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Optimizing the Volume–Value Relationship in Laminectomy

An Evidence-Based Analysis of Outcomes and Economies of Scale

Frankel, William C., BS; Navarro, Sergio M., BS; Haeberle, Heather S., BS; Ramanathan, Deepak, MD; Ramkumar, Prem N., MD, MBA

doi: 10.1097/BRS.0000000000002910
OUTCOMES
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Study Design. Retrospective cohort study.

Objective. The objective of the present study was to establish evidence-based volume thresholds for surgeons and hospitals predictive of enhanced value in the setting of laminectomy.

Summary of Background Data. Previous studies have attempted to characterize the relationship between volume and value; however, none to the authors’ knowledge has employed an evidence-based approach to identify thresholds yielding enhanced value.

Methods. In total, 67,758 patients from the New York Statewide Planning and Research Cooperative System database undergoing laminectomy in the period 2009 to 2015 were included. We used stratum-specific likelihood ratio analysis of receiver operating characteristic curves to establish volume thresholds predictive of increased length of stay (LOS) and cost for surgeons and hospitals.

Results. Analysis of LOS by surgeon volume produced strata at: <17 (low), 17 to 40 (medium), 41 to 71 (high), and >71 (very high). Analysis of cost by surgeon volume produced strata at: <17 (low), 17 to 33 (medium), 34 to 86 (high), and >86 (very high). Analysis of LOS by hospital volume produced strata at: <43 (very low), 43 to 96 (low), 97 to 147 (medium), 148 to 172 (high), and >172 (very high). Analysis of cost by hospital volume produced strata at: <43 (very low), 43 to 82 (low), 83 to 115 (medium), 116 to 169 (high), and >169 (very high). LOS and cost decreased significantly (P < 0.05) in progressively higher volume categories for both surgeons and hospitals. For LOS, medium-volume surgeons handle the largest proportion of laminectomies (36%), whereas very high-volume hospitals handle the largest proportion (48%).

Conclusion. This study supports a direct volume–value relationship for surgeons and hospitals in the setting of laminectomy. These findings provide target-estimated thresholds for which hospitals and surgeons may receive meaningful return on investment in our increasingly value-based system. Further value-based optimization is possible in the finding that while the highest volume hospitals handle the largest proportion of laminectomies, the highest volume surgeons do not.

Level of Evidence: 3

There is a paucity of literature available that use data-driven methodology to stratify surgeons and hospitals by volume in the setting of laminectomy. We used stratum-specific likelihood ratio (SSLR) analysis of receiver operating characteristic (ROC) curves to establish evidence-based volume thresholds for surgeons and hospitals in the setting of laminectomy.

Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX

Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH.

Address correspondence and reprint requests to Prem N. Ramkumar, MD, MBA, Department of Orthopaedic Surgery, Cleveland Clinic, 2049 E 100th St, Cleveland, OH 44195; E-mail: premramkumar@gmail.com

Received 6 August, 2018

Revised 17 September, 2018

Accepted 3 October, 2018

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

No relevant financial activities outside the submitted work.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.