title: Variations in hospitals costs for surgical procedures: inefficient care or sick patients?
abstract: BACKGROUND
  Reducing unwanted variations has been identified as an avenue for cost containment. We sought to characterize variations in hospital costs after major surgery and quantitate the variability attributable to the patient, procedure, and provider.
  
  
  METHODS
  A total of 22,559 patients undergoing major surgical procedure at a tertiary-care center between 2009 and 2013 were identified. Hierarchical linear regression analysis was performed to calculate risk-adjusted fixed, variable and total costs.
  
  
  RESULTS
  The median cost of surgery was $23,845 (interquartile ranges, 13,353 to 43,083). Factors associated with increased costs included insurance status (Medicare vs private; coefficient: 14,934; 95% CI = 12,445.7 to 17,422.5, P < .001), preoperative comorbidity (Charlson Comorbidity Index = 1; coefficient: 10,793; 95% CI = 8,412.7 to 13,174.2; Charlson Comorbidity Index ≥2; coefficient: 24,468; 95% CI = 22,552.7 to 26,383.6; both P < .001) and the development of a postoperative complication (coefficient: 58,624.1; 95% CI = 56,683.6 to 60,564.7; P < .001). Eighty-six percent of total variability was explained by patient-related factors, whereas 8% of the total variation was attributed to surgeon practices and 6% due to factors at the level of surgical specialty.
  
  
  CONCLUSIONS
  Although inpatient costs varied markedly between procedures and providers, the majority of variation in costs was due to patient-level factors and should be targeted by future cost containment strategies.
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.
authors.forename: John
authors.initials: J
authors.lastname: Hundt
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 688, Baltimore, MD 21287, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Daniel
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 688, Baltimore, MD 21287, USA.
authors.forename: Jonathan E
authors.initials: JE
authors.lastname: Efron
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 688, Baltimore, MD 21287, USA.
authors.forename: Martin A
authors.initials: MA
authors.lastname: Makary
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 688, Baltimore, MD 21287, USA. Electronic address: tpawlik1@jhmi.edu.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D005260:Female; D006304:Health Status; D017721:Hospital Costs; D006760:Hospitalization / Q000191:economics; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000191:economics*; D012189:Retrospective Studies; D018570:Risk Assessment; D013514:Surgical Procedures, Operative / Q000191:economics*; D062606:Tertiary Care Centers
keywords: Costs; Patient; Provider; Surgery; Variation