Relationship between occurrence of surgical complications and hospital finances.

IMPORTANCE: The effect of surgical complications on hospital finances is unclear. OBJECTIVE: To determine the relationship between major surgical complications and per-encounter hospital costs and revenues by payer type. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of administrative data for all inpatient surgical discharges during 2010 from a nonprofit 12-hospital system in the southern United States. Discharges were categorized by principal procedure and occurrence of 1 or more postsurgical complications, using International Classification of Diseases, Ninth Revision, diagnosis and procedure codes. Nine common surgical procedures and 10 major complications across 4 payer types were analyzed. Hospital costs and revenue at discharge were obtained from hospital accounting systems and classified by payer type. MAIN OUTCOMES AND MEASURES: Hospital costs, revenues, and contribution margin (defined as revenue minus variable expenses) were compared for patients with and without surgical complications according to payer type. RESULTS: Of 34,256 surgical discharges, 1820 patients (5.3%; 95% CI, 4.4%-6.4%) experienced 1 or more postsurgical complications. Compared with absence of complications, complications were associated with a $39,017 (95% CI, $20,069-$50,394; P < .001) higher contribution margin per patient with private insurance ($55,953 vs $16,936) and a $1749 (95% CI, $976-$3287; P < .001) higher contribution margin per patient with Medicare ($3629 vs $1880). For this hospital system in which private insurers covered 40% of patients (13,544), Medicare covered 45% (15,406), Medicaid covered 4% (1336), and self-payment covered 6% (2202), occurrence of complications was associated with an $8084 (95% CI, $4903-$9740; P < .001) higher contribution margin per patient ($15,726 vs $7642) and with a $7435 lower per-patient total margin (95% CI, $5103-$10,507; P < .001) ($1013 vs -$6422). CONCLUSIONS AND RELEVANCE: In this hospital system, the occurrence of postsurgical complications was associated with a higher per-encounter hospital contribution margin for patients covered by Medicare and private insurance but a lower one for patients covered by Medicaid and who self-paid. Depending on payer mix, many hospitals have the potential for adverse near-term financial consequences for decreasing postsurgical complications.

An Apgar score for surgery.

BACKGROUND: Surgical teams have not had a routine, reliable measure of patient condition at the end of an operation. We aimed to develop an Apgar score for the field of surgery, an outcomes score that teams could calculate at the end of any general or vascular surgical procedure to accurately grade a patient's condition and chances of major complications or death. STUDY DESIGN: We derived our surgical score in a retrospective analysis of data from medical records and the National Surgical Quality Improvement Program for 303 randomly selected patients undergoing colectomy at Brigham and Women's Hospital, Boston. The primary outcomes measure was incidence of major complication or death within 30 days of operation. We validated the score in two prospective, randomly selected cohorts: 102 colectomy patients and 767 patients undergoing general or vascular operations at the same institution. RESULTS: A 10-point score based on a patient's estimated amount of blood loss, lowest heart rate, and lowest mean arterial pressure during general or vascular operations was significantly associated with major complications or death within 30 days (p < 0.0001; c-index = 0.72). Of 767 general and vascular surgery patients, 29 (3.8%) had a surgical score

Risk and patterns of secondary complications in surgical inpatients.

