The Costs of Postoperative Complications After Major Abdominal Surgery: Opportunities and Challenges

Key Points

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Major abdominal surgery is associated with a high prevalence of complications.
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Postoperative complications are associated with increased hospital costs.
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Postoperative complications are associated with increased hospital length of stay.
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Minor complications (Clavien-Dindo grade I and II) are common and associated with a significant increase in costs.
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Preventing complications is a key target for cost containment.

Introduction

Cost-effective health care in the hospital setting is crucial for the sustainability of our health care system. With the rising costs of providing health care, governments and health care institutions need to consider the composition of cost expenditure. Internationally, health care expenditure has increased at a faster annual rate than economy growth, and now represents approximately 10% of global gross domestic product (GDP). On a global perspective, $7.2 trillion is estimated to be spent on health care annually, with 35%–40% of these costs attributed directly towards hospital costs. In some countries, hospital expenditure has been reported to represent more than 38% of total health care expenditure. Logically, hospital costs represent the single greatest economic target for reducing health care expenditure. Postoperative complications have been reported as being the strongest indicators of in-hospital costs. ^, While numerous mitigation strategies have aimed at reducing their occurrence, postoperative surgical complications remain common and are associated with both poorer health and cost outcomes.

In order to better understand opportunities for cost containment to reduce improvident spending, it is imperative to appreciate the hospital costs of complications following surgery. Given that major abdominal surgery is a commonly performed complex intervention of high acuity, with known risks of complications causing morbidity and mortality, we provide a contemporary overview of the drivers for hospital costs associated with major surgical procedures. Relevant to colonic, rectal, liver resection and pancreatic surgery, this chapter reviews (i) the costs of individual complications after surgery, (ii) the association of severity of complications and hospital costs, (iii) the costs associated with postoperative complications by surgical technique, (iv) the costs associated with postoperative complications by surgical urgency (emergency or elective), and (iv) the impact of complications on length of hospital stay and 30-day readmission rates.

A detailed search strategy was constructed based on the topic title and applied to EconLit MEDLINE, EMBASE, and The Cochrane Library. MeSH terms and free-text terms on costs, health economics, colonic, rectal, pancreatic and liver resections, and complications were used. Eligible studies had their data extracted into predetermined categories, which included study characteristics, procedure and surgical technique used, incidence of complications, their severity and mortality, length of stay, and 30-day readmission rates. All currencies were converted to a standardized form of $USD, taking into account inflation for the respective currency using a validated online application.

Rectal Resection Surgery

The incidence of complications ranged from 6.41% to 64.71%, with a consistent pattern that the presence of complications was associated with increased costs ( Fig. 59.1 ).

Open surgery may have a smaller additional cost based on depth of infection as compared with a laparoscopic approach, ^, and laparoscopy for a low anterior resection was associated with a decrease in complication (anastomotic leak, surgical site infection [SSI], and bleeding) rates and therefore costs. All studies that reported length of stay demonstrated that where complications occurred, the length of stay increased. The presence of complications was also associated with a higher mortality. The highest mortality rate reported was 4.9%. Only one study reported 30-day readmissions.

Colonic Resection Surgery

Postoperative complication incidence varied greatly between the studies ranging from 6.0% to 66.0%. This variance can be attributed to the different definitions of complications adopted by the studies with some studies reporting the incidence of specific complications, while others reported the incidence of any complication. The use of different hospital resource utilization measures amongst the studies restricted the ability to directly compare the study outcomes. Postoperative complications resulted in a substantial increase in hospital costs ( Fig. 59.2 ). The additional costs of complications varied from $2290 to $43,146 ; this is in part due to the heterogeneous definitions of hospital costs adopted by the different studies, as well as the different complication types reported. Asgeirsson et al. and Knechtle et al. further demonstrate a positive correlation between the number of complications and the additional cost incurred by the hospital.

Asgeirsson et al. and Fukuda et al. demonstrated increasing hospital resource use with increasing SSI severity. The additional cost of SSI increased from $24,563 to $33,211 if an SSI was classified as deep. Similarly, additional hospital charges for SSI in open colonic surgery increased from $995 for superficial SSI to $2155 and $2337 for deep and space/organ SSI, respectively. Similar increases in additional charges were evident in laparoscopic colonic surgery. Widmar et al. further explored the relationship between costs and complication severity by analyzing the impact of complication severity on Medicare reimbursements by utilizing the Clavien-Dindo classification. Thirty-day hospital reimbursements increased from $3756 for no complication to $5943 and $8119 for grade I and grade II complications, respectively. Grade I and grade II complications occurred at a prevalence of 29% and 49%, respectively. This highlights the high prevalence of minor complications and emphasizes the significant health care burden of minor complications on total hospital costs. Notably, there was an exponential rise in reimbursements to $18,270 for grade ≥III complications.

