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Original Investigation
Pacific Coast Surgical Association
July 17, 2019

Association of Work Measures and Specialty With Assigned Work Relative Value Units Among Surgeons

Author Affiliations
  • 1Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles
  • 2Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles
  • 3Department of Surgery, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
JAMA Surg. 2019;154(10):915-921. doi:10.1001/jamasurg.2019.2295
Key Points

Question  Are objective measures of surgeon effort and surgical specialty associated with the assigned work relative value units of procedures?

Findings  In this cross-sectional study of 628 unique Current Procedural Terminology codes from 1 239 991 patient observations, 80% of the variations in assigned work relative value units were associated with procedures’ operative time, length of stay, and readmission and reoperation rates. Statistically significant differences remained, however, across surgical specialties despite controlling for these measures.

Meaning  Incorporating objective data from a surgical registry may improve the relative value unit assignment and update processes, including reducing the differences across specialties.


Importance  The primary data sources used to generate and update work relative value units (RVUs) are surveys of small groups of specialists who are asked to estimate the time and intensity needed to perform surgical procedures. Because these surveys are conducted by specialty societies and rely on subjective data, these sources have been challenged as potentially biased.

Objective  To assess whether objective work measures are associated with a surgical procedure’s assigned work RVUs and whether differences exist by surgical specialty.

Design, Setting, and Participants  This cross-sectional study obtained data from the 2016 and 2017 participant use files of the American College of Surgeons National Surgical Quality Improvement Program. The 2017 physician fee schedule of the Centers for Medicare & Medicaid Services was a secondary data source. Procedures were included if they had at least 100 patient-level observations over the 2-year period. Data were analyzed from August 29, 2018, to April 2, 2019.

Main Outcomes and Measures  The dependent variable was a procedure’s assigned work RVU. Independent variables of work RVUs were 4 procedure-level work measures (median operative time, median postoperative length of stay, all-cause 30-day readmission rate, and all-cause 30-day reoperation rate) and surgeon specialty (10-level category using general surgery as the reference).

Results  The data set included 628 unique Current Procedural Terminology (CPT) codes and 726 CPT-specialty combinations from 1 239 991 patient observations. Statistically significant associations were found between each work measure and assigned work RVU, as follows: median operative time (R2 = 0.74; 95% CI, 0.71-0.78), postoperative length of stay (R2 = 0.42; 95% CI, 0.36-0.48), rate of readmission (R2 = 0.18; 95% CI, 0.13-0.23), and rate of reoperation (R2 = 0.15; 95% CI, 0.10-0.20). Including all 4 measures explained 80.2% (95% CI, 77.3%-83.1%) of the variation. Adding the surgical specialty improved the overall fit of the model (likelihood ratio test χ2 = 231.27; P < .001). Cardiac (7.78; 95% CI, 4.25-11.31; P < .001) and neurosurgery (2.46; 95% CI, 1.08-3.83; P < .001) had higher work RVUs compared with general surgery, whereas orthopedics (–1.53; 95% CI, –2.48 to –0.59; P = .002), urology (–1.58; 95% CI, –2.88 to –0.29; P = .02), plastics (–2.70; 95% CI, –4.39 to –1.01; P = .002), and otolaryngology (–3.05; 95% CI, –4.69 to –1.42; P < .001) had lower work RVUs compared with general surgery.

Conclusions and Relevance  Objective work measures appeared to be associated with assigned work RVUs, predominantly with operative time; registry data can be used to augment and inform the generation and updating processes of the work RVUs.

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