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Physician Work Relative Value Units Do Not Adequately Account for Operative Time in Pediatric Urology
Da David Jiang, MD, Nicholas Chakiryan, MD, Kyle Gillis, MD, Ann Martinez Acevedo, MPH, J. Christopher Austin, MD, Casey Seideman, MD.
Doernbecher Children's Hospital at Oregon Health and Science University, Portland, OR, USA.

Background
Physician work relative value units (wRVU) are the measure of value used in United States Medicare reimbursement, as well as private insurance. Medicare determines physician wRVU for a particular procedure based on operative time, technical skill and effort, mental effort and judgement, and stress. In theory, wRVU should account for the operative time involved in a procedure, resulting in similar wRVUs per unit time for most short and long procedures. The primary aim of this study was to assess whether operative time is adequately accounted for in the wRVU system.
Methods
The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was utilized from 2012-2017. Pediatric Urology current procedural terminology (CPT) codes with a minimum of 50 recorded operations were included in the analysis. Using wRVUs and total operative time, not including anesthesia time, the primary variable of wRVU per hour was generated (wRVU/hr). Multivariable linear regression analysis was used to assess the relative influence that wRVU and operative time had on the wRVU/hr variable.
Results
20,979 cases were included in the final study population from 51 separate Pediatric Urology CPT codes. Median wRVU was 17.02, median operative time was 130 minutes, and median wRVU/hr was 7.0. Mean wRVU/hr weighted by number of procedures was 9.1. The three procedures with the highest wRVU/hr were Deflux (15.5), Meatoplasty (14.5), and MAGPI or V-flap hypospadias repair (12.5) (Table 1). Procedures with operative time less than 90 minutes had higher wRVU/hr compared with procedures longer than 90 minutes (10.9 vs 8.2, p < 0.001; Table 2). Multivariable linear regression analysis revealed that each additional hour of operative time was expected to decrease wRVU/hr by 0.72 (-0.012 per minute, 95% CI: -0.013 - -0.011, p < 0.001), and that wRVU did not have a statistically significant independent association with wRVU/hr (0.006, 95%CI: -0.001 - 0.013, p = 0.06).
Conclusion
This analysis of large population national-level data suggests that the wRVU system significantly favors shorter procedures in Pediatric Urologic surgery.
Table 1. Urologic operations by wRVU/hr (10 highest and 10 lowest wRVU/hr)

Rank	Procedure	N	wRVU	Operative Time (min)	wRVU/hr
1	Deflux	370	5.18	20	15.5
2	Meatoplasty with mucosal advancement	1336	6.77	28	14.5
3	Distal hypospadias, 1-stage (MAGPI or V-flap)	866	13.98	67	12.5
4	ESWL	66	9.77	49	12.0
5	Adjacent tissue transfer (Byar's flaps)	1844	8.6	44	11.7
6	Orchiopexy, abdominal	421	12.39	66	11.3
7	Laparoscopic ureteral reimplant without stent	73	23.82	130	11.0
8	Distal hypospadias, 1-stage (local flaps, flip flap, etc)	2193	17.55	97	10.9
9	Hypo complications requiring flaps (fistula, stricture)	427	17.06	95	10.8
10	Partial cystectomy with ureteral reimplantation	65	23.68	134	10.6
42	Second stage hypospadias urethroplasty, > 3cm	290	14.51	150.5	5.8
43	Vaginoplasty for intersex state	95	20.02	211	5.7
44	Cystotomy for excision of diverticulum	60	15.42	178	5.2
45	Closure of cystostomy	64	7.87	91	5.2
46	Cutaneous appendicovesicostomy	475	22.46	289	4.7
47	Closure of extrophy	112	30.66	422	4.4
48	Cystoscopy and stent placement	117	2.82	39	4.3
49	Excision, benign lesion (0.6-1cm or less)	58	1.47	21	4.2
50	Enterocystoplasty, including intestinal anastomosis	432	25.4	381	4.0
51	Excision, benign lesion, (0.5cm or less)	103	1.03	23	2.7

Table 2. wRVU/hr, Grouped by Operative Time Greater or Less than 90 Minutes

Operative Time	N	wRVU/hr	P
90 minutes or less	7,769	10.8
> 90 minutes	13,207	8.2	< 0.001

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