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The Impact of Complications on Costs of Major Surgical Procedures: A Cost Analysis of 1200 Patients

Vonlanthen, René MD*; Slankamenac, Ksenija MD*; Breitenstein, Stefan MD*; Puhan, Milo A. MD, PhD†,‡; Muller, Markus K. MD*; Hahnloser, Dieter MD*; Hauri, Dimitri; Graf, Rolf PhD*; Clavien, Pierre-Alain MD, PhD, FACS, FRCS*

doi: 10.1097/SLA.0b013e31821d4a43
Original Articles

Objective: To assess the impact of postoperative complications on full in-hospital costs per case.

Background: Rising expenses for complex medical procedures combined with constrained resources represent a major challenge. The severity of postoperative complications reflects surgical outcomes. The magnitude of the cost created by negative outcomes is unclear.

Patients and Methods: Morbidity of 1200 consecutive patients undergoing major surgery from 2005 to 2008 in a tertiary, high-volume center was assessed by a validated, complication score system. Full in-hospital costs were collected for each patient. Statistical analysis was performed using a multivariate linear regression model adjusted for potential confounders.

Results: This study population included 393 complex liver/bile duct surgeries, 110 major pancreas operations, 389 colon resections, and 308 Roux-en-Y gastric bypasses. The overall 30-day mortality rate was 1.8%, whereas morbidity was 53.8%. Patients with an uneventful course had mean costs per case of US$ 27,946 (SD US$ 15,106). Costs increased dramatically with the severity of postoperative complications and reached the mean costs of US$ 159,345 (SD US$ 151,191) for grade IV complications. This increase in costs, up to 5 times the cost of a similar operation without complications, was observed for all types of investigated procedures, although the magnitude of the increase varied, with the highest costs in patients undergoing pancreas surgery.

Conclusion: This study demonstrates the dramatic impact of postoperative complications on full in-hospital costs per case and that complications are the strongest indicator of costs. Furthermore, the study highlights a relevant savings capacity for major surgical procedures, and supports all efforts to lower negative events in the postoperative course.

The costs associated with a number of uneventful major surgical procedures are remarkably similar, but increase up to five times in the presence of a complicated course. The severity of the complications is the strongest indicator of overall cost and a target for improvement and monitoring.

*Department of Surgery

Horten Center for Patient Oriented Research, University Hospital Zurich, Zurich, Switzerland

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Reprints: Pierre-Alain Clavien, MD, PhD, FACS, FRCS, Department of Surgery, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland. E-mail:

Disclosure: Supported by the Liver and Gastro-Intestinal Diseases Foundation (LGID).

R.V. and K.S. contributed equally to this work.

© 2011 Lippincott Williams & Wilkins, Inc.