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Drivers of Inpatient Costs After Colorectal Surgery Within a Publicly Funded Healthcare System

Springer, Jeremy E. M.Sc., M.D.1; Doumouras, Aristithes G. M.P.H., M.D.1; Saleh, Fady M.P.H., M.D., F.R.C.S.C.2; Lee, Jennie M.D.1; Amin, Nalin M.D., C.C.F.P., F.R.C.S.C.1; Cadeddu, Margherita M.D., F.R.C.S.C.1; Eskicioglu, Cagla M.Sc., M.D., F.R.C.S.C.1; Hong, Dennis M.Sc., M.D., F.R.C.S.C.1

Diseases of the Colon & Rectum: June 2019 - Volume 62 - Issue 6 - p 747–754
doi: 10.1097/DCR.0000000000001309
Original Contributions: Socioeconomic
Denotes Associated Video Abstract
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BACKGROUND: The morbidity and mortality associated with colorectal resections are responsible for significant healthcare use. Identification of efficiencies is vital for decreasing healthcare cost in a resource-limited system.

OBJECTIVE: The purpose of this study was to characterize the short-term cost associated with all colon and rectal resections.

DESIGN: This was a population-based, retrospective administrative analysis.

SETTINGS: This analysis was composed of all colon and rectal resections with anastomosis in Canada (excluding Quebec) between 2008 and 2015.

PATIENTS: A total of 108,304 patients ≥18 years of age who underwent colon and/or rectal resections with anastomosis were included.

MAIN OUTCOME MEASURES: Total short-term inpatient cost for the index admission and the incremental cost of each comorbidity and complication (in 2014 Canadian dollars) were measured. Cost predictors were modeled using hierarchical linear regression and Monte Carlo Markov Chain estimation.

RESULTS: Multivariable regression demonstrated that the adjusted average cost of a 50-year–old man undergoing open colon resection for benign disease with no comorbidities or complications was $9270 ((95% CI, $7146–$11,624; p = <0.001). With adjustment for complications, laparoscopic colon resections carried a cost savings of $1390 (95% CI, $1682–$1099; p = <0.001) compared with open resections. Surgical complications were the main driver for increased cost, because anastomotic leaks added $9129 (95% CI, $8583–$9670; p = <0.001). Medical complications such as renal failure requiring dialysis ($16,939 (95% CI, $15,548–$18,314); p = <0.001) carried significant cost. Complications requiring reoperation cost $16,313 (95% CI, $15,739–$16,886; p = <0.001). The costliest complication cumulatively was reoperation, which exceeded $95 million dollars over the course of the study.

LIMITATIONS: Inherent biases associated with administrative databases limited this study.

CONCLUSIONS: Medical and surgical complications (especially those requiring reoperation) are major drivers of increased resource use. Laparoscopic colorectal resection with or without adjustment for complications carries a clear cost advantage. There is opportunity for considerable cost savings by reducing specific complications or by preoperatively optimizing select patients susceptible to costly complication. See Video Abstract at

1 Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada

2 Division of General Surgery, Department of Surgery, William Osler Health, Etobicoke, Ontario, Canada

Funding/Support: None reported.

Financial Disclosures: None reported.

Correspondence: Dennis Hong, M.Sc., M.D., F.R.C.S.C., Division of General Surgery, St Joseph’s Healthcare, Room G814, 50 Charlton Ave East, Hamilton, Ontario, Canada L8N 4A6. E-mail:

© 2019 The American Society of Colon and Rectal Surgeons