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.
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.
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.
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).
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|
|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|
|5||Adjacent tissue transfer (Byar's flaps)||1844||8.6||44||11.7|
|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|
|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
|90 minutes or less||7,769||10.8|
|> 90 minutes||13,207||8.2||< 0.001|
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