Between-hospital and -physician variation in outcomes and costs in high- and low-complex surgery: A nationwide multi-level analysis

Open AccessPublished:November 24, 2022DOI:
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      • It is often difficult to pinpoint the sources of variation in outcomes and costs. For effective variation reduction strategies, more insight is required into at what level(s) (e.g., hospitals, professionals, patients) variation exists.
      • Partitioned physician-level variation was typically low and is generally exceeded by hospital-level variation. Additionally, case-mix corrected comparisons on outcomes and costs between individual physicians were unreliable, whereas the opposite often appears to hold for hospitals.
      • Variation-reduction strategies should be designed and applied with caution and with consideration of the potentially large differences in both level-specific attributed variation and reliability that may exist across treatments and outcomes.



      Clinicians and policymakers are increasingly exploring strategies to reduce unwarranted variation in outcomes and costs. Adequately accounting for case-mix and better insight into the level(s) at which variation exists is crucial for such strategies. This nationwide study investigates variation in surgical outcomes and costs at the level of hospitals and individual physicians, and evaluates whether these can be reliably compared on performance.


      Variation was analysed using 92,330 patient records collected from 62 Dutch hospitals who underwent surgery for colorectal cancer (n=6,640), urinary bladder cancer (n=14,030), myocardial infarction (n=31,870) or knee osteoarthritis (n=39,790) in the period 2018-2019. Multilevel regression modelling with and without case-mix adjustment was used to partition variation in between-hospital and between-physician components for in-hospital mortality, ICU admission, length of stay, 30-day readmission, 30-day reintervention, and in-hospital costs. Reliability was calculated for each treatment-outcome combination at both levels.


      Across outcomes, hospital-level variation relative to total variation ranged between ≤1% and 15%, and given the high caseloads this typically yielded high reliability (>0.9). In contrast, physician-level variation components were typically ≤1%, with limited opportunities to make reliable comparisons. The impact of case-mix adjustment was limited, but nonnegligible.


      It is not typically possible to make reliable comparisons between physicians due to limited partitioned variation and low caseloads. For hospitals, however, the opposite often holds. Although variation-reduction efforts directed at hospitals are thus more likely to be successful, this should be approached cautiously, partly because level-specific variation and the impact of case-mix vary considerably across treatments and outcomes.

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