title: Assessing the Costs Associated with Volume-Based Referral for Hepatic Surgery.
abstract: Although proposed as a means for quality improvement, little is known regarding the economic consequences of volume-based referral. The objective of the current study was to investigate the relationship between inpatient costs and hospital volume.
  
  
  
  Patients undergoing elective liver surgery were identified using the Nationwide Inpatient Sample from 2001 to 2012. Multivariable hierarchical regression analyses were performed to calculate and compare risk-adjusted costs and postoperative outcomes across hospital volume terciles.
  
  
  
  A total of 27,813 patients underwent surgery at 2207 hospitals. Although costs were comparable across the three volume groups (all p > 0.05), patients who developed a postoperative complication incurred a higher overall cost (complication vs. no complication; median costs $17,974 [IQR 13,865-25,623] vs. $41,731 [IQR 27,008-64,266], p < 0.001). In contrast, while the incidence of postoperative complications (low vs. intermediate vs. high; 22.0 vs. 19.2 vs. 13.0 %, p < 0.001) and subsequent failure-to-rescue (low vs. intermediate vs. high; 16.6 vs. 24.7 vs. 15.1 %, p < 0.001) was lower at high-volume hospitals, costs associated with "rescue" were substantially higher at high-volume hospitals (low vs. intermediate vs. high; $39,289 vs. $36,157 vs. $48,559, both p < 0.001).
  
  
  
  Compared with lower volume hospitals, improved outcomes among patients who developed a complication at high-volume hospitals were associated with an increased cost.
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street Blalock 688, Baltimore, MD, 21287, USA.
authors.forename: Faiz
authors.initials: F
authors.lastname: Gani
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street Blalock 688, Baltimore, MD, 21287, USA. tpawlik1@jhmi.edu.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006498:Hepatectomy / Q000191:economics* / Q000706:statistics & numerical data; D006760:Hospitalization / Q000191:economics* / Q000706:statistics & numerical data; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data*; D061846:Hospitals, Low-Volume / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D008099:Liver / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000191:economics* / Q000453:epidemiology; D018570:Risk Assessment; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: Complication; Costs; Hospital variation; Liver surgery