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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.