Does Decreasing Variability Affect Quality

The cost of health care in theUnited States has been the topic of countless studiesduring the last severaldecades.Manyremedies have been proposed and implemented, but cost continues to rise. One puzzling aspect of cost has been the variability of cost for the same disease process. Variability in the cost of surgical procedures has been easier to evaluate than other aspects of health care and has generated significant interest from a policy standpoint. Variability. This seems like something obvious. Everyone would like to make health care outcomes better and variability seems like a great place to start. But, is this code for further erosionof the autonomy of surgeons and health care professionals in general? Surgeons are intrinsically skeptical of this process and believe with perhaps some justification that clinical pathwayswill be developed that focusmore on cost than clinical outcome. And, variability is code for decreasing cost, not bringing costs to the mean. Surgeons have typically embraced variability. We have watched and read ofmany differentways tomanage the same disease. Ihaveseenpancreatoduodenectomyperformedmany waysbyspectacularsurgeons.This technicalvariabilitysparked debatethatcertainlyresultedinbetterclinicaloutcomes.Thecost variability studied and embraced by hepatopancreaticobiliary (HPB)surgeons isabit less real thantechnicalvariabilityandhas focusedon inpatient costs, as in the article byNelson-Williams et al1 in this issue of JAMASurgery. Thepreoperative decisions (who shouldnot have a resection) andpostacute care costs are also important but verydifficult to quantitate, and theywill be afocusofsavingsaswetransitiontopopulationhealth.But,what reallymatters to a surgeon is the outcome of our intervention. This logic generates a provocative question: does variability in cost result in inferior clinical outcomes? Nelson-Williamsandcolleaguesevaluatedvariability incost of liver andpancreas procedures. Somecost variability is obvious: ifyouhaveacomplication,a longerhospital stay,orcomorbidities, the cost is higher. Some are not as obvious: at lowervolume hospitals if the procedure goes well, the cost is lower. Therearealso2more subtlebut important findings:during the last 10years, thecomplicationratehasrisenbut thecosthasnot. Letmeemphasize the lastpoint—thecostof thesecomplexsurgicalprocedureshasnot increaseddespitecontinuingescalation in theoverall costofhealthcare.Perhaps thecostofhealthcare is not affected significantly by the variability in the cost of surgical proceduresbut rather bymore subtle things that aredifficult tomeasure, suchas thecopays forambulatory imaging, the cost of drugs, orwho the patient sees first. Does variability in cost result in inferior outcomes in these 2 procedures and is there an intervention that will lower cost? Mostof thevariables theauthorsevaluatedcannotbechanged: sex, procedure, comorbidities,whether thepatient hada complication,etc.Thestudydid lookatvariables thatarepotentially open to change, suchas the typeofhospital and the locationof the hospital. The authors did find that the cost is lower in lowvolume hospitals for these procedures. It seems equally clear basedonthe literature that thesurgicalmortality ishigher.This paradox is the essence of the debate on value.We as clinicians shouldbedeeplycognizantofcostbutnotattheexpenseofquality.Takentoits logicalconclusion, thisstudysuggests that itmay be less expensive if HPB procedures were done in low-volume hospitals. However, the outcomewill likely be inferior. So, variability is code for lowering the cost of care. The article by Nelson-Williams and colleagues specifically asks the question, canwe lower the cost of care for inpatientsundergoingHPBprocedures?Thereareopportunities tomakecaremore efficient,whichwehave takenonasacommunityasevidenced by the flat cost for the last 10 years.We can andwill do better. The real cost savings, however, come fromnothaving complicationsandnotperformingproceduresonpatientsat riskfornot benefiting fromresection.So, theanswer to thequestion“Does variability (higher cost) result in inferior clinical outcomes?” is almost certainlyno.Weas a communityofHPBsurgeonsobviouslycannotaccept lower-qualitycareforourpatients.Thechallengewill continue to be the following: how canwe lower the cost of carewhile improving quality?