Abstract
Objective:
Vascular surgeons provide assistance to other surgical specialties through planned and unplanned joint operative cases. The financial impact to the hospital of vascular surgeons as consultants in this context has yet to be quantified. We sought to quantify the financial value of services provided by consulting vascular surgeons in the performance of joint operative procedures, both planned and unplanned.
Methods:
Hospital financial data were reviewed for all inpatient operative cases during a 3-year period (2013–2015). Cases in which a vascular surgeon provided operative assistance as a consultant to a nonvascular surgeon were identified and designated planned or unplanned. Contribution margin, defined as hospital revenue minus variable cost, was deter-mined for each case. In addition, the contribution margin ratio (contribution margin divided by revenue) was determined for each cohort. Financial data for consulting cases was compared with all nonconsult cases. Data analysis was performed with nonparametric statistics.
Results:
There were 208 cases with a primary nonvascular surgeon that required a vascular co-surgeon during the study period, 169 planned and 39 unplanned. For comparison, 19,594 nonconsult cases of other surgical specialties were identified. The median contribution margin was higher for vascular surgery consult cases compared with nonconsult cases ($14,406 [interquartile range, $63,192] vs $5491 [interquartile range $28,590]; P = .002). The overall contribution margin ratio was higher for vascular surgery consult cases (0.41) compared with control nonconsult cases (0.35). There was no difference in contribution margin and contribution margin ratio between planned and unplanned vascular surgery consult cases.
Conclusions:
Vascular surgeons provide essential operative assistance to other surgical specialties. This operative assistance is frequent and provides significant financial value, with high contribution margin and contribution margin ratio. Vascular surgeons, as consulting surgeons, enable the completion of highly complex cases and in this capacity provide significant financial value to the hospital. (J Vasc Surg 2019;69:1314–21.)
Keywords: Cost analysis, Contribution margin, Vascular surgery, Operative consults
Vascular surgeons are frequently involved in complex operations as consulting surgeons to other surgical specialties. The specific advanced skill set of a vascular surgeon is often called on for vascular exposure, hemorrhage control, or reconstruction for both elective and emergent operative cases.1–3 Intraoperative consultations arise from all surgical subspecialties, are frequently unplanned, and often occur in the middle of the night.4 This paradigm assumes that a vascular surgeon should be available at any hour without hesitation, yet hospital structures underestimate how consultations that are unplanned and after-hours can affect the surgeon’s scheduled practice.4 Although the volume of vascular surgeons as consultants has recently been described, the financial impact for the hospital has yet to be examined and is not captured by current hospital tracking systems.
To the hospital, contribution margin represents overall profit generation for a specific service, ignoring overhead and fixed costs. Contribution margin is defined as total revenue or payment minus the variable costs for a service based on the actual resources used. A few studies have attempted to compare hospital financial data for specific surgical services and found that cases with greater complexity and those performed emergently can be valuable to the hospital, despite complications or increased costs.5,6 The purpose of this study was to quantify the financial value to the hospital of services provided by consulting vascular surgeons to other surgical specialties in the performance of joint operative procedures, both planned and unplanned.
METHODS
All inpatient operative cases during a 3-year period (2013–2015) at Keck Medical Center were retrospectively reviewed. Operations in which a vascular surgeon was a consulting surgeon to another surgical specialty were identified. Operative vascular surgery consultations included those that required a vascular surgeon for vascular exposure, hemorrhage control, repair, or reconstruction and were classified as planned or unplanned. Planned was defined as a consultation in which the vascular surgeon was involved in the preoperative planning and was scheduled to be available on the day of the operative procedure. An unplanned consultation was defined as one in which the vascular surgeon had no prior contact with the patient and was asked to provide an emergency intraoperative consultation.2 At our hospital, unplanned intraoperative consults are directed toward the scheduled on-call vascular surgeon who also staffs nonoperative consultations, service admissions, and his or her own regularly scheduled cases. All operations performed by other surgical specialties in which vascular surgery was not involved were designated other surgical specialty cases. Only operations that were classified as inpatient were included.
This study was approved by the Keck School of Medicine Institutional Review Board, and patients’ consent was not required. Data were collected from the hospital electronic medical record, including demographics, operative intervention and details, patients’ comorbidities, surgical service requesting vascular surgery services, indication for vascular consultation, and case mix index (CMI). CMI is a standardized value assigned to a case that represents the amount of hospital resources likely to be needed in caring for patients; cases of greater complexity have a higher associated CMI.
