Is the relative value of surgeon effort equal across surgical specialties?

Background: Although relative value units are used to measure physician productivity, research has demonstrated incongruencies between relative value units and actual surgeon work effort. We sought to determine whether this variation extends across surgical specialties.

Methods: A retrospective review of surgical cases was conducted using the 2017 American College of Surgeons National Surgical Quality Improvement Program database. For each case, we identified the primary Current Procedural Terminology, surgical specialty, total relative value units, and 5 alternative measures of work effort. We then examined the correlation between a Current Procedural Terminology's mean total relative value unit and work effort. Finally, we constructed a multivariable linear regression model to evaluate the association between surgical specialty and the expected mean total relative value unit adjusting for work effort and patient characteristics.

Results: A total of 876,515 cases met the inclusion criteria. Overall, median operative time correlated well with mean total relative value unit (R = 0.85), though it was lowest for cardiac surgery (R = 0.51) and highest for otolaryngology (R = 0.97). Neurosurgery had the greatest increase in mean total relative value unit per hour of operative time (12.9/h). Mean total relative value unit correlated modestly with length of stay (R = 0.58) and serious adverse events (R = 0.61) and weakly with readmission (R = 0.42) and mortality (R = 0.29). When holding these metrics constant, the multivariable model showed mean total relative value units differed according to surgical specialty alone. Compared with general surgery, neurosurgery and cardiac surgery earned 3.41 to 3.61 additional mean total relative value units (P < .05), while orthopedics, otolaryngology, thoracic, urology, and vascular surgery received fewer mean total relative value units (-1.84 to -4.43, P < .05).

Conclusion: Surgeon productivity is increasingly measured using relative value units. While mean total relative value units correlate well with operative time, they may not reflect other aspects of work effort. Differences in mean total relative value units by surgical specialty demonstrate potential inequities in the determination of physician productivity.