Putting the Value Framework to Work in Surgery Kenan W Yount, MD, Florence E Turrentine, RN, PhD, Christine L Lau, MD, R Scott Jones, MD, FACS BACKGROUND: Health policy experts have proposed a framework defining value as outcomes achieved per dollar spent on health care. However, few institutions quantify their delivery of care along these dimensions. Our objective was to measure the value of our surgical services over time. STUDY DESIGN: We reviewed the data of patients undergoing general and vascular surgery from 2002 through 2012 at a tertiary care university hospital as abstracted by the American College of Surgeons NSQIP. Morbidity and mortality data from the American College of Surgeons NSQIP data- base were risk adjusted to calculate observed-to-expected ratios, which were then inverted into a numerator as a surrogate for quality. Costs, the denominator of the value equation, were determined for each patient’s hospitalization. The ratio was then transformed by a constant and analyzed with linear regression to analyze and compare values from 2002 through 2012. RESULTS: A total of 25,453 patients met criteria for inclusion. Overall, the value of surgical services increased from 2002 through 2012. The observed increase in value was greater in general sur- gery than in vascular surgery, and value actually decreased in vascular procedures. Although there was a similar increase in outcomes in vascular surgery compared with general surgery, costs rose significantly higher ($474/year vs À$302/year; p < 0.001). These increased costs were mostly observed from 2006 through 2010 with the adoption of endovascular technology. CONCLUSIONS: Despite the challenges posed by current information systems, calculating risk-adjusted value in surgical services represents a critical first step for providers seeking to improve outcomes, avoid ill-advised cost containment, and determine the costs of innovation. (J Am Coll Surg 2015;220:596e604. Ó 2015 by the American College of Surgeons) The vexing problem of escalating American health care costs has challenged health policy experts for the past 4 de- cades. Reform efforts highlighting issues of access, safety, quality, and cost have failed to decrease health care cost because they fail to comprehend the dysfunctional cost shifting and conflicting incentives among payers, pro- viders, insurers, and regulators. 1 In this context, a focus on increasing value, defined as the improvement in health outcomes achieved per dollar spent, emerged as a concept that can unite all stakeholders. 2 However, the current health care system remains ill equipped to embrace the concept of value because the fee- for-service model rewards volume of service provided rather than the value of services. 3 Current pay-for-performance schemes seeking to mitigate volume growth primarily focus on process compliance or “best practices,” that is, inputs and tactics rather than results. 4 Even obvious outcomes remain obscured in free text of electronic medical records. 2 Costing systems currently support clinician and hospital billing for reimbursement and neglect the measure of resource use. 5 For these reasons, value remains a theoretical rather than a practical goal. Surgically treated diseases provide a logical opportunity to develop and implement the value framework. The availability of preoperative, intraoperative, and postopera- tive data permits risk-adjusted quantification of treatment outcomes. Taking advantage of such data, the Veterans Administration Health System, the Society of Thoracic Surgeons, and the American College of Surgeons (ACS) have each developed and maintained robust surgical quality-improvement programs ripe for developing sys- tems to focus on value. 1 First-step efforts to measure value must begin by relying on simple surrogate quality measures, then improving the methods with continued use and refine- ment. In this investigation, we developed measures of Disclosure Information: Nothing to disclose. Disclosures outside the scope of this work: Dr Lau is a paid member of an Ethicon advisory board, is a paid consultant for Vitrolife, receives pay as a legal consultant giving expert testimony, and received a grant from Pfizer (#WS2231368). Presented at the Southern Surgical Association 126th Annual Meeting, Palm Beach, FL, November 30eDecember 3, 2014. Received December 17, 2014; Accepted December 17, 2014. From the Department of Surgery, University of Virginia, Charlottesville, VA. Correspondence address: R Scott Jones, MD, FACS, Department of Sur- gery, University of Virginia, Box 800709, Charlottesville, VA 22908. email: rsj@virginia.edu 596 ª 2015 by the American College of Surgeons Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jamcollsurg.2014.12.037 ISSN 1072-7515/15