Cases with surgical complications cost more. Duh. Sounds like an oxymoron. Of course they cost more. But who is really paying attention?
An analysis of patients undergoing elective colorectal surgery showed 35% of patients developed at least one complication (Zoucas 2014). Complications increased hospital costs at least 2-fold, primarily due to increased length of stay and ICU costs. Largest costs were related to wound dehiscence and suture line failure requiring reoperation. In addition, if a patient required readmission because of a complication, costs were further substantially increased. Factors that increased complication rates were obesity, complexity of surgery, and factors related to the surgeon.
A study of surgical complications in cancer patients demonstrated a significant financial cost attributable to surgical complications (Short 2014). The researchers looked at the AHRQ PSI’s (patient safety indicators) in patients having 6 cancer surgeries: colectomy, rectal resection, esophagectomy, pancreatic resection, pneumonectomy, and pulmonary lobectomy. They found that the occurrence of one PSI increased the hospital cost by 20% for most types of surgery but for respiratory failure the costs increased 53-77%.
The authors note that, whether justified or not, there seems to be a higher tolerance for complications in patients with cancer undergoing surgery compared to patients with benign conditions. However, many complications in cancer patients may in fact be preventable or avoidable.
Post-op DVT or pulmonary embolism increased costs 28-37%. Certainly cancer is a significant risk factor for DVT/PE but that makes it even more imperative that appropriate prophylaxis be used in such patients. A decubitus increased costs 28-60%. Malnutrition or other factors related to cancer might make render such patients at greater risk for decubiti. But that just increases the need for appropriate surveillance and preventive measures.
Of course, in the current reimbursement system hospitals have little financial incentive to avoid surgical complications. Yes, such cases cost hospitals more but they also bill more in most cases. Researchers have demonstrated that for patients with Medicare and private insurance, hospitals actually reap higher contribution margins for cases with surgical complications (Eappen 2013). However, as we move to different reimbursement models (eg. accountable care organizations, bundled payments, global budgets, capitation and others) any savings from avoiding surgical complications should begin to accrue to someone other than the payors. So the financial incentive will be added to the moral imperative to improve care and avoid complications.
Zoucas E, Marie-Louise Lydrup M-L. Hospital costs associated with surgical morbidity after elective colorectal procedures: a retrospective observational cohort study in 530 patients. Patient Safety in Surgery 2014; 8: 2 (3 January 2014)
Short MN, Aloia TA, Ho V. The influence of complications on the costs of complex cancer surgery. Cancer 2014; 120(7): 1035–1041
Eappen S, Lane BH, Rosenberg B, et al. Relationship Between Occurrence of Surgical Complications and Hospital Finances. JAMA 2013; 309(15): 1599-1606
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