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Original Investigation
October 2017

An Instrumental Variable Analysis Comparing Medicare Expenditures for Laparoscopic vs Open Colectomy

Author Affiliations
  • 1Department of Surgery, University of Michigan, Ann Arbor
  • 2Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor
  • 3Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor
  • 4Department of Economics, University of Michigan, Ann Arbor
  • 5National Bureau of Economic Research, Cambridge, Massachusetts
  • 6Surgical Innovation Editor, JAMA Surgery
JAMA Surg. 2017;152(10):921-929. doi:10.1001/jamasurg.2017.1578
Key Points

Question  After accounting for selection bias from patient characteristics, what are the real-world cost differences of laparoscopic and open colectomy?

Findings  In our fully adjusted instrumental variable analysis in this population-based study, laparoscopic colectomy was associated with lower Medicare expenditures than open surgery; however, the magnitude of the association was less than what is observed from conventional multiple regression models. Index hospitalization payments were similar between laparoscopic and open surgery; in contrast, payments for readmissions and postacute care were less common after laparoscopic surgery and resulted in lower overall payments.

Meaning  For patients considered candidates for either approach, laparoscopic colectomy is associated with lower Medicare payments, and the mechanism of cost savings comes from reductions in readmission and postacute care payments.


Importance  Numerous study findings suggest that the use of laparoscopy is associated with lower health care costs for many operations, including colectomy. The extent to which these differences are due to the laparoscopic approach itself or selection bias from healthier patients undergoing the less invasive procedure is unclear.

Objective  To evaluate the differences in Medicare expenditures for laparoscopic and open colectomy.

Design, Setting, and Participants  A population-based study was conducted of Medicare beneficiaries undergoing laparoscopic or open colectomy between January 1, 2010, and December 31, 2012. The dates of the analysis were November 13 to December 10, 2016. Using instrumental variable methods to account for selection bias, actual Medicare payments after each procedure were evaluated. To identify the mechanisms of potential cost savings, the frequency and amount of physician, readmission, and postacute care payments were evaluated. Several sensitivity analyses were performed restricting the study population by patient demographic or surgeon specialty.

Main Outcomes and Measures  Actual Medicare expenditures up to 1 year after the index operation.

Results  The study population included 428 799 patients (mean [SD] age, 74 [10] years; 57.0% female). When using standard methods, patients undergoing laparoscopic colectomy (vs open) had lower total Medicare expenditures (mean, −$5547; 95% CI, −$5408 to −$5684; P < .01). When using instrumental variable methods, which account for potentially unmeasured patient characteristics, patients undergoing laparoscopic colectomy (vs open) still had lower Medicare expenditures (mean, −$3676; 95% CI, −$2444 to −$4907; P < .01), although the magnitude of the association was reduced. When examining the root causes of the difference in costs between patients who underwent laparoscopic and open colectomy, the key drivers were a reduction in costs from readmissions (mean, −$1102; 95% CI, −$1373 to −$831) and postacute care (mean, −$1446; 95% CI, −$1988 to −$935; P < .01).

Conclusions and Relevance  This population-based study demonstrates the influence of selection bias on cost estimates in comparative effectiveness research. While the use of laparoscopy reduced total episode payments, the source of savings is in the postacute care period, not the index hospitalization.