For all inpatient cases during the study period, financial data were obtained from the hospital accounting warehouse and confirmed for accuracy by the hospital Chief Financial Officer. The contribution margin was calculated for individual cases by subtracting variable cost from hospital revenue. Variable cost equals total cost minus hospital overhead and fixed costs and is representative of costs that fluctuate on the basis of the complexity of the patient. Hospital revenue or net revenue is the sum of all payments and reimbursements attributed to an account, including patient and third-party payments. The contribution margin was negative for cases in which no revenue was collected or if variable cost was greater than net revenue. All cases were used during analysis, with contribution margin median and interquartile range (IQR) calculated for each group. The contribution margin ratio, defined as overall contribution margin divided by overall revenue, was determined for the two vascular surgery and other surgical specialty cohorts. Overall contribution margin was the summed value of all positive and negative contribution margin for each case. The primary outcome, contribution margin, was compared between vascular surgery consulting cases and all other surgical specialty cases. Subanalysis by primary surgical service was a secondary outcome.
Data were captured on an Excel spreadsheet (Microsoft Corp, Redmond, Wash), and statistical analysis was conducted using R statistical software (R Foundation for Statistical Computing, Vienna, Austria). Wilcoxon rank sum tests were used to compare contribution margins and CMI between groups. Payer mix was compared between groups using a Fisher exact test. Statistical significance was set at P < .05.
RESULTS
Between January 2013 and December 2015, a total of 19,802 inpatient operations were performed at Keck Medical Center. Of those, 208 operations (1.1%) were identified with a vascular surgeon as a consulting surgeon, with 19,594 cases performed by other surgical services without a vascular surgeon consultant (other surgical specialty). Of the vascular surgery cases, 169 (81%) were identified as planned consults, and 39 cases were identified as unplanned consults.
Demographics for vascular surgery consult cases are listed in Table I. The average age of consult patients was 57.1 ± 14.4 years, and 48% of vascular surgery consult patients were male. The requesting specialties and indication for consultation are collated in Tables II and III. Spine exposure was the most common indication for vascular surgery consultation (67%). Spinal cases that did not require a vascular co-surgeon were included with their respective primary nonconsult service. Other major consulting services included cardiothoracic surgery (8%), urology (6%), hepatobiliary surgery (5%), orthopedic surgery (4%), and nonspine neurosurgery (2%), with services of fewer than five consults grouped together as other (7%; general surgery, plastic surgery, otolaryngology, gynecology, colorectal surgery, oncologic surgery). Inferior vena cava filter placement at the conclusion of the primary operation was the indication for consultation in two patients (1%).
Table I.
Characteristics of patients of vascular surgery consult cohort
| No. (%)a | ||
|---|---|---|
| Sex | ||
| Female | 109 (52) | |
| Male | 99 (48) | |
| Medical conditions | ||
| Coronary artery disease | 13 (19) | |
| Congestive heart failure | 8 (12) | |
| Chronic kidney disease | 8 (12) | |
| Chronic obstructive pulmonary disease | 3 (4) | |
| Diabetes mellitus | 17 (25) | |
| Hyperlipidemia | 23 (34) | |
| Hypertension | 36 (53) | |
| Past tobacco use | 29 (43) | |
| Current tobacco use | 8 (12) | |
|
| ||
| Mean ± SD | Median (IQR) | |
|
| ||
| Age, years | 57.1 ± 14.4 | 59 (22) |
| Body mass index, kg/m2 | 26.6 ± 5.7 | 26.2 (7) |
IQR, Interquartile range; SD, standard deviation.
Sex and age were available for all patients. Additional characteristics for 140 spine patients were not available. Percentages reflect patients with nonmissing data.
Table II.
Case mix index (CMI) by specialty and consult type
| CMI |
P value | ||||
|---|---|---|---|---|---|
| Consult |
No consult |
||||
| No. | Median (IQR) | No. | Median (IQR) | ||
| Specialty | |||||
| Spine exposure | 140 | 6.3 (4.1) | 0 | ||
| Cardiothoracic surgery | 17 | 9.6 (13) | 1810 | 7.7 (2.6) | .09 |
| Hepatobiliary surgery | 10 | 3.5 (2.7) | 1788 | 3.3 (3) | .36 |
| Neurosurgery | 5 | 3.1 (1.2) | 2179 | 2.9 (1.7) | .72 |
| Orthopedic surgery | 9 | 3.4 (1.5) | 3938 | 2.1 (0.8) | .03 |
| Urology | 13 | 3.4 (2.4) | 3787 | 1.6 (0.8) | <.001 |
| Vascular surgery | 0 | 735 | 2.6 (1.5) | ||
| Other | 14 | 2.3 (1.2) | 5357 | 1.8 (1) | .87 |
| All | 208 | 5.4 (4.1) | 19,594 | 2.1 (1.8) | <.001 |
| Consult typea | |||||
| Planned | 169 | 6.3 (4.1) | |||
| Unplanned | 39 | 3.4 (3) | |||
IQR, Interquartile range.
