The Impact of Complications on Costs of Major Surgery
The Impact of Complications on Costs of Major Surgery
Objective: To assess the impact of postoperative complications on full in-hospital costs per case.
Background: Rising expenses for complex medical procedures combined with constrained resources represent a major challenge. The severity of postoperative complications reflects surgical outcomes. The magnitude of the cost created by negative outcomes is unclear.
Patients and Methods: Morbidity of 1200 consecutive patients undergoing major surgery from 2005 to 2008 in a tertiary, high-volume center was assessed by a validated, complication score system. Full in-hospital costs were collected for each patient. Statistical analysis was performed using a multivariate linear regression model adjusted for potential confounders.
Results: This study population included 393 complex liver/bile duct surgeries, 110 major pancreas operations, 389 colon resections, and 308 Roux-en-Y gastric bypasses. The overall 30-day mortality rate was 1.8%, whereas morbidity was 53.8%. Patients with an uneventful course had mean costs per case of US$ 27,946 (SD US$ 15,106). Costs increased dramatically with the severity of postoperative complications and reached the mean costs of US$ 159,345 (SD US$ 151,191) for grade IV complications. This increase in costs, up to 5 times the cost of a similar operation without complications, was observed for all types of investigated procedures, although the magnitude of the increase varied, with the highest costs in patients undergoing pancreas surgery.
Conclusion: This study demonstrates the dramatic impact of postoperative complications on full in-hospital costs per case and that complications are the strongest indicator of costs. Furthermore, the study highlights a relevant savings capacity for major surgical procedures, and supports all efforts to lower negative events in the postoperative course.
Health care expenditures are increasing worldwide, and at a faster pace than in any other industry, and therefore are a leading focal point in the search for cost containment. In 2008, the United States spent US$ 2.3 trillion, which reflected 16.2% of the gross domestic product (GDP), 4.4% more than in 2007. There is a comparable situation in Switzerland, with expenditures for health care at almost US$ 60 billion, representing over 11.5% of the GDP in 2008. About 35% of total health care costs in Switzerland are generated by hospitals, and one third of those are generated by surgical departments. These rising expenses, combined with limited resources and a lack of clinical practice standards, have triggered the interest of health care payers (government or insurance) and providers to accurately measure the precise economic impact of quality of care delivery. In the surgical field, postoperative complications are the most sensitive surrogate marker for quality. As a prerequisite for a valuable quality-cost assessment, relevant data on outcomes, and on their respective cost, must be obtained in a standardized and reproducible manner.
Only a few relevant studies on cost relative to the quality of care are available in the surgical fields, all indicating that structure and process variables as well as postoperative complications genuinely influence the cost of a procedure. Such data are somewhat expected, but the magnitude of this impact remains obscure.
To further dissect the origin of costs, complete datasets require the description of the patient population, convincing documentation on the case mix of patients, and, importantly, standardization of the definition of the severity of postoperative complications. For analysis of cost assessment this data set needs to include solid cost reports that may vary from hospital to hospital and may depend on the bookkeeping system. A cost analysis within the same hospital might shed light on simple questions, eg, on the actual costs of surgical therapies and on the impact of complications, even though the absolute figures may change from hospital to hospital.
A few scoring systems of postoperative negative events are available and may offer new tools to calculate the economic impact of a procedure based on the severity of the postoperative course. We developed and validated a therapy-oriented complication score system ranking complications by severity into 5 grades.
Although the cost of a given surgical procedure and care can be determined fairly accurately, subsequent complications confound the cost estimation. The most appropriate and accurate—but also the most complex—method to track resource use and assign costs requires an accurate and detailed cost accounting system.
We designed a study to comprehensively assess the economic consequences of complications, following a variety of general surgical procedures, including hepato-pancreato-biliary (HPB) and colorectal as well as bariatric operations.
Abstract and Introduction
Abstract
Objective: To assess the impact of postoperative complications on full in-hospital costs per case.
Background: Rising expenses for complex medical procedures combined with constrained resources represent a major challenge. The severity of postoperative complications reflects surgical outcomes. The magnitude of the cost created by negative outcomes is unclear.
Patients and Methods: Morbidity of 1200 consecutive patients undergoing major surgery from 2005 to 2008 in a tertiary, high-volume center was assessed by a validated, complication score system. Full in-hospital costs were collected for each patient. Statistical analysis was performed using a multivariate linear regression model adjusted for potential confounders.
Results: This study population included 393 complex liver/bile duct surgeries, 110 major pancreas operations, 389 colon resections, and 308 Roux-en-Y gastric bypasses. The overall 30-day mortality rate was 1.8%, whereas morbidity was 53.8%. Patients with an uneventful course had mean costs per case of US$ 27,946 (SD US$ 15,106). Costs increased dramatically with the severity of postoperative complications and reached the mean costs of US$ 159,345 (SD US$ 151,191) for grade IV complications. This increase in costs, up to 5 times the cost of a similar operation without complications, was observed for all types of investigated procedures, although the magnitude of the increase varied, with the highest costs in patients undergoing pancreas surgery.
Conclusion: This study demonstrates the dramatic impact of postoperative complications on full in-hospital costs per case and that complications are the strongest indicator of costs. Furthermore, the study highlights a relevant savings capacity for major surgical procedures, and supports all efforts to lower negative events in the postoperative course.
Introduction
Health care expenditures are increasing worldwide, and at a faster pace than in any other industry, and therefore are a leading focal point in the search for cost containment. In 2008, the United States spent US$ 2.3 trillion, which reflected 16.2% of the gross domestic product (GDP), 4.4% more than in 2007. There is a comparable situation in Switzerland, with expenditures for health care at almost US$ 60 billion, representing over 11.5% of the GDP in 2008. About 35% of total health care costs in Switzerland are generated by hospitals, and one third of those are generated by surgical departments. These rising expenses, combined with limited resources and a lack of clinical practice standards, have triggered the interest of health care payers (government or insurance) and providers to accurately measure the precise economic impact of quality of care delivery. In the surgical field, postoperative complications are the most sensitive surrogate marker for quality. As a prerequisite for a valuable quality-cost assessment, relevant data on outcomes, and on their respective cost, must be obtained in a standardized and reproducible manner.
Only a few relevant studies on cost relative to the quality of care are available in the surgical fields, all indicating that structure and process variables as well as postoperative complications genuinely influence the cost of a procedure. Such data are somewhat expected, but the magnitude of this impact remains obscure.
To further dissect the origin of costs, complete datasets require the description of the patient population, convincing documentation on the case mix of patients, and, importantly, standardization of the definition of the severity of postoperative complications. For analysis of cost assessment this data set needs to include solid cost reports that may vary from hospital to hospital and may depend on the bookkeeping system. A cost analysis within the same hospital might shed light on simple questions, eg, on the actual costs of surgical therapies and on the impact of complications, even though the absolute figures may change from hospital to hospital.
A few scoring systems of postoperative negative events are available and may offer new tools to calculate the economic impact of a procedure based on the severity of the postoperative course. We developed and validated a therapy-oriented complication score system ranking complications by severity into 5 grades.
Although the cost of a given surgical procedure and care can be determined fairly accurately, subsequent complications confound the cost estimation. The most appropriate and accurate—but also the most complex—method to track resource use and assign costs requires an accurate and detailed cost accounting system.
We designed a study to comprehensively assess the economic consequences of complications, following a variety of general surgical procedures, including hepato-pancreato-biliary (HPB) and colorectal as well as bariatric operations.