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Original Investigation
October 2016

Addressing the High Costs of Pancreaticoduodenectomy at Safety-Net Hospitals

Author Affiliations
  • 1Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
JAMA Surg. 2016;151(10):908-914. doi:10.1001/jamasurg.2016.1776
Key Points

Question  What is the best way to reduce costs of complex surgery at safety-net hospitals?

Findings  Using a decision analytic model, this study found that reducing complications would have a negligible effect but that redistributing patients away from safety-net hospitals for complex surgery may have the greatest effect on cost reduction.

Meaning  Future research and policy should focus on improving processes of care at safety-net hospitals and potentially reallocating complex patients to more cost-effective hospitals.


Importance  Safety-net hospitals care for vulnerable patients, providing complex surgery at increased costs. These hospitals are at risk due to changing health care reimbursement policies and demand for better value in surgical care.

Objective  To model different techniques for reducing the cost of complex surgery performed at safety-net hospitals.

Design, Setting, and Participants  Hospitals performing pancreaticoduodenectomy (PD) were queried from the University HealthSystem Consortium database (January 1, 2009, to December 31, 2013) and grouped according to safety-net burden. A decision analytic model was constructed and populated with clinical and cost data. Sensitivity analyses were then conducted to determine how changes in the management or redistribution of patients between hospital groups affected cost.

Main Outcomes and Measures  Overall cost per patient after PD.

Results  During the 5 years of the study, 15 090 patients underwent PD. Among safety-net hospitals, low-burden hospitals (LBHs), medium-burden hospitals (MBHs), and high-burden hospitals (HBHs) treated 4220 (28.0%), 9505 (63.0%), and 1365 (9.0%) patients, respectively. High-burden hospitals had higher rates of complications or comorbidities and more patients with increased severity of illness. Perioperative mortality was twice as high at HBHs (3.7%) than at LBHs (1.6%) and MBHs (1.7%) (P < .001). In the base case, when all clinical and cost data were considered, PD at HBHs cost $35 303 per patient, 30.1% and 36.2% higher than at MBHs ($27 130) and LBHs ($25 916), respectively. Reducing perioperative complications or comorbidities by 50% resulted in a cost reduction of up to $4607 for HBH patients, while reducing mortality rates had a negligible effect. However, redistribution of HBH patients to LBHs and MBHs resulted in significantly more cost savings of $9155 per HBH patient, or $699 per patient overall.

Conclusions and Relevance  Safety-net hospitals performing PD have inferior outcomes and higher costs, and improving perioperative outcomes may have a nominal effect on reducing these costs. Redirecting patients away from safety-net hospitals for complex surgery may represent the best option for reducing costs, but the implementation of such a policy will undoubtedly meet significant challenges.