Conference Coverage

How complications drive post-surgery spending upward


Key clinical point: Complications after major surgery are a huge driver of increasing post-acute care spending.

Major finding: Complications after major surgery that led to post-acute care increased costs by $4,083 for coronary artery bypass grafting, $4,049 for colectomy, and $1,742 for total hip replacement.

Data source: Cross-sectional cohort study of all Medicare beneficiaries who had coronary artery bypass graft (n = 281,940), colectomy (n = 189,229) and total hip replacement (n = 231,773) between January 2009 and June 2012.

Disclosures: Dr. Kanters and her coauthors reported having no financial disclosures.

Source: Kanters AE. Annual Academic Surgical Congress 2018.



– Post-hospital care after major surgery is a significant driver of overall surgery-related spending, and hospitals are focused on reducing this spending as payers move away from the fee-for-service model.

Post-acute care following complications after major surgery can add from $1,700 to more than $4,000 to the patient’s bill, with a trend toward utilizing more expensive inpatient post-acute care and less outpatient care, according to an analysis of more than 700,000 Medicare procedures presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Dr. Arielle E. Kanters

Dr. Arielle E. Kanters

“In medical populations, post-acute care use reflects some degree of discretionary practice variation among providers,” Arielle E. Kanters, MD, of the University of Michigan, Ann Arbor, said in a presentation of the results. “However, in surgical populations, discharge disposition is greatly impacted by postoperative complications. Given this relationship between complications and receipt of post-acute care services, it is likely that the quality of surgical care drives differences in post-acute care spending after surgery.”

This cross-sectional cohort study involved 707,943 cases in the Medicare database of coronary artery bypass grafting (CABG), colectomy, and total hip replacement (THR) from January 2009 to June 2012. The study found postoperative complication rates of 32% for CABG, 31% for colectomy, and 5% for THR. Postoperative complications resulted in an additional $4,083 spent on post-acute care following a CABG, an additional $4,049 after a colectomy, and an additional $1,742 after a THR.

This spending followed an increasing utilization of inpatient post-acute care and decreasing use of outpatient settings. “Relative to clinically similar patients with an uncomplicated course, patients who experienced a postoperative complication were more likely to utilize inpatient post-acute care than outpatient care,” Dr. Kanters said. For CABG, utilization rates of inpatient post-acute care increased 9.6% versus a decrease of 10.4% for outpatient post-acute care; for colectomy, inpatient post-acute care utilization increased 7.3% versus a drop of 6.2% for outpatient care; and for THR, inpatient post-acute care utilization rose 5.3% versus a drop of 2.4% for outpatient post-acute care. “The greatest impact is seen in the higher-risk procedures,” Dr. Kanters said.

The complications included cardiopulmonary complications, venous thromboembolism, renal failure, surgical site infections, and postoperative hemorrhage.

“Reductions in post-acute care spending will be central to hospitals’ efforts to reduce episode costs around major surgery,” Dr. Kanters said. “It is understood that complications are associated with increased cost, and this study helps quantify to what degree complications drive differences in spending on post-acute care.”

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