Abstract
The work relative value unit (wRVU) is a commonly cited surrogate for surgical complexity; however, it is highly susceptible to subjective interpretation and external forces. Our objective was to evaluate whether wRVU is associated with perioperative outcomes, including complications, after brain tumor surgery. The 2006–2014 American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients ≥ 18 years who underwent brain tumor resection. Patients were categorized into approximate quintiles based on total wRVU. The relationship between wRVU and several perioperative outcomes was assessed with univariate and multivariate analyses. Subgroup analyses were performed using a Current Procedural Terminology code common to all wRVU groups. The 16,884 patients were categorized into wRVU ranges 0–30.83 (4664 patients), 30.84–34.58 (2548 patients), 34.59–38.04 (3147 patients), 38.05–45.38 (3173 patients), and ≥ 45.39 (3352 patients). In multivariate logistic regression analysis, increasing wRVU did not predict more 30-day postoperative complications, except respiratory complications and need for blood transfusion. Linear regression analysis showed that wRVU was poorly correlated with operative duration and length of stay. On multivariate analysis of the craniectomy subgroup, wRVU was not associated with overall or respiratory complications. The highest wRVU group was still associated with greater risk of requiring blood transfusion (OR 3.01, p < 0.001). Increasing wRVU generally did not correlate with 30 days postoperative complications in patients undergoing any surgery for brain tumor resection; however, the highest wRVU groups may be associated with greater risk of respiratory complications and need for transfusion. These finding suggests that wRVU may be a poor surrogate for case complexity.
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References
Bekelis K, Labropoulos N, Coy S (2017) Risk of venous thromboembolism and operative duration in patients undergoing neurosurgical procedures. Neurosurgery 80:787–792. https://doi.org/10.1093/neuros/nyw129
Beyer DC, Mohideen N (2008) The role of physicians and medical organizations in the development, analysis, and implementation of health care policy. Semin Radiat Oncol 18:186–193. https://doi.org/10.1016/j.semradonc.2008.01.006
Birkmeyer JD, Shahian DM, Dimick JB, Finlayson SR, Flum DR, Ko CY, Hall BL (2008) Blueprint for a new American College of Surgeons: National Surgical Quality Improvement Program. J Am Coll Surg 207:777–782. https://doi.org/10.1016/j.jamcollsurg.2008.07.018
Cheng H, Clymer JW, Po-Han Chen B, Sadeghirad B, Ferko NC, Cameron CG, Hinoul P (2018) Prolonged operative duration is associated with complications: a systematic review and meta-analysis. J Surg Res 229:134–144. https://doi.org/10.1016/j.jss.2018.03.022
Chiu RG, Siddiqui N, Nunna RS, Patel S, Rosinski CL, Chaker AN, Hobbs JG, Mehta AI (2020) Association of neurosurgical work relative value units with objective markers of operative complexity. World Neurosurg. https://doi.org/10.1016/j.wneu.2020.10.077
Donovan WD, Leslie-Mazwi TM, Silva E 3rd, Woo HH, Nicola GN, Barr RM, Bello JA, Tu R, Hirsch JA (2014) Diagnostic carotid and cerebral angiography: a historical summary of the evolving changes in coding and reimbursement in a complex procedure family. J Neurointerv Surg 6:712–717. https://doi.org/10.1136/neurintsurg-2014-011416
Dunn D, Hsiao WC, Ketcham TR, Braun P (1988) A method for estimating the preservice and postservice work of physicians’ services. JAMA 260:2371–2378. https://doi.org/10.1001/jama.1988.03410160045006
Flexman AM, Merriman B, Griesdale DE, Mayson K, Choi PT, Ryerson CJ (2014) Infratentorial neurosurgery is an independent risk factor for respiratory failure and death in patients undergoing intracranial tumor resection. J Neurosurg Anesthesiol 26:198–204. https://doi.org/10.1097/ANA.0b013e3182a43ed8
Hsiao WC, Dunn DL, Verrilli DK (1993) Assessing the implementation of physician-payment reform. N Engl J Med 328:928–933. https://doi.org/10.1056/NEJM199304013281306
Hsiao WC, Yntema DB, Braun P, Dunn D, Spencer C (1988) Measurement and analysis of intraservice work. JAMA 260:2361–2370. https://doi.org/10.1001/jama.1988.03410160035005
Jacobs JP, Lahey SJ, Nichols FC, Levett JM, Johnston GG, Freeman RK, St Louis JD, Painter J, Yohe C, Wright CD, Kanter KR, Mayer JE Jr, Naunheim KS, Rich JB, Bavaria JE (2017) How is physician work valued? Ann Thorac Surg 103:373–380. https://doi.org/10.1016/j.athoracsur.2016.11.059
