Excess Costs Attributable to Postoperative Complications
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.
[Show abstract] [Hide abstract] ABSTRACT: Background 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. Methods 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. Results 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. Conclusions 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.0Comments 1Citation
- "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 [1,2]. 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 . "
[Show abstract] [Hide abstract] 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.0Comments 3Citations
- "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. "
[Show abstract] [Hide abstract] ABSTRACT: This review of progress toward reliable prediction of postoperative pulmonary complications (PPCs) discusses risk assessment against the background of patient management strategies, clinical outcomes, and cost of healthcare. Among the variety of conditions grouped as PPCs are pneumonia, aspiration pneumonitis, respiratory failure, reintubation within 48 h, weaning failure, pleural effusion, atelectasis, bronchospasm, and pneumothorax. PPC incidence rates range from 2 to 40% depending on context. These events increase mortality, postoperative length of stay, ICU admissions, hospital readmissions, and costs. PPC-associated mortality varies, but can reach as high as 48% in some contexts. ICU admission rates are between 9.5 and 91% higher in patients with PPCs. The mean increase in PPC-related postoperative length of stay is approximately 8 days. The cost of surgery can be two-fold to 12-fold higher when PPCs develop. Strategies proposed to reduce the impact of modifiable risk factors include alcohol and smoking abstinence before surgery, shortening the duration of surgery, and physiotherapy and incentive spirometry techniques; however, little scientific evidence supports them at this time. PPCs are associated with a higher incidence of life-threatening events and higher costs. Reliable PPC risk-stratification tools are essential for guiding clinical decision-making in the perioperative period. The care team can act on modifiable factors and optimize vigilance over nonmodifiable ones. It would be useful to focus resources on determining whether low-cost preemptive interventions improve outcomes satisfactorily or new strategies need to be developed.0Comments 16Citations
- "A predictive model may define a composite PPC outcome as the dependent variable [13,14,18,22,24, 26,29,32,38,40,47,48] or it may focus on a particular complication, such as pneumonia [15,17,1939], or acute respiratory distress syndrome [34,36,51]. Some models have been developed with data from a large mixed surgical population, such as patients undergoing noncardiac surgeries [13,32, 34,35,37] or various thoracic , cardiac , or upper abdominal procedures [14,18,33]. Others focus on specific surgical settings, such as hyster- ectomy , partial hepatectomy [15,24] , pancrea- ticoduodenectomy [23 & ], colorectal surgery , esophagectomy , bariatric surgery  , uvulo- palatopharyngoplasty , spine surgery , transoral odontoidectomy and posterior fixation for craniovertebral junction  , microsurgical clipping of ruptured intracranial aneurysms , lower extremity amputation  , open infrarenal abdominal aortic aneurysm repair , lung resection [1,40,54], prostatectomy  , and radical cystec- tomy  . "