Boldface entries indicate statistical significance (P < .05).
Planned CMI vs unplanned CMI: P < .001.
Table III.
Contribution margin by specialty and indication
| Contribution margin |
P value | ||||
|---|---|---|---|---|---|
| Consult |
No consult |
||||
| No. | Median (IQR), $ | No. | Median (IQR), $ | ||
| Specialty | |||||
| Spine exposure | 140 | $12,957 ($69,236) | 0 | ||
| Cardiothoracic surgery | 17 | $40,350 ($315,475) | 1810 | $19,501 ($75,991) | .07 |
| Hepatobiliary surgery | 10 | $10,192 ($33,939) | 1788 | $5,457 ($48,521) | .44 |
| Neurosurgery | 5 | $20,925 ($27,287) | 2179 | $8,626 ($31,519) | .92 |
| Orthopedic surgery | 9 | $20,708 ($42,242) | 3938 | $2,667 ($21,561) | .06 |
| Urology | 13 | $15,854 ($57,622) | 3787 | $2,780 ($20,208) | .58 |
| Vascular | 0 | 735 | $913 ($19,094) | ||
| Other | 14 | —$2,744 ($31,698) | 5357 | $8,123 ($27,470) | .04 |
| All | 208 | $14,406 ($62,696) | 19594 | $5,491 ($28,587) | .002 |
| Indicationa | |||||
| All | 8 | $45,842 ($294,262) | |||
| Bleeding | 13 | $3,236 ($22,734) | |||
| Exposure | 155 | $13,538 ($64,235) | |||
| Reconstruction | 28 | $19,341 ($64,201) | |||
| Other | 4 | $9,884 ($115,709) | |||
IQR, Interquartile range.
Boldface entries indicate statistical significance (P < .05).
No indication for cases without consult.
Case complexity: CMI for vascular surgery consult vs other surgical specialty.
CMI (Table II; Fig 1) was significantly higher for vascular surgery consult cases (5.4 [IQR, 4.1]) compared with other surgical specialty (2.1 [IQR, 1.8]; P < .001). Among vascular surgery consults, median CMI was greater for planned consults (6.3 [IQR, 4.1]) compared with unplanned consults (3.4 [IQR, 3]; P < .001). When broken down by specialty, median CMI was significantly increased with vascular surgery consultation compared with other surgical specialty nonconsult cases for both orthopedic surgery (3.4 [IQR, 1.5] vs 2.1 [IQR, 0.8]; P = .03) and urology (3.4 [IQR, 2.4] vs 1.6 [IQR, 0.8]; P < .001).
Fig 1.
Case mix index (CMI) by consult status. Vascular surgery consult cases had significantly higher CMI compared with nonconsult cases, with planned consult CMIs greater than unplanned consult CMIs. CTS, Cardiothoracic surgery; HBS, hepatobiliary surgery; NSG, neurosurgery; ORTHO, orthopedic surgery; URO, urology.
Payer mix (Fig 2) was not significantly different between vascular surgery consult and other surgical specialty operations (P = .38). Consistent with the historical break-down of payers at our tertiary referral hospital, the majority of payer plans were private insurance for both vascular surgery consults (62%) and other surgical specialty (56%). The remaining were Medicare (34% and 38%) or Medicaid (4% and 5%) for vascular surgery and other surgical specialty, respectively. No vascular surgery consults were self-insured compared with 1% of other surgical specialty cases.
Fig 2.
Payer mix by consult status. There was no significant difference in payer mix between consult and nonconsult cases.
Financial impact: Contribution margin for vascular surgery consult vs other surgical specialty.
Financial data are displayed in Table III and Fig 3. Overall, the median contribution margin for vascular surgery cases was 2.6 times as high as the median contribution margin for other surgical specialty cases ($14,406 [IQR, $63,192] vs $5491 [IQR, $28,590]; P = .002). There was no difference in contribution margin between planned and unplanned vascular surgery cases ($13,568 [IQR, $69,480] vs $20,246 [IQR, $57,622]; P = .76; not shown). The overall contribution margin ratio was higher for vascular surgery consult cases (41%) compared with other surgical specialty cases without vascular surgery (35%).
Fig 3.