Jiang DD, Chakiryan NH, Gillis KA, Acevedo AM, Chen Y, Austin JC, Seideman CA (2020) Relative value units do not adequately account for operative time in pediatric urology. J Pediatr Surg. https://doi.org/10.1016/j.jpedsurg.2020.06.043
Karhade AV, Fandino L, Gupta S, Cote DJ, Iorgulescu JB, Broekman ML, Aglio LS, Dunn IF, Smith TR (2017) Impact of operative length on post-operative complications in meningioma surgery: a NSQIP analysis. J Neurooncol 131:59–67. https://doi.org/10.1007/s11060-016-2262-2
Khuri SF, Daley J, Henderson W, Hur K, Gibbs JO, Barbour G, Demakis J, Irvin G 3rd, Stremple JF, Grover F, McDonald G, Passaro E Jr, Fabri PJ, Spencer J, Hammermeister K, Aust JB (1997) Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg 185:315–327. https://doi.org/10.1016/S1072-7515(01)00938-3
Khuri SF, Henderson WG, Daley J, Jonasson O, Jones RS, Campbell DA Jr, Fink AS, Mentzer RM Jr, Neumayer L, Hammermeister K, Mosca C, Healey N (2008) Successful implementation of the Department of Veterans Affairs’ National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study. Ann Surg 248:329–336. https://doi.org/10.1097/SLA.0b013e3181823485
Kim BD, Smith TR, Lim S, Cybulski GR, Kim JY (2014) Predictors of unplanned readmission in patients undergoing lumbar decompression: multi-institutional analysis of 7016 patients. J Neurosurg Spine 20:606–616. https://doi.org/10.3171/2014.3.SPINE13699
Kim RB, Garcia RM, Smith ZA, Dahdaleh NS (2016) Impact of resident participation on outcomes after single-level anterior cervical diskectomy and fusion: an analysis of 3265 patients from the American College of Surgeons National Surgical Quality Improvement Program Database. Spine (Phila Pa 1976) 41(5):E289-296. https://doi.org/10.1097/BRS.0000000000001230
Malangoni MA (2020) Invited commentary: surgeons and RVU’s Surgery 168:379–380. https://doi.org/10.1016/j.surg.2020.05.011
Nayar SK, Aziz KT, Zimmerman RM, Srikumaran U, LaPorte DM, Giladi AM (2020) Misvaluation of hospital-based upper extremity surgery across payment, relative value units, and operative time. Iowa Orthop J 40:173–183
Nguyen KT, Gart MS, Smetona JT, Aggarwal A, Bilimoria KY, Kim JY (2012) The relationship between relative value units and outcomes: a multivariate analysis of plastic surgery procedures. EPlasty 12:e60
Nguyen KT, Gart, Michael S., Smetona, John T., Aggarwal, A, Bilimoria, Karl Y., Kim, John Y.S. (2012) The relationship between relative value units and outcomes: a multivariate analysis of plastic surgery procedures. EPlasty 12:e60
Ramirez JL, Gasper WJ, Seib CD, Finlayson E, Conte MS, Sosa JA, Iannuzzi JC (2020) Patient complexity by surgical specialty does not correlate with work relative value units. Surgery 168:371–378. https://doi.org/10.1016/j.surg.2020.03.002
Rosner MH, Falk RJ (2020) Understanding work: moving beyond the RVU. Clin J Am Soc Nephrol 15:1053–1055. https://doi.org/10.2215/CJN.12661019
Sellers MM, Merkow RP, Halverson A, Hinami K, Kelz RR, Bentrem DJ, Bilimoria KY (2013) Validation of new readmission data in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg 216:420–427. https://doi.org/10.1016/j.jamcollsurg.2012.11.013
Shah D, Bold RJ, Yang AD, Khatri VP, Martinez SR, Canter RJ (2014) Relative value units poorly correlate with measures of surgical effort and complexity. J Surg Res 190:465–470. https://doi.org/10.1016/j.jss.2014.05.052
Shiloach M, Frencher SK Jr, Steeger JE, Rowell KS, Bartzokis K, Tomeh MG, Richards KE, Ko CY, Hall BL (2010) Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg 210:6–16. https://doi.org/10.1016/j.jamcollsurg.2009.09.031
Vieira BL, Hernandez DJ, Qin C, Smith SS, Kim JY, Dutra JC (2016) The impact of resident involvement on otolaryngology surgical outcomes. Laryngoscope 126:602–607. https://doi.org/10.1002/lary.25046
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We thank Kristin Kraus, MSc, for editorial support.
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Study conception: RK; manuscript preparation: RK, JS, RJ, SM; data analysis: RK, MK, SL.
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Kim, R.B., Scoville, J.P., Karsy, M. et al. Work relative value units and perioperative outcomes in patients undergoing brain tumor surgery. Neurosurg Rev 45, 719–728 (2022). https://doi.org/10.1007/s10143-021-01601-6
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DOI: https://doi.org/10.1007/s10143-021-01601-6