SSI and anastomotic leak were associated with the greatest financial burden amongst postoperative complications in colon resection surgery. The additional hospital cost of SSI varied greatly across studies from $2388 to $22,209, whereas the hospital cost of postoperative ileus remained relatively consistent across studies ranging from NZD $5486 to $7608. This significant variation in costs for SSI can be attributed to the geographic differences in health care system costs with the study by Phothong et al. being completed in Thailand, whereas the studies by Asgeirsson et al. and Delissovoy et al. were completed in the United States. Asgeirsson et al. was the only study directly comparing SSI with postoperative ileus demonstrating significantly higher additional costs in the presence of SSI $24,563 and deep SSI $33,211 than with postoperative ileus $5792. Anastomotic leak was shown to be associated with significant postoperative costs of $29,340 and $43,146. One study compared the impact of SSI and anastomotic leak on diagnosis related group (DRG)-based cost coverage and demonstrated a 2.6-fold greater decrease in cost coverage for SSI, as compared with anastomotic leak $8026 versus $3128, respectively. Postoperative complications in open surgery were shown to be associated with higher hospital costs than postoperative complications in laparoscopic surgery across all studies except Kashimura et al. In addition to greater hospital costs, the incidence of complications was consistently higher in open surgery, as compared with laparoscopic surgery. Postoperative complications in open surgery were observed to be associated with greater additional hospital charges than postoperative complications in laparoscopic surgery ^, ; however, the statistical significance of this association was not reported.

All studies demonstrated an increased hospital length of stay with postoperative complications, as compared with patients with an uncomplicated postoperative course. In addition, the greater the cumulative number of complications a patient experienced the greater their hospital length of stay. Increasing SSI severity is also associated with increased hospital length of stay. No study assessed the cost impact of length of stay. Three studies ^, ^, reported increased mortality rates associated with incidence of postoperative complications. No study reported the cost impact of mortality.

Phothong et al. demonstrated consistently higher costs with SSI, as compared with without SSI in all cost categories assessed except for anesthetic and instrument costs where the difference did not reach statistical significance. However, the greatest cost difference was in the combined cost of nursing, medication, laboratory, and radiology, which can be explained by the increased length of stay associated with SSI in this study. Wick et al. demonstrated consistently higher reimbursements with SSI, as compared with without SSI in inpatient, ambulatory, emergency department, home care, and pharmacy costs. The impact of surgical urgency on incidence and cost of complications is inconclusive across all studies. Fukuda et al. reported no statistical association between surgical urgency and risk of SSI. However, Asgeirsson et al. reported higher complication incidence and hospital costs with urgent/emergent admissions, as compared with elective admissions.

Liver Resection

The complication incidence across all studies varies between 7.6% and 73.2%. Despite variability in complication incidence, increasing costs with the occurrence of complications was a common finding across all studies ( Fig. 59.3 ) . All four studies that graded complications ^, demonstrated that costs increased along with severity of complications. The increase in cost due to major complications varied between $3282 and $64,677. The only exception was the group of patients experiencing minor complications following open resection in the study by Vanounou et al., where the cost was $1185 less than those without complications. Two studies ^, reported increasing costs with increasing number of complications, which supported the evidence across all studies of increasing costs with increasing complication incidence and severity.

Three studies reported the costs of mortality in addition to complications, with a consistent finding of greatly increased costs associated with mortality. In high-volume hospitals, Gani et al. reported a $30,102 increase in costs due to mortality compared with patients having complications and an increase of $70,633 compared with patients with an uncomplicated course. A similar finding was reported for low- and intermediate-volume hospitals. Lock et al. found patients dying following liver resection cost $88,379 more than patients who recovered, corresponding to findings by Idrees et al., which found an increased cost of $88,337 for mortality compared with those without complications. Lock et al. reported a $89,450 increase in costs as a result postoperative liver failure, which was the most expensive complication across the included studies. Additionally, 87.5% patients with postoperative liver failure died, highlighting the clinical cost of postoperative liver failure.

There was disagreement amongst the three studies reporting financial information by surgical technique. Cannon et al. reported mixed results, finding the laparoscopic and open techniques were equivocal for all patients aside those experiencing major complications. As only the open resection group experienced major complications, which carried a higher cost, the overall cost was $11,902 less for the laparoscopic group. Vanounou et al. supported this finding, reporting the overall cost for the laparoscopic group was $3198 less than the open group, and additionally laparoscopy without a hand-port was $3068 cheaper the hand-assisted technique. However, Fretland et al. found the overall costs of laparoscopic and open resection to be equivocal.

