Longitudinal Trends in Efficiency and Complexity of Surgical Procedures: Analysis of 1.7 Million Operations Between 2019 and 2023

BACKGROUND: The Centers for Medicare & Medicaid Services has proposed reducing the work relative value unit valuations for most surgical procedures by 2. 5% through an efficiency adjustment based on the assumption that surgical work and operative length have decreased over time. Whether the length and complexity of surgical procedures have decreased or increased is unknown. Empirical data on trends in surgical length and complexity are needed to guide evidence-based regulations by federal policymakers. STUDY DESIGN: The NSQIP registry was analyzed in 2019 and 2023. Analysis was performed at the CPT level and limited to codes with at least 1, 000 underlying cases. The primary outcome was surgical efficiency, defined as skin-to-skin operative time. Secondary outcomes were measures of patient complexity, including preoperative risk factors (eg age, comorbidities) and 30-day morbidity and mortality. RESULTS: The sample included 1, 704, 311 operations across 249 CPT codes and 11 surgical specialties. Collectively, these codes accounted for 3. 2B in fee-for-service Medicare spending in 2023. Overall, operative times increased by 3. 1% (95% CI 3. 0% to 3. 3%, p < 0. 001) in 2023 compared with 2019, or 0. 8% per year (95% CI 0. 7% to 0. 8% per year, p < 0. 001). At the procedure level, 90% of CPT codes had longer or similar operative times in 2023 compared with 2019. Statistically, all measures of complexity also increased during the study time period, without a change in operative mortality. CONCLUSIONS: For the majority of surgical procedures, operative times have stayed the same or increased from 2019 to 2023. Patient complexity also correspondingly increased. The rationale for an efficiency adjustment to the Medicare physician fee schedule for surgical procedures is not supported by objective data from a national surgical registry.