Geographic variation in surgical outcomes and cost between the United States and Japan.
OBJECTIVE
Unwarranted geographic variation in spending has received intense scrutiny in the United States. However, few studies have compared variation in spending and surgical outcomes between the United States healthcare system and those of other nations. In this study, we compare the geographic variation in postsurgical outcomes and cost between the United States and Japan.


METHODS
This retrospective cohort study uses Medicare Part A data from the United States (2010-2011) and similar inpatient data from Japan (2012). Patients 65 years or older undergoing 1 of 5 surgeries (coronary artery bypass graft, abdominal aortic aneurysm repair, colectomy, pancreatectomy, or gastrectomy) were selected in the United States and Japan.


METHODS
Reliability- and case-mix-adjusted coefficient of variation (COV) values were calculated using hierarchical modeling and empirical Bayes techniques for the following 5 outcomes: postoperative mortality, the development of a complication, death after complication (failure to rescue), length of stay, and the cost of the hospitalization. Sensitivity analyses were also performed by calculating patient demographic-and case-mix-adjusted COV values for each outcome using weighted age- and sex-standardized values.


RESULTS
The variability of the postsurgical outcomes was uniformly lower in the United States compared with Japan. Cost variation was consistently higher in the United States for all surgeries.


CONCLUSIONS
Although the US healthcare system may be more inefficient regarding costs, the presence of higher geographic variation in postoperative care in Japan, relative to the United States, suggests that the observed geographic variation in the United States-both for health expenditures and outcomes-is not a unique manifestation of its structural shortcomings.
UCSF Department of Internal Medicine, 1382 8th Ave, Apt 1, San Francisco, CA 94122. E-mail: Michael.Hurley@ucsf.edu.
Michael P
MP
Hurley
Lena
L
Schoemaker
John M
JM
Morton
Sherry M
SM
Wren
William B
WB
Vogt
Sachiko
S
Watanabe
Aki
A
Yoshikawa
Jay
J
Bhattacharya
D000368:Aged; D015331:Cohort Studies; D017052:Hospital Mortality; D006760:Hospitalization / Q000191:economics; D006801:Humans; D007564:Japan; D007902:Length of Stay; D015233:Models, Statistical; D017063:Outcome Assessment, Health Care / Q000191:economics; D011183:Postoperative Complications; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000191:economics; D014481:United States