Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
Department of Surgery, Stanford University, Palo Alto, CA, USA.
Surgery. 2020 Sep;168(3):371-378. doi: 10.1016/j.surg.2020.03.002. Epub 2020 Apr 24.
Understanding the differences in how patient complexity varies across surgical specialties can inform policy decisions about appropriate resource allocation and reimbursement. This study evaluated variation in patient complexity across surgical specialties and the correlation between complexity and work relative value units.
The 2017 American College of Surgeons National Surgical Quality Improvement Program was queried for cases involving otolaryngology and general, neurologic, vascular, cardiac, thoracic, urologic, orthopedic, and plastic surgery. A total of 10 domains of patient complexity were measured: American Society of Anesthesiologists class ≥4, number of major comorbidities, emergency operation, major complications, concurrent procedures, additional procedures, length of stay, non-home discharge, readmission, and mortality. Specialties were ranked by their complexity domains and the domains summed to create an overall complexity score. Patient complexity then was evaluated for correlation with work relative value units.
Overall, 936,496 cases were identified. Cardiac surgery had the greatest total complexity score and was most complex across 4 domains: American Society of Anesthesiologists class ≥4 (78.5%), 30-day mortality (3.4%), major complications (56.9%), and mean length of stay (9.8 days). Vascular surgery had the second greatest complexity score and ranked the greatest on the domains of major comorbidities (2.7 comorbidities) and 30-day readmissions (10.1%). The work relative value units did not correlate with overall complexity score (Spearman's ρ = 0.07; P < .01). Although vascular surgery had the second most complex patients, it ranked fifth greatest in median work relative value units. Similarly, general surgery was the fifth most complex but had the second-least median work relative value units.
Substantial differences exist between patient complexity across specialties, which do not correlate with work relative value units. Physician effort is determined largely by patient complexity, which is not captured appropriately by the current work relative value units.
了解不同外科专业之间患者复杂性的差异，可以为关于适当资源分配和报销的政策决策提供信息。本研究评估了外科专业之间患者复杂性的变化，以及复杂性与工作相对价值单位之间的相关性。
查询了 2017 年美国外科医师学会国家外科质量改进计划中涉及耳鼻喉科和普通外科、神经外科、血管外科、心脏外科、胸外科、泌尿科、骨科和整形外科的病例。共测量了 10 个患者复杂性领域：美国麻醉医师协会分类≥4 级、主要合并症数量、急诊手术、主要并发症、同期手术、附加手术、住院时间、非家庭出院、再入院和死亡率。根据其复杂性领域对专业进行排名，并对这些领域进行求和，以创建一个整体复杂性评分。然后评估患者复杂性与工作相对价值单位的相关性。
共确定了 936496 例病例。心脏外科的总复杂性评分最高，在 4 个领域最为复杂：美国麻醉医师协会分类≥4 级（78.5%）、30 天死亡率（3.4%）、主要并发症（56.9%）和平均住院时间（9.8 天）。血管外科的复杂性评分排名第二，在主要合并症（2.7 种合并症）和 30 天再入院率（10.1%）方面排名最高。工作相对价值单位与整体复杂性评分没有相关性（Spearman's ρ=0.07；P<.01）。尽管血管外科的患者最为复杂，但它的工作相对价值单位中位数排名第五。同样，普通外科的患者排名第五，但工作相对价值单位中位数排名第二低。
不同专业之间的患者复杂性存在显著差异，但与工作相对价值单位不相关。医生的工作量主要取决于患者的复杂性，但目前的工作相对价值单位并不能很好地反映这一点。