Contribution margin by consult status. The median contribution margin was higher for consult cases compared with nonconsult cases.
Subanalysis for surgical service.
There was no statistically significant difference in median contribution margin for surgical specialties between vascular surgery consult and other surgical specialty cases (Table III; Fig 4). Post hoc power calculations based on the observed differences in contribution margin between vascular surgery and other surgical specialty operations by specialty indicate that each specialty would need between 80 and 2180 consult cases to demonstrate a statistically significant difference (80% power, .05 a, 1 vascular surgery consult for every 100 other surgical specialty cases).
Fig 4.
Contribution margin by specialty and consult status. Differences in contribution margin between consult and nonconsult cases did not reach statistical significance at the .05 level when stratified by individual specialty; post hoc analysis revealed insufficient power. CTS, Cardiothoracic surgery; HBS, hepatobiliary surgery; NSG, neurosurgery; ORTHO, orthopedic surgery; URO, urology.
DISCUSSION
Recent work by our group and others has demonstrated the essential value that vascular surgeons bring to the hospital through critical support of other nonvascular surgical services.1–3 In both planned and unplanned settings, vascular surgeons provide exposure, control, and reconstruction of vasculature in a wide variety of indications, surgical specialties, and vascular beds.2 Intraoperative consultation services by a vascular surgeon enable the safe completion of complex cases that require vascular control and otherwise would not be possible or could result in devastating outcomes for the patients.
This study builds on our previous work by including patients who require vascular assistance for spinal exposure to provide a better representation of the full breadth of consultation cases performed by vascular surgeons. Inclusion of these patients emphasizes the volume and complexity of cases that can be completed in a hospital when a vascular surgeon is available. We have demonstrated that the presence of a vascular surgeon in nonvascular cases is associated with cases of greater complexity, with consult cases having a significantly higher than average CMI. The complexity of cases that can be performed is even higher on collaborating with a vascular surgeon preoperatively, as shown with a greater CMI for planned joint operations compared with unplanned intraoperative consultations. In planned operations, vascular surgeons provide a multidisciplinary perspective preoperatively, which allows the hospital to support complex procedures that would otherwise not be feasible. Unplanned consultations occur when unexpected difficulties arise, often transforming an elective operation into one with significant anesthesia time and blood loss1,2 and therefore potential for increased morbidity and mortality. Despite the potential for significant complications associated with cases that require both planned and unplanned vascular assistance, involvement of vascular surgery in these cases provides good outcomes that are comparable to those of the complex operations that receive significant preoperative planning.2
Providing high-quality patient care in the setting of this high CMI demonstrates the specific advanced skill set that vascular surgeons must maintain to care for these complex patients. As surgical specialties diversify, the skill set of a vascular surgeon has become increasingly unique and valuable. Most of the consults reported here were open surgery, yet current training favors endovascular exposure; vascular fellowships must continue to develop educational programs that ensure the development and maintenance of these complex open surgical skills.7 In addition, it must be recognized that this skill set will become increasingly valuable as exposure to advanced open vascular cases becomes less common in general surgery training.8 The frequency of unplanned vascular consultations reported by us and others suggests that nonvascular surgeons may be overconfident with their skill around vascular structures, turning an elective case into an emergent case that requires a vascular surgeon as an intraoperative consultant.1,2 The value of a multidisciplinary team and the benefit of a vascular consultation in the preoperative setting of nonvascular cases will become even more evident as both technical skills and intraoperative decision-making are likely to be affected by the continued decrease in exposure to these cases during training.
The focus of this study is on the unseen financial impact of vascular surgeons to the hospital. Vascular surgeons have a unique role as in-hospital providers because of their advanced skill set and the urgency of consults from other services.9 Some have advocated the use of reported contribution margin and operating room utilization as surrogates for productivity in the hospital.10,11 Our group and others have reported significant value in terms of physician time by examining the relative value units (RVUs) associated with these cases.1–3 Unfortunately, much of this value and volume is not readily visible to hospital administration as most tracking systems account for only the primary admitting service, and a recent study by Perri et al12 suggested that RVU-based reimbursement is actually declining for vascular surgeons. Furthermore, unplanned intraoperative consultations can actually interfere with the documented productivity of the vascular surgeon, as the cost of service disruption, rescheduled cases, and extended hours for the surgeon are difficult to quantify. To account for this, Danczyk et al1 advocated that a hospital-based vascular consultation service should be valued by hospital administration not just for the additional work RVUs provided but also for the quality factors not captured with CMI and RVUs. We believe that patient safety and the successful completion of complex operations by other surgical services should also be included in examining the value of vascular surgeons.
