Reducing the Cost of Pulmonary Complications Post Surgery

At the ongoing annual American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Conference in Chicago, physicians from the Thomas Jefferson University Hospital in Philadelphia shared information on an analytical tool that can help regulate costly respiratory complications following surgery. The tool, devised by Adam P. Johnson, MD, MPH, and his coauthors on the study, scores patients for their risk of ventilator dependence due to postoperative respiratory failure.

"The need for artificial mechanical ventilation after operations is infrequent, but when it happens it does carry high costs," Dr Johnson explained. "Ventilator dependence is highly associated with mortality, and in and of itself is a morbidity."

Studies have indicated that the percentage of individuals who need ventilation support following non-emergency surgery is not very high, but the associated costs stay elevated. Analysis of patient databases from 253 hospitals in the United States back in 2002 found that the daily cost of intensive care stay was on average $4000 higher on the first day when patients were on a ventilator. When the authors adjusted for patient and hospital characteristics, the mean incremental cost of mechanical ventilation in intensive care unit patients was $1522 per day. The study results led to the conclusion that interventions to reduce the length of a hospital stay or duration of mechanical ventilation could reduce overall inpatient costs.

The Jefferson study analyzed ACS NSQIP data on 7473 patients who had elective general or vascular operations at the institution between 2006 and 2013. The scoring system assigned points for different factors, such as current smoker (1 point), age older than 60 years (2 points), and esophagus procedures (3 points); total risk scores ranged from 0 to 7. The median risk score for patients who did not need the ventilator after operations was 2, while that for patients who did need the ventilator was 3. Those with a score above 3 comprised the 20% of patients who experienced 70% of adverse events. Other risk factors for postoperative ventilator dependence were a diagnosis of severe chronic obstructive pulmonary disease, signs of active infection or inflammatory response, and low albumin counts.

According to the authors, their scoring system is flexible in that institutions can apply it to their specific patient populations. Future work by the physicians involves using the risk score in preadmission testing of every patient to undergo surgery and including it in the electronic medical record of each patient.