Variation in Medicare Expenditures for Treating Perioperative Complications: The Cost of Rescue

• Published in: JAMA surgery Vol. 151; no. 12; p. e163340
• Main Authors: Pradarelli, Jason C, Healy, Mark A, Osborne, Nicholas H, Ghaferi, Amir A, Dimick, Justin B, Nathan, Hari
• Format: Journal Article
• Language: English
• Published: United States 21-12-2016
• Subjects: Aged; Aged, 80 and over; Aortic Aneurysm, Abdominal - surgery; Arthroplasty, Replacement, Hip - adverse effects; Colectomy - adverse effects; Failure to Rescue, Health Care - statistics & numerical data; Female; Health Expenditures - statistics & numerical data; Hospital Costs - statistics & numerical data; Humans; Insurance, Health, Reimbursement; Male; Medicare - economics; Medicare - statistics & numerical data; Pneumonectomy - adverse effects; Postoperative Complications - economics; Postoperative Complications - etiology; Postoperative Complications - therapy; Retrospective Studies; Survival Rate; United States
• ISSN: 2168-6262
• DOI: 10.1001/jamasurg.2016.3340

Treating surgical complications presents a major challenge for hospitals striving to deliver high-quality care while reducing costs. Costs associated with rescuing patients from perioperative complications are poorly characterized.
To evaluate differences across hospitals in the costs of care for patients surviving perioperative complications after major inpatient surgery.
Retrospective cohort study using claims data from the Medicare Provider Analysis and Review files. We compared payments for patients who died vs patients who survived after perioperative complications occurred. Hospitals were stratified using average payments for patients who survived following complications, and payment components were analyzed across hospitals. Administrative claims database of surgical patients was analyzed at hospitals treating Medicare patients nationwide. This study included Medicare patients aged 65 to 100 years who underwent abdominal aortic aneurysm repair (n = 69 207), colectomy for cancer (n = 107 647), pulmonary resection (n = 91 758), and total hip replacement (n = 307 399) between 2009 and 2012. Data analysis took place between November 2015 and March 2016.
Clinical outcome of surgery (eg, no complication, complication and death, or complication and survival) and the individual hospital where a patient received an operation.
Risk-adjusted, price-standardized Medicare payments for an episode of surgery. Risk-adjusted perioperative outcomes were also assessed.
The mean age for Medicare beneficiaries in this study ranged from 74.1 years (pulmonary resection) to 78.2 years (colectomy). The proportion of male patients ranged from 37% (total hip replacement) to 77% (abdominal aortic aneurysm repair), and most patients were white. Among patients who experienced complications, those who were rescued had higher price-standardized Medicare payments than did those who died for all 4 operations. Assessing variation across hospitals, payments for patients who were rescued at the highest cost-of-rescue hospitals were 2- to 3-fold higher than at the lowest cost-of-rescue hospitals for abdominal aortic aneurysm repair ($60 456 vs $23 261; P < .001), colectomy ($56 787 vs $22 853; P < .001), pulmonary resection ($63 117 vs $21 325; P < .001), and total hip replacement ($41 354 vs $19 028; P < .001). Compared with lowest cost-of-rescue hospitals, highest cost-of-rescue hospitals had higher risk-adjusted rates of serious complications with similar rates of failure to rescue and overall 30-day mortality.
After 4 selected inpatient operations, substantial variation was observed across hospitals regarding Medicare episode payments for patients rescued from perioperative complications. Notably, higher Medicare payments were not associated with improved clinical performance. These findings highlight the potential for hospitals to target efficient treatment of perioperative complications in cost-reduction efforts.