Attributable Incidence and Costs of Postoperative Pulmonary Complications Following Common Abdominal Surgical Procedures

Jonathan D Bloom, MD, Santosh J Agarwal, BPharm MS, Mary G Erslon, RN MS MBA, Douglas M Hansell, MD MPH, Ross D Segan, MD FACS. Covidien

Introduction: We hypothesized that Postoperative Pulmonary Complications (PPCs) are relatively common and may increase hospital costs significantly. The purpose of this study was to estimate the impact of PPCs on length of stay and total hospital costs following eight common abdominal surgical procedures. While the impact of PPCs on abdominal surgical outcomes has been examined in a number of smaller studies, there is no current estimate on the additional costs associated with PPCs.

Methods: We used the Premier Perspective® Database (Premier, Inc.) to identify adults who underwent either open or laparoscopic appendectomy, cholecystectomy, colectomy and Roux-en-Y gastric bypass in 2009. ICD-9-CM codes were used to identify patients with pulmonary complications. We compared the incidence of pulmonary complications, mortality rates, total hospitalization costs and hospital length of stay among open and laparoscopic procedures. Multivariate regression analysis was used to predict the total costs and length of stay, controlling for age, race, sex, geographic region, provider characteristics, APR severity, Charlson comorbidity index, malignant diagnosis, procedure type and PPC. National projections for the year 2009 were made using Premier supplied projection weights.

Results: There were 132,231 surgical discharges that met inclusion criteria. PPCs were present in 14,165 (10.7%) of discharges and were associated with 78.2% of all in-hospital postoperative deaths. PPCs were associated with significant increases for in-hospital mortality (0.9% vs. 9.3%, p<0.001). PPCs were more common after open surgical procedures than laparoscopic procedures (20.9% vs. 6.5%, p < 0.0001). After risk adjustment, PPCs were associated with significant increases in total costs ($26,683 vs. $20,430, p<0.001) and length of stay (9.7d vs. 7.7d, p<0.001). Projecting these numbers to national levels, there were 190,000 added hospital days, and $611 million in added costs attributable to PPCs after the eight procedures in 2009.

Economic outcomes of laparoscopic and open procedures, with and without PPCs
Procedure N % with PPC Adjusted mean total cost Adjusted mean length of stay (d)

All Laparoscopic

93,896 6.5% $21,916 $17,611 8.0 6.4
Lap Appendectomy 22,311 3.1% $16,619 $13,654 6.4 5.1
Lap Cholecystectomy 50,562 7.8% $18,883 $14,594 7.7 5.9
Lap Colectomy 11,316 9.4% $28,759 $24,013 10.9 9.5
Lap Roux-en-Y 9,636 4.4% $29,544 $26,056 8.6 7.5
All Open 38,335 20.9% $30,387 $22,347 11.3 9.1
Open Appendectomy 7,398 6.9% $21,374 $16,512 8.5 7.0
Open Cholecystectomy 6,334 18.9% $28,464 $20,451 11.0 8.4
Open Colectomy 22,929 26.3% $34,053 $25,524 13.1 10.9
Open Roux-en-Y 1,654 16.6% $34,232 $27,434 12.5 11.5
TOTAL 132,231 10.7% $26,683 $20,430 9.7 7.7

P-values for differences between adjusted costs and LOS were <0.0001, except for Open Roux-en-Y (0.0003 and 0.1692, respectively).

Conlusions: PPCs were very common and associated with more than three-fourths of all in-hospital postoperative deaths after open and laparoscopic appendectomy, cholecystectomy, colectomy and Roux-en-Y gastric bypass. PPCs are also associated with significant increases in length of stay and total costs of care. Although laparoscopic procedures may be associated with lower rates of PPCs, PPCs remain a large healthcare burden. Additional strategies for the prevention and management of PPCs may lead to greatly improved patient outcomes and cost savings.

Session: Poster
Program Number: P446
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