Complications and costs after high-risk surgery: Where should we focus quality improvement initiatives?

• Published in: Journal of the American College of Surgeons Vol. 196; no. 5; pp. 671 - 678
• Main Authors: DIMICK, Justin B, PRONOVOST, Peter J, COWAN, John A, LIPSETT, Pamela A
• Format: Conference Proceeding Journal Article
• Language: English
• Published: New York, NY Elsevier Science 01.05.2003
• Subjects: Biological and medical sciences; Esophagectomy - adverse effects; Esophagectomy - economics; Esophagectomy - mortality; Female; Health Resources - economics; Health Resources - utilization; Hepatectomy - adverse effects; Hepatectomy - economics; Hepatectomy - mortality; Hospital Costs - statistics & numerical data; Hospital Mortality; Humans; Incidence; Length of Stay - economics; Male; Maryland - epidemiology; Medical sciences; Middle Aged; Miscellaneous; Multivariate Analysis; Patient Discharge - statistics & numerical data; Postoperative Complications - economics; Postoperative Complications - epidemiology; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Total Quality Management; Maryland; Human; Postoperative; High risk; Q factor; Health economy; Surgery; Complication; Selection criterion; Technique; Cost efficiency analysis; Incidence
• ISSN: 1072-7515; 1879-1190
• DOI: 10.1016/s1072-7515(03)00122-4

Data on the relative clinical and economic impact of postoperative complications are needed in order to direct quality improvement efforts. Patients undergoing two high-risk surgical procedures, hepatectomy (n = 569) and esophagectomy (n = 366), from 1994 to 1998 were included. Data were abstracted from the Maryland hospital discharge database. Relative resource use was determined using median regression, adjusting for patient comorbidities and other case-mix variables. A total of 935 patients were studied. Overall in-hospital mortality was 6.1%; complication rate was 38.4%. Median cost for all patients was $14,527 (interquartile range $10,936-$21,412) and length of stay 9 days (interquartile range 7-13 days). Median hospital cost was increased for patients with complications ($16,868 versus $12,861; p < 0.001). In the multivariate analysis, several complications remained associated with increased cost. Acute renal failure ($25,219), septicemia ($18,852), and myocardial infarction ($9,573) were associated with the greatest increase in resource use. But because the incidence of each complication varies, the attributable fraction of total resource use was highest for acute renal failure (19%), septicemia (16%), and surgical complications (16%). Complications are independently associated with increased resource use after high-risk surgery. Population-based studies may be valuable in determining the relative economic importance of postoperative complications. Quality improvement efforts for these complications should be prioritized based on both the incidence of the complication and its independent contribution to increased resource use.