Between-Hospital and Between-Physician Variation in Outcomes and Costs in High- and Low-Complex Surgery: A Nationwide Multilevel Analysis

Nèwel Salet*, Vincent A Stangenberger, Rolf H Bremmer, Frank Eijkenaar

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

2 Downloads (Pure)


OBJECTIVES: Clinicians and policy makers are increasingly exploring strategies to reduce unwarranted variation in outcomes and costs. Adequately accounting for case mix and better insight into the levels 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.

METHODS: Variation was analyzed using 92 330 patient records collected from 62 Dutch hospitals who underwent surgery for colorectal cancer (n = 6640), urinary bladder cancer (n = 14 030), myocardial infarction (n = 31 870), or knee osteoarthritis (n = 39 790) in the period 2018 to 2019. Multilevel regression modeling with and without case-mix adjustment was used to partition variation in between-hospital and between-physician components for in-hospital mortality, intensive care unit 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.

RESULTS: 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.

CONCLUSIONS: It is not typically possible to make reliable comparisons among physicians due to limited partitioned variation and low caseloads. Nevertheless, for hospitals, 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.

Original languageEnglish
Pages (from-to)536-546
Number of pages11
JournalValue in Health
Issue number4
Publication statusE-pub ahead of print - 25 Nov 2022

Bibliographical note

Copyright © 2023 International Society for Pharmacoeconomics and Outcomes Research, Inc. Published by Elsevier Inc. All rights reserved.


Dive into the research topics of 'Between-Hospital and Between-Physician Variation in Outcomes and Costs in High- and Low-Complex Surgery: A Nationwide Multilevel Analysis'. Together they form a unique fingerprint.

Cite this