Secondary Logo

Institutional members access full text with Ovid®

Share this article on:

The Comprehensive Complication Index (CCI®) is a Novel Cost Assessment Tool for Surgical Procedures

Staiger, Roxane D., MD*; Cimino, Matteo, MD; Javed, Ammar, MD; Biondo, Sebastiano, MD, PhD§; Fondevila, Constantino, MD, PhD; Périnel, Julie, MD||; Aragão, Ana Carolina, MD**; Torzilli, Guido, MD, PhD; Wolfgang, Christopher, MD, PhD; Adham, Mustapha, MD, PhD||; Pinto-Marques, Hugo, MD, PhD**; Dutkowski, Philipp, MD*; Puhan, Milo A., MD, PhD††; Clavien, Pierre-Alain, MD, PhD*

doi: 10.1097/SLA.0000000000002902

Objective: The aim of this study was to identify a readily available, reproducible, and internationally applicable cost assessment tool for surgical procedures.

Summary of Background Data: Strong economic pressure exists worldwide to slow down the rising of health care costs. Postoperative morbidity significantly impacts on cost in surgical patients. The comprehensive complication index (CCI®), reflecting overall postoperative morbidity, may therefore serve as a new marker for cost.

Methods: Postoperative complications and total costs from a single tertiary center were prospectively collected (2014 to 2016) up to 3 months after surgery for a variety of abdominal procedures (n = 1388). CCI® was used to quantify overall postoperative morbidity. Pearson correlation coefficient (r pears) was calculated for cost and CCI®. For cost prediction, a linear regression model based on CCI®, age, and type of surgery was developed and validated in an international cohort of patients.

Results: We found a high correlation between CCI® and overall cost (r pears = 0.75) with the strongest correlation for more complex procedures. The prediction model performed very well (R 2 = 0.82); each 10-point increase in CCI® corresponded to a 14% increase to the baseline cost. Additional 12% of baseline cost must be added for patients older than 50 years, or 24% for those over 70 years. The validation cohorts showed a good match of predicted and observed cost.

Conclusion: Overall postoperative morbidity correlates highly with cost. The CCI® together with the type of surgery and patient age is a novel and reliable predictor of expenses in surgical patients. This finding may enable objective cost comparisons among centers, procedures, or over time obviating the need to look at complex country-specific cost calculations (

*Department of Surgery and Transplantation, University Hospital of Zurich, Zurich, Switzerland

Department of Surgery & Division of Hepatobiliary and General Surgery, Humanitas Research Hospital, Milan, Italy

Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA

§Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain

Department of Surgery, Hospital Clinic de Barcelona, Barcelona, Spain

||Department of General and Digestive Surgery, University Hospital of Lyon, Lyon, France

**Hepato-Biliary-Pancreatic and Transplantation Centre, Curry Cabral Hospital, CHLC, Lisbon, Portugal

††Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.

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

Milo A. Puhan and Pierre-Alain Clavien shared senior authorship.

This study is supported by LGID (Liver and Gastrointestinal Disease) Foundation, Zurich, Switzerland and the Clinical Research and Priority Program “Liver tumors” from the University of Zurich, Switzerland (to P.-A. Clavien).

R.D. Staiger is a recipient of a grant/research funding from the Olga Mayenfish Foundation, Zurich, Switzerland.

The authors have no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.