In an effort to better quantify the true financial benefit of vascular consultation services to the hospital, this study takes the conversation further by examining the contribution margin of individual patients. When looking at this specific group of patients, we have shown that both planned and unplanned intraoperative vascular consultations are financially profitable to the hospital. Cases with a vascular surgeon consultant had a contribution margin 2.6 times as high as that of nonconsult cases. Furthermore, although the study was not powered to detect a difference at the individual specialty service level, cases with a vascular surgery consult consistently demonstrated a contribution margin greater than the median contribution margin for each requesting service. Even on accounting for the service volume by indexing to overall revenue, the contribution margin ratio was greater for consultation cases than for nonconsult cases by 6%. Availability of a vascular surgeon for nonvascular operations appears to increase the overall complexity of patients that a hospital can safely manage, and the hospital receives significant financial benefit from these operations.
Consult cases had a significantly higher CMI than non-consult cases, consistent with the expected complexity of this group of patients. However, the contribution margin of vascular surgery primary nonconsult patients was much lower than anticipated, given an associated CMI comparable to that of orthopedics and neurosurgery. This has prompted further analysis into potential causes for this discrepancy and suggests significant issues with coding and reimbursement at our institution. Ayub et al13 recently highlighted systemic undercoding in vascular surgery that potentially explains this mismatch between CMI and contribution margin in primary vascular patients, raising the question of how vascular surgeons are valued at other institutions.
The financial value presented here for consult cases represents only part of the total value of vascular surgeons to the hospital as they must also care for their own service inpatients, provide intraoperative consults in which no vascular intervention is ultimately required, and respond to inpatient consults outside of the operating room. This study is important because it attaches a tangible value to the vascular surgeon’s involvement in procedures that administratively are attributed only to the specialty service. For any given hospital, as case complexity and technology increase, the need for the presence and support of vascular surgeons can be expected to increase. Consequently, when hospitals finance expansion of specialty surgical services, including the use of robotic technology and other minimally invasive techniques, it is essential that vascular surgeons who are equipped to handle unexpected hemorrhage and life-threatening complications be available. In addition, this study documents that vascular surgery’s involvement, whether planned or unplanned, is profitable for the hospital. Vascular surgeons should be considered a necessary hospital resource akin to the critical care and blood bank support that is required for the increasingly complex procedures being performed in the contemporary health care environment.
This study was retrospective, which may have limited its ability to detect a difference between planned and unplanned operations. Cases were considered planned if a vascular surgeon left a note in the chart before the case, including the morning of surgery, or was listed as co-surgeon on the preoperative case line-up. However, a vascular surgeon’s influence on a case may differ if consultation is requested earlier in the preoperative process, which may allow more collaborative planning. In addition, it was not possible to differentiate specific costs or revenue that should be attributed to vascular surgery or the requesting service. Although our data demonstrate significant financial value of vascular consult cases, our hospital, as do most hospitals, attributes financial data only to the primary service, neglecting the contribution of vascular surgery. Furthermore, there was great variability in patients’ financial data in this study as demonstrated by large IQRs, resulting in an inability to detect a difference between requesting specialties because of insufficient power. Despite these limitations, the data support that vascular surgeons facilitate the care of highly complex patients, which is financially valuable to the hospital. With a shift in health care toward value-based reimbursement, it will become more important to critically evaluate not only the specific benefit of services but the impact of these services on the hospital as a whole.
CONCLUSIONS
We have shown that the availability of vascular surgery services is of significant financial benefit to hospitals. Unless it is specifically looked at, as in this study, the financial value described is unseen by most hospital administrators and governing hospital boards. To ensure that vascular surgery services remain available, stake-holders need to recognize these findings and help develop a methodology to account for and support the unique financial and patient care contributions of vascular surgeons.
ARTICLE HIGHLIGHTS.
Type of Research: Single-center, retrospective, cohort study
Key Findings: During a 3-year period, vascular surgeons provided planned or unplanned intraoperative consultation or assistance in 208 patients. Compared with nonconsultation cases, these cases resulted in higher contribution margin and contribution margin ratios for planned and unplanned cases.
Take Home Message: This study reports that as consulting surgeons, vascular surgeons, along with providing clinical service, also provide financial value to their hospital.
Acknowledgments
Data analytics and statistical support for this project were provided by NIH/NCRR SC-CTSI Grant No. UL1 RR031986. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.
Footnotes
Presented at the Forty-sixth Annual Symposium of the Society for Clinical Vascular Surgery, Las Vegas, Nev, March 17–21, 2018.
The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
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