Excess Costs Attributable to Postoperative Complications
VA Center for Health Quality, Outcomes and Economic Research. Medical Care Research and Review
(Impact Factor: 2.62).
05/2011; 68(4):490-503. DOI: 10.1177/1077558710396378
This article estimates excess costs associated with postoperative complications among inpatients treated in Veterans Health Administration (VA) hospitals. The authors conducted an observational study on 43,822 hospitalizations involving inpatient surgery in one of 104 VA hospitals during fiscal year 2007. Hospitalization-level cost regression analyses were performed to estimate the excess cost of each of 18 unique postoperative complications. The authors used generalized linear modeling techniques to account for the heavily skewed cost distribution. Costs were measured using an activity-based cost accounting system and complications were assessed based on medical chart review conducted by the VA 'National Surgical Quality Improvement Program. The authors found excess costs associated with postoperative complications ranging from $8,338 for "superficial surgical site infection" to $29,595 for "failure to wean within 24 hours in the presence of respiratory complications." The results obtained suggest that quality improvement efforts aimed at reducing postoperative complications can contribute significantly to lowering of hospital costs.
Available from: Jeanne M Farnan
- "Judgment about the appropriateness of surgery or anticipated postoperative outcomes is influenced by a variety of clinical and nonclinical factors. The risk of major complications after some operations is high, leading to prolonged duration of hospitalization and increased costs for affected patients , . Physicians are not very accurate in predicting surgical risk when using written vignettes of actual patients, and the additional knowledge of a risk score based on data from test results contained in the vignette does not importantly improve the accuracy of risk estimation . "
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Frailty is a predictor of poor outcomes following many types of operations. We measured thoracic surgeons' accuracy in assessing patient frailty using videos of standarized patients demonstrating signs of physical frailty. We compared their performance to that of geriatrics specialists.
We developed an anchored scale for rating degree of frailty. Reference categories were assigned to 31 videos of standarized patients trained to exhibit five levels of activity ranging from “vigorous” to “frail.” Following an explanation of frailty, thoracic surgeons and geriatrics specialists rated the videos. We evaluated inter-rater agreement and tested differences between ratings and reference categories. The influences of clinical specialty, clinical experience, and self-rated expertise were examined.
Inter-rater rank correlation among all participants was high (Kendall's W 0.85) whereas exact agreement (Fleiss' kappa) was only moderate (0.47). Better inter-rater agreement was demonstrated for videos exhibiting extremes of behavior. Exact agreement was better for thoracic surgeons (n = 32) than geriatrics specialists (n = 9; p = 0.045), whereas rank correlation was similar for both groups. More clinical years of experience and self-reported expertise were not associated with better inter-rater agreement.
Videos of standarized patients exhibiting varying degrees of frailty are rated with internal consistency by thoracic surgeons as accurately as geriatrics specialists when referenced to an anchored scale. Ratings were less consistent for moderate degrees of frailty, suggesting that physicians require training to recognize early frailty. Such videos may be useful in assessing and teaching frailty recognition.
Available from: Lee A Fleisher
- "In this study, we did not evaluate the impact of individual types of complications on financial performance or the preventability of different complications. Previous studies have demonstrated that certain complications are far more expensive to treat than others [20,21]. Additionally, certain complications may be far more difficult to prevent than others, whereas some complications may simply be inevitable because of the underlying disease burden of surgical patients. "
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ABSTRACT: When hospitals suffer financial losses when postoperative complications occur, they may have a direct financial incentive to initiate quality improvement programs. The purpose of this research was to determine the relationship between complications following open colectomy and hospital finances.
After obtaining Institutional Review Board approval, we conducted a retrospective chart review of 276 open colectomies performed at the Hospital of the University of Pennsylvania. The medical records were manually reviewed for complications that occurred within 30 days after surgery. Financial information, including total, fixed and variable costs, was obtained from the hospital's cost accounting database. Reimbursement assuming payment by Medicare was calculated. Differences in costs, reimbursements and total margins were analyzed.
Of 276 patient records reviewed, 61 (22%) of the patients experienced postoperative complications. When complications occurred, mean total costs increased from $23,101 to $48,180, fixed costs increased from $14,516 to $30,339 and variable costs increased from $8,535 to $17,848 (P < 0.001 for each comparison); the mean reimbursement increased from $23,231 to $35,651 (P < 0.001); and the total margin decreased from $131 to - $12,528 (P < 0.001). Complications were associated with a more than twofold increase in length of stay in the hospital. Multiple regression modeling indicated similar increases in each of the financial variables and length of stay as a result of postoperative complications. The impact of these complications on each outcome measure was similar in effect for patients in the matched subset of 100 patients.
Our results demonstrate a financial incentive for hospitals to investigate quality improvement measures to prevent postoperative complications and avoid the associated financial losses.
Available from: Christopher P Snowden
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ABSTRACT: The development of preoperative clinics and the increasing importance of the anaesthetist in the management of surgical risk have expanded the concept of preoperative optimization. This review will focus on the rationale and process for cost-effective preoperative optimization.
Postoperative morbidity, rather than mortality, is the most important surgical outcome in economic terms. Since preoperative comorbidity, in association with surgical complexity, is more predictive of hospital costs than the subsequent treatment of postoperative complications per se, preoperative optimization represents an appropriate economic target. Process management, including guidelines to reduce unnecessary investigations and specialist referrals and enhancing perioperative recovery, makes economical sense in the majority of patients who undergo noncardiac surgery with few complications. Preoperative optimization of a minority of high-risk surgical patients is also important given limited critical care resource. However, the evidence for specific optimization strategies in this latter group continues to evolve and requires further clarification in well designed trials.
The requirement for appropriate methods of risk stratification of surgical patients targeted at the reduction of postoperative morbidity, underpins the development of cost-effective preoperative optimization. Specific process-based and clinical measures may then be applied to the development of individualized perioperative care packages.
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