title: Does relative value unit-based compensation shortchange the acute care surgeon?
abstract: BACKGROUND
  Studies have demonstrated that relative value units (RVUs) do not appropriately reflect cognitive effort or time spent in patient care, but RVU continues to be used as a standardized system to track productivity. It is unknown how well RVU reflects the effort of acute care surgeons. Our objective was to determine if RVUs adequately reflect increased surgeon effort required to treat emergent versus elective patients receiving similar procedures.
  
  
  METHODS
  A retrospective analysis using The American College of Surgeons' National Surgical Quality Improvement Program 2011 data set was conducted. The control group consisted of patients undergoing elective colectomy, hernia repair, or biliary procedures as identified by Current Procedural Terminology. Comparison was made to emergent cases after being stratified to laparoscopic or open technique. Generalized linear models and logistic regression were used to assess specific outcomes, controlling for demographics and comorbidities of interest. The RVUs, operative time, and length of stay (LOS) were primary variables, with major/minor complications, mortality, and readmissions being evaluated as the relevant outcomes.
  
  
  RESULTS
  A total of 442,149 patients in the National Surgical Quality Improvement Program underwent one of the operative procedures of interest; 27,636 biliary (91% laparoscopic; 8.5% open), 28,722 colorectal (40.3% laparoscopic, 59.7% open), and 31,090 hernia (26.6% laparoscopic, 73.4% open) operations. Emergent procedures were found to have average RVU values that were identical to their elective case counterparts. Complication rates were higher and LOS were increased in emergent cases. Odds ratios for complications and readmissions in emergent cases were twice those of elective procedures. Mortality was skewed toward emergent cases.
  
  
  CONCLUSIONS
  Our data indicate that the emergent operative management for various procedures is similarly valued despite increased LOS, more complications, higher mortality risk, and subsequently increased physician attention. Our findings suggest that the RVU system for acute care surgeons may need to be reevaluated to better capture the additional work involved in emergent patient care.
authors.affiliation: From the Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins School of Medicine, and the Johns Hopkins Bayview Medical Center, Baltimore, Maryland.
authors.forename: Diane A
authors.initials: DA
authors.lastname: Schwartz
authors.forename: Xuan
authors.initials: X
authors.lastname: Hui
authors.forename: Catherine G
authors.initials: CG
authors.lastname: Velopulos
authors.forename: Eric B
authors.initials: EB
authors.lastname: Schneider
authors.forename: Shalini
authors.initials: S
authors.lastname: Selvarajah
authors.forename: Donald
authors.initials: D
authors.lastname: Lucas
authors.forename: Elliott R
authors.initials: ER
authors.lastname: Haut
authors.forename: Nathaniel
authors.initials: N
authors.lastname: McQuay
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
authors.forename: David T
authors.initials: DT
authors.lastname: Efron
authors.forename: Adil H
authors.initials: AH
authors.lastname: Haider
mesh_terms: D001662:Biliary Tract Surgical Procedures / Q000191:economics / Q000706:statistics & numerical data; D003082:Colectomy / Q000191:economics / Q000706:statistics & numerical data; D005260:Female; D059685:Herniorrhaphy / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care / Q000191:economics / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000191:economics / Q000453:epidemiology; D015895:Relative Value Scales; D012189:Retrospective Studies; D013043:Specialties, Surgical / Q000191:economics* / Q000458:organization & administration / Q000706:statistics & numerical data; D013997:Time Factors; D014481:United States