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What’s New in the Patient Safety World

March 2021

The Fiscal Costs of Delirium



A lot has been written about the human costs of delirium. But there is also a significant financial impact of delirium. A couple recent articles have attempted to quantify those costs.


Gou and colleagues prospectively analyzed almost 500 elderly patients undergoing major elective surgery in the Successful Aging after Elective Surgery (SAGES) study (Gou 2021). During the index hospitalization, 122 patients (25%) developed postoperative delirium, whereas 375 (75%) did not (note: we were surprised that percentages of patients having post-op delirium were not even higher).


Mean health care costs for patients with delirium compared to those without delirium were: $146,358 vs $94,609. After adjusting for relevant confounders, the cumulative health care costs attributable to delirium were $44,291 per patient per year, with the majority of costs coming from the first 90 days. Breakout of those attributable costs were $20,327 for the index hospitalization, $27,797 for subsequent rehospitalizations, and $2,803 for postacute rehabilitation stays.


The authors also rated the severity of delirium, using the Confusion Assessment Method–Severity long form. Health care costs increased directly and significantly with level of delirium severity (none-mild $83,534, moderate $99,756, severe $140,008). Overall, the adjusted mean cumulative costs attributable to severe delirium were $56,474 per patient per year.


If their findings were extrapolated nationally, the health care costs attributable to postoperative delirium were estimated at $32.9 billion per year. The authors note that these costs rival those associated with cardiovascular disease and diabetes and identify postoperative delirium as a large-scale public health issue.


Another study (Boone 2020) included delirium in the larger category of postoperative neurocognitive disorders (PND’s). A PND was defined as a diagnosis of delirium, mild cognitive impairment, or dementia within 1 year of discharge from the index surgical admission. The primary outcome was total inflation-adjusted Medicare postacute care payments within 1 year after the index surgical procedure. Eligible for the study were all Medicare patients aged 65 years or older who underwent an inpatient hospital admission associated with a surgical procedure, who did not experience a PND before index admission. Patients on dialysis and those concurrently enrolled in Medicaid were excluded.  Of 2,380 473 patients who underwent surgical procedures, 1.9% were diagnosed with a PND.


Patients with a PND, compared with those without a PND, experienced a significantly longer hospital length of stay (mean 5.91 days vs 4.29 days), were less likely to be discharged home (22.1% vs 39.2%), and had a higher incidence of mortality at 1 year after treatment (10.2% vs 4.4%). After adjusting for patient and hospital characteristics, the presence of a PND within 1 year of the index procedure was associated with an increase of $17,275 in cost in the 1-year postadmission period.


This association was driven largely by differences in skilled nursing care costs during the 1 year following the index surgical procedure. Payments made during the index hospital admission for patients with PND were also higher than for those without PND. Episode and acute care payments for the inpatient stay tied to their index surgical admission were associated with an increase (median $50,63 for those with a PND compared $26,587 for those without a PND).


In our August 17, 2010 Patient Safety Tip of the Week “Preoperative Consultation – Time to Change” we recommended that assessment for delirium risk should be one of the 3 most important considerations in pre-operative assessments (the other 2 being assessment for obstructive sleep apnea and frailty).


Delirium, of course, does not just occur in patients undergoing surgery. The incidence of delirium is significant in patients hospitalized for medical conditions, particularly those requiring stays in the ICU. We would expect that the attributable cost of delirium in those medical patients would likely be comparable to those having postoperative delirium.


We agree with the authors of both studies that delirium is a significant public health issue that adds considerably to our nation’s health care cost burden. The editorial accompanying the Gou study (Katlic 2021) points out that the surgical community has begun to recognize the significant human and financial impact of delirium and calls attention to the American College of Surgeons Geriatric Surgery Verification Program, which we discussed in our September 17, 2019 Patient Safety Tip of the Week “American College of Surgeons Geriatric Surgery Verification Program”.



Some of our prior columns on delirium assessment and management:


·       February 12, 2019 “2 ER Drug Studies: Reassurances and Reservations”

·       September 17, 2019 “American College of Surgeons Geriatric Surgery Verification Program”






Gou RY, Hshieh TT, Marcantonio ER, et al. One-Year Medicare Costs Associated With Delirium in Older Patients Undergoing Major Elective Surgery. JAMA Surg 2021; Published online February 24, 2021



Boone MD, Sites B, von Recklinghausen FM, Mueller A, Taenzer AH, Shaefi S. Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients. JAMA Netw Open 2020; 3(7): e208931



Katlic MR, Robinson TN. The Costs of Postoperative Delirium. JAMA Surg 2021; Published online February 24, 2021



ACS (American College of Surgeons). Geriatric Surgery Verification Program





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