The cause of the disagreement is likely attributable to the heterogeneity amongst studies. Vanounou et al. and Fretland et al. included only minor resections, while Cannon et al. included both major and minor resections. Additionally, all three studies had varying selection criteria, and study design varied greatly between Fretland et al., a randomized controlled trial, and the two retrospective studies. ^,

Increased length of stay following the occurrence of complications was a consensus finding amongst the six studies ^, ^, ^, ^, ^, reporting the outcome. Additionally, Knechtle et al. demonstrated that length of stay increased as the number of complications increased. Only Idrees et al. described the financial impact associated with length of stay, reporting a mean incremental cost of $8929 (95% CI, $3321–14,536; P < 0.001) for patients exceeding a length of stay beyond 8 days. Fretland et al. was the only study to report the cost of readmission and did so in the context of laparoscopic versus open resection, reporting that the two techniques were equivocal in terms of readmission costs: $1886 (4869) versus $2027 (7490), P = 0.914. Knechtle et al. was the only study to report readmissions in terms of complications: rate of readmission increased from 5% for patients with no complications to 14.3% for patients with four or more complications.

Studies comparing the cost between major and minor resection showed an increased cost associated with major liver resection. ^, Only Idrees et al. drew a direct comparison, reporting a mean incremental cost of $15,291 (95% CI, $5272–$25,310; P < 0.001) for hemi-hepatectomy, compared with a partial resection. Cannon et al. reported an increased cost of $11,709 for the laparoscopic right hepatectomy subgroup, in comparison to the entire cohort, although found that open resection was $1536 cheaper for the right hepatectomy subgroup. No statistical analysis was included for this comparison. In the two studies, ^, including only minor resections, both had lower total cost than the major resection groups of Idrees et al. and Cannon et al. However, given the heterogeneity of different hospital and economic environments, comparison across studies was difficult.

Pancreatic Resection

The incidence of complications after pancreaticoduodenectomy has been previously reviewed and ranged from 38% to 77%. The distribution of minor and moderate–major complications, defined as Clavien-Dindo I or II and Clavien-Dindo III or above, respectively, was heterogeneous among included studies. Notably deviant results include the studies by Topal et al. and Santema et al. These results can be explained by the utility of modified Clavien-Dindo systems. The incidence of postoperative pancreatic fistula (POPF) was similarly heterogeneous between cohorts, with overall incidence ranging from 7.9% to 36.8%. The incidence of delayed gastric emptying varied between studies. Brown et al. reported an overall incidence of 14.6% in their cohort, while Eisenberg et al. ⁴⁷ reported a 19.4% incidence of delayed gastric emptying. According to the International Study Group of Pancreatic Surgery criteria for delayed gastric emptying, 55.7% were grade A, 25.7% were grade B, and 18.6% were grade C. Santema et al. found isolated delayed gastric emptying occurred at an incidence of 18%, compared with 12.2% in Eisenberg’s primary delayed gastric emptying group.

A consistent finding across all included studies is the substantial increase of hospital cost with complications, and when applicable, the severity of the complication. Costs were generally higher in North American and European studies compared with Asian studies. Cost stratification according to Clavien-Dindo or similar systems was available in four studies. ^, ^, ^, The development of major complications (Clavien-Dindo grade III or above) led costs to more than double compared with uncomplicated patients in multiple studies. ^, ^, ^, Vanounou et al. found that major deviations from the expected postoperative course after clinical pathway implementation cost $65,361 compared with $23,868 for uncomplicated patients. Similarly, Enestvedt et al. found that patients with a major complication cost $64,898 compared with $33,518. Cecka et al. was the only study reporting full cost data for each severity grade, and interestingly found only a small cost increase from no complications ($5147) to grade III complications ($8415), yet a substantial increase when a grade IV complication occurred ($39,464). This may reflect the relative costs of performing a procedure for a grade III complication compared with ICU stay with a grade IV complication.

Pancreatic fistula was the most commonly studied complication, with its impact on costs analyzed in eight studies. ^, ^, The vast financial consequences of POPF have once again been shown in the included studies, with an incremental burden according to severity. Studies that analyzed hospital costs, not charges, of POPF are displayed in Fig. 59.4 . Clinically insignificant fistulas, also known as “transient fistulas” and classified as grade A, were found across our studies to contribute little to patients’ hospital costs. Grade B and C fistulas, however, had significant clinical burden among the included articles. Daskalaki et al. found that grade B and C fistulas had total hospital costs of $32,657 and $75,601, compared with patients without fistulas ($12,282). Similarly, Vanounou et al. found patients with grade B and C fistulas had costs of $39,466 and $145,939 compared with $23,557 in patients without POPF. Huang et al. found that patients with a clinically relevant POPF had a hospital charge of $14,077 compared with $10,601 in patients without. Goyert et al. reported that patients with clinically relevant POPF cost $70,819 compared with $33,562 in patients without.