IMPORTANCE: Little empirical evidence exists on how a first (index) complication influences the risk of specific subsequent secondary complications. Understanding these risks is important to elucidate clinical pathways of failure to rescue or death after postoperative complication. OBJECTIVE: To understand patterns of secondary complications in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). DESIGN, SETTING, AND PARTICIPANTS: Matched analysis using a cohort of 890 604 patients undergoing elective inpatient surgery from January 1, 2005, through December 31, 2011, identified in the NSQIP Participant Use Data File. Five index complications were studied: pneumonia, acute myocardial infarction, deep space surgical site infection, bleeding or transfusion event, and acute renal failure. Each patient with an index complication was matched to a control patient based on propensity for the index event and the number of event-free days. Outcomes were compared using conditional logistic regression. MAIN OUTCOMES AND MEASURES: Rates of 30-day secondary complications and 30-day mortality. RESULTS: Five cohorts were developed, each with 1:1 matching to controls, which were well balanced. Index pneumonia (n = 7947) was associated with increased odds of 30-day reintubation (odds ratio [OR], 17.1; 95% CI, 13.8-21.3; P < .001), ventilatory failure (OR, 15.9; 95% CI, 12.8-19.8; P < .001), sepsis (OR, 7.3; 95% CI, 6.2-8.6; P < .001), and shock (OR, 13.0; 95% CI, 10.4-16.2; P < .001). Index acute myocardial infarction was associated with increased rates of secondary bleeding or transfusion events (OR, 4.3; 95% CI, 3.3-5.8; P < .001), pneumonia (OR, 5.1; 95% CI, 2.6-10.2; P < .001), cardiac arrest (OR, 12.0; 95% CI, 7.5-19.2; P < .001), and reintubation (OR, 11.7; 95% CI, 8.4-16.3; P < .001). Deep space surgical site infection was associated with dehiscence (OR, 30.4; 95% CI, 19.9-46.5; P < .001), sepsis (OR, 13.1; 95% CI, 10.2-16.7; P < .001), shock (OR, 10.6; 95% CI, 6.4-17.7; P < .001), kidney injury (OR, 8.6; 95% CI, 3.9-18.8; P < .001), and acute renal failure (OR, 10.5; 95% CI, 3.8-29.3; P < .001). Index acute renal failure was associated with increased odds of cardiac arrest (OR, 25.3; 95% CI, 9.3-68.6; P < .001), reintubation (OR, 11.3; 95% CI, 7.4-17.1; P < .001), ventilatory failure (OR, 12.4; 95% CI, 8.2-18.8; P < .001), bleeding or transfusion events (OR, 11.3; 95% CI, 6.3-20.5; P < .001), and shock (OR, 11.2; 95% CI, 7.2-17.3; P < .001). CONCLUSIONS AND RELEVANCE: This investigation quantified the effect of index complications on patient risk of specific secondary complications. The defined pathways merit investigation as unique targets for quality improvement and benchmarking.

Failure to rescue in safety-net hospitals: availability of hospital resources and differences in performance.

IMPORTANCE: Failure to rescue (FTR), the mortality rate among surgical patients with complications, is an emerging quality indicator. Hospitals with a high safety-net burden, defined as the proportion of patients covered by Medicaid or uninsured, provide a disproportionate share of medical care to vulnerable populations. Given the financial strains on hospitals with a high safety-net burden, availability of clinical resources may have a role in outcome disparities. OBJECTIVES: To assess the association between safety-net burden and FTR and to evaluate the effect of clinical resources on this relationship. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort of 46,519 patients who underwent high-risk inpatient surgery between January 1, 2007, and December 31, 2010, was assembled using the Nationwide Inpatient Sample. Hospitals were divided into the following 3 safety-net categories: high-burden hospitals (HBHs), moderate-burden hospitals (MBHs), and low-burden hospitals (LBHs). Bivariate and multivariate analyses controlling for patient, procedural, and hospital characteristics, as well as clinical resources, were used to evaluate the relationship between safety-net burden and FTR. MAIN OUTCOMES AND MEASURES: FTR. RESULTS: Patients in HBHs were younger (mean age, 65.2 vs 68.2 years; P = .001), more likely to be of black race (11.3% vs 4.2%, P < .001), and less likely to undergo an elective procedure (39.3% vs 48.6%, P = .002) compared with patients in LBHs. The HBHs were more likely to be large, major teaching facilities and to have high levels of technology (8.6% vs 4.0%, P = .02), sophisticated internal medicine (7.7% vs 4.3%, P = .10), and high ratios of respiratory therapists to beds (39.7% vs 21.1%, P < .001). However, HBHs had lower proportions of registered nurses (27.9% vs 38.8%, P = .02) and were less likely to have a positron emission tomographic scanner (15.4% vs 22.0%, P = .03) and a fully implemented electronic medical record (12.6% vs 17.8%, P = .03). Multivariate analyses showed that HBHs (adjusted odds ratio, 1.35; 95% CI, 1.19-1.53; P < .001) and MBHs (adjusted odds ratio, 1.15; 95% CI, 1.05-1.27; P = .005) were associated with higher odds of FTR compared with LBHs, even after adjustment for clinical resources. CONCLUSIONS AND RELEVANCE: Despite access to resources that can improve patient rescue rates, HBHs had higher odds of FTR, suggesting that availability of hospital clinical resources alone does not explain increased FTR rates.