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 L. Hall, Clifford Y. Ko

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

17 Scopus citations


Methods: Records (2005-2008) for all patients undergoing colectomy procedures 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 a National Quality Forum-endorsed colectomy measure.

Objective: To evaluate the relationship between risk-adjusted cost and quality for colectomy procedures and to identify characteristics of "high value" hospitals (high quality, low cost).

Background: Policymakers are currently focused on rewarding high-value health care. Hospitals will increasingly be held accountable for both quality and cost.

Results: The study population included 14,745 colectomy patients in 169 hospitals. Average hospitalization cost was $21,350 (SD $20,773, median $16,092, interquartile range $14,341-$24,598). Thirty-four percent of patients had a postoperative complication and/or death. Higher hospital quality was significantly correlated with lower cost (correlation coefficient 0.38, P 0.001). Among hospitals classified as high quality, 52% were found to be low cost (representing highest value hospitals) whereas 14% were high cost (P = 0.001). Forty-one percent of low-quality hospitals were high cost. Highest "value" hospitals represented a mix of teaching/nonteaching affiliation, small/large bed sizes, and regional locations.

Conclusions: Using national ACS-NSQIP and Medicare data, this study reports an association between higher quality and lower cost surgical care. These results suggest that high-value surgical care is being delivered in a wide spectrum of hospitals and hospital types.

Original languageEnglish (US)
Pages (from-to)668-679
Number of pages12
JournalAnnals of surgery
Issue number4
StatePublished - 2014


  • Cost
  • Medicare
  • Quality
  • Surgery
  • Value
  • colectomy

ASJC Scopus subject areas

  • Surgery


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