• Howard Nelson-Williams, Faiz Gani, Arman Kilic, Gaya Spolverato, Yuhree Kim, Doris Wagner, Neda Amini, Aslam Ejaz, and Timothy M Pawlik.
• Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.
• JAMA Surg. 2016 Feb 1; 151 (2): 155-63.

ImportanceIn an era of accountable care, understanding variation in health care costs is critical to reducing health care spending.ObjectiveTo identify factors associated with increased hospital costs and quantify variations in costs among individual hospitals in patients undergoing liver and pancreatic surgery in the United States.Design, Setting, And ParticipantsRetrospective analysis of total costs among 42 480 patients undergoing hepatopancreaticobiliary surgery from January 1, 2002, through December 31, 2011, using a nationally representative data set (Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project). Analysis was conducted in May 2015.Main Outcomes And MeasuresTotal inpatient costs and proportional variation in inpatient costs among individual hospitals.ResultsAmong the 42 480 patients who underwent liver or pancreatic resection, the median age was 62 years, 52.4% were female, and 72.9% had a Charlson Comorbidity Index of 2 or higher. The median cost for the entire cohort was $21,535 (interquartile range, $15,373-$31,104), varying from $3320 to $279,102 among individual hospitals. On multivariable analysis, increasing patient comorbidity (coefficient, 2000.30; 95% CI, 1363.33-2637.27; P < .001) and operative characteristics (total pancreatectomy: coefficient, 12 742.31; 95% CI, 10 063.66-15 420.94; P < .001; lobectomy: coefficient, 6336.42; 95% CI, 3934.61-8737.24; P < .001) were associated with higher hospital costs. The development of postoperative complications, such as sepsis (coefficient, 30 571.25; 95% CI, 29 308.96-31 833.54; P < .001) or stroke (coefficient, 8925.34; 95% CI, 2801.38-15 049.30; P = .004), and a longer length of stay were most strongly predictive of higher inpatient cost (length of stay >14 days: coefficient, 44 162.24; 95% CI, 43 125.56-45 198.92; P < .001). After adjusting for patient and hospital characteristics, the overall cost of hepatopancreaticobiliary surgery varied by $9000 among individual hospitals.Conclusions And RelevanceSignificant variability was noted in hospital costs among patients undergoing pancreatic and liver surgery. Future policies should focus on reducing variations in costs by promoting payment paradigms that support a better quality of care and lower costs.

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