-11.31；P<.001）和神经外科（2.46；95%CI，1.08-3.83；P<.001）的工作 RVU 高于普通外科，而骨科（-1.53；95%CI，-2.48 至-0.59；P=.002）、泌尿科（-1.58；95%CI，-2.88 至-0.29；P=.02）、整形外科（-2.70；95%CI，-4.39 至-1.01；P=.002）和耳鼻喉科（-3.05；95%CI，-4.69 至-1.42；P<.001）的工作 RVU 低于普通外科。
客观工作指标似乎与分配工作 RVU 相关，主要与手术时间相关；登记数据可用于增强和告知工作 RVU 的生成和更新过程。
