Large Variability in the Diversity of Physiologically Complex Surgical Procedures Exists Nationwide Among All Hospitals Including Among Large Teaching Hospitals

BACKGROUND: Multiple previous studies have shown that having a large diversity of procedures has a substantial impact on quality management of hospital surgical suites. At hospitals with substantial diversity, unless sophisticated statistical methods suitable for rare events are used, anesthesiologists working in surgical suites will have inaccurate predictions of surgical blood usage, case durations, cost accounting and price transparency, times remaining in late running cases, and use of intraoperative equipment. What is unknown is whether large diversity is a feature of only a few very unique set of hospitals nationwide (eg, the largest hospitals in each state or province). METHODS: The 2013 United States Nationwide Readmissions Database was used to study heterogeneity among 1981 hospitals in their diversities of physiologically complex surgical procedures (ie, the procedure codes). The diversity of surgical procedures performed at each hospital was quantified using a summary measure, the number of different physiologically complex surgical procedures commonly performed at the hospital (ie, 1/Herfindahl). RESULTS: A total of 53.9% of all hospitals commonly performed 3-fold larger diversity (ie, >30 commonly performed physiologically complex procedures). Larger hospitals had greater diversity than the small- and medium-sized hospitals (P 30 procedures (lower 99% CL, 71.9% of hospitals). However, there was considerable variability among the large teaching hospitals in their diversity (interquartile range of the numbers of commonly performed physiologically complex procedures = 19.3; lower 99% CL, 12.8 procedures). CONCLUSIONS: The diversity of procedures represents a substantive differentiator among hospitals. Thus, the usefulness of statistical methods for operating room management should be expected to be heterogeneous among hospitals. Our results also show that "large teaching hospital" alone is an insufficient description for accurate prediction of the extent to which a hospital sustains the operational and financial consequences of performing a wide diversity of surgical procedures. Future research can evaluate the extent to which hospitals with very large diversity are indispensable in their catchment area. Accepted for publication October 3, 2017. Funding: Departmental funding. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). The Division of Management Consulting, Department of Anesthesia, University of Iowa, performs the calculations described in the Introduction and Discussion of this article. F.D. receives no funds personally other than his salary and allowable expense reimbursements from the University of Iowa and has tenure with no incentive program. He and his family have no financial holdings in any company related to his work, other than indirectly through mutual funds for retirement. Income from the Division's consulting work is used to fund Division research. Reprints will not be available from the authors. Address correspondence to Franklin Dexter, MD, PhD, Division of Management Consulting, Department of Anesthesia, University of Iowa, 200 Hawkins Drive, 6 JCP, Iowa City, IA 52242. Address e-mail to Franklin-Dexter@UIowa.edu. © 2017 International Anesthesia Research Society

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