More costly care for postoperative complications is associated with worse patient outcomes, according to a study published October 5 in JAMA Surgery.
Surgical complications are common and expensive adverse events, and have been increasingly targeted by quality initiatives, write Jason C. Pradarelli, MD, from Brigham and Women’s Hospital in Boston, Massachusetts, and colleagues. Such initiatives often aim to reduce complications and provide effective treatment when they do occur, but costs associated with rescuing patients from surgical complications have not been well studied.
“A more nuanced understanding of the costs of perioperative complications would help hospitals and policy makers better gauge cost efficiency with surgery to more appropriately incentivize high-quality, low-cost surgical care,” the authors write.
In the study, Dr Pradarelli and colleagues analyzed Medicare payments for patients undergoing four common procedures: abdominal aortic aneurysm repair, colectomy for cancer, pulmonary resection, and total hip replacement. They then compared payments for these procedures for patients without complications, those who died as a result of complications, and those who survived complications across hospitals. Payments from the day of admission for the surgery through 30 days postdischarge were included in the analysis.
As they expected, payments were higher for patients with complications than those without, and patients who survived complications had higher average payments than those who died after complications. Higher costs for survivors of complications were largely driven by readmissions and postacute care, the authors note.
However, when the authors examined the costs of rescuing patients from surgical complications across hospitals, they found large variations. Payments at the highest-cost hospitals were two- to threefold higher than those at the lowest-cost hospitals. This large cost variation was seen for all four conditions, with mean costs for abdominal aortic aneurysm repair of $60,456 for the high-cost-of-rescue hospitals vs $23,261 for the low-cost-of-rescue hospitals; $56,787 vs $22,853 for colectomy, $63,117 vs $21,325 for pulmonary resection, and $41,354 vs $19,028 for total hip replacement. All four comparisons were significantly different (P < .001 for each comparison).
Moreover, the high-cost hospitals did not deliver better patient outcomes. The hospitals that received the highest payments for rescuing patients with surgical complications also had higher rates of overall and serious surgical complications compared with the hospitals that received the lowest rescue-associated payments.
The authors note that rates of failure to rescue patients with surgical complications were comparable between the high- and low-payment hospitals for all four conditions. However 30-day mortality rates for patients after abdominal aortic aneurysm repair (relative risk [RR], 1.17; 95% confidence interval [CI], 1.03 – 1.32) and colectomy (RR, 1.11; 95% CI, 1.03 – 1.19) were higher at the high-cost facilities.
The results suggest that inefficient care for surgical complications greatly drives up costs, the authors conclude.
“Our finding that the lowest cost-of-rescue hospitals have 3-fold lower Medicare payments without sacrificing clinical quality highlights a potential target for surgical cost reduction,” the authors write.
They note that the findings may not be generalizable to patients who are not old enough to qualify for Medicare. The study also does not account for unreimbursed costs of care for hospitals.
However, the results may reassure individuals who were concerned that reimbursement strategies that reward more efficient care might erode surgical quality at more expensive hospitals, leading to poorer patient care.
“This analysis suggests that steering patients away from these hospitals has the potential to both lower Medicare spending and improve the safety of surgical care for patients,” they write.