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Ann Thorac Surg 2008;85:1980-1986. doi:10.1016/j.athoracsur.2008.01.053
© 2008 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

The Frequency and Cost of Complications Associated With Coronary Artery Bypass Grafting Surgery: Results from the United States Medicare Program

Phillip P. Brown, MDa, Aaron D. Kugelmass, MDb, David J. Cohen, MD, MSc, Matthew R. Reynolds, MD, MSd, Steven D. Culler, PhDe,*, Ansley D. Dee, MSe, April W. Simon, RN, MSNa

a Cardiac Data Solutions, Inc, Atlanta, Georgia
b Henry Ford Hospital, Detroit, Michigan
c Saint-Luke's Mid America Heart Institute, Kansas City, Missouri
d Beth Israel Deaconess Medical Center, Boston, Massachusetts
e Rollins School of Public Health, Emory University, Atlanta, Georgia, Atlanta, Georgia

Accepted for publication January 17, 2008.

* Address correspondence to Dr Culler, Health Policy and Management, Emory University, 1518 Clifton R, NE, Atlanta, GA 30322 (Email: sculler{at}sph.emory.edu).


Ms Simon discloses that she has a financial relationship with Cardiac Data Solutions, Inc.

 

   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: We estimate the incremental hospital resource consumption associated with treating selected complications experienced by Medicare beneficiaries undergoing coronary artery bypass grafting (CABG).

Methods: This retrospective study, using the Medicare Provider Analysis and Review file, identified 114,233 Medicare beneficiaries who survived CABG without concomitant valve repair during a hospitalization for fiscal year 2005. The frequencies of seven complications were determined: hemorrhage or postoperative shock, reoperation, postoperative adult respiratory distress syndrome, new-onset hemodialysis, postoperative stroke, postoperative infection and septicemia. The observed and adjusted incremental hospital resources consumed (cost and length-of-stay) in treating beneficiaries experiencing each of the selected complications were estimated.

Results: The mean cost of a hospitalization associated with a CABG procedure among Medicare beneficiaries was $32,201 ± $23,059, and the mean length of stay was 9.9 ± 7.8 days. After adjusting for patient demographics and comorbid conditions, the 13.64% of Medicare beneficiaries experiencing any of the study complications consumed significantly more hospital resources (incremental cost, $15,468) and had a longer length of stay (incremental stay, 5.3 days).

Conclusions: Despite ongoing improvements in outcomes, major complications remain common after bypass grafting and add substantially to hospital costs for these procedures. These findings suggest that the potential cost savings of redirecting resources currently spent on treating complications will help make the "business case" for investing in patient safety initiatives and best practices guidelines shown to reduce selected complications.

The use and safety of coronary artery bypass graft (CABG) surgery in treating patients with coronary artery disease is well established [1–4]. Further, hospital and 30-day mortality rates associated with CABG surgery continue to decline despite the procedure being performed on a patient population that is older and presenting with an increasing number of comorbid conditions [5, 6]. Studies have also identified the total hospital resources consumed by patients undergoing CABG and the cost-effectiveness of CABG compared with alternative revascularization procedures [7–10]. However, little is known about the frequency or the cost of treating specific acute complications associated with CABG surgery in contemporary practice [11].

The primary objective of this analysis was to estimate the incremental hospital resources consumed, defined as dollar value of direct medical care provided and length of stay (LOS), while treating acute complications experienced by Medicare beneficiaries who survived hospitalization after CABG. To the extent that evidence-based practice guidelines and quality improvement initiatives decrease complication rates, the estimated incremental cost of treating selected complications presented in this article can be used to evaluate the business case for quality improvement initiatives. Further, the relative size of the incremental resource savings provide both administrators and the medical staff with an empirical means for prioritizing quality improvement efforts that could potentially reduce the average cost of care and improve patient outcomes.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Data Source
The Medicare Provider Analysis and Review file for fiscal year 2005 (October 1, 2004, through September 30, 2005) was the data source for this retrospective analysis. The Medicare Provider Analysis and Review file is an administrative database that is maintained by the Centers for Medicare and Medicaid Services and contains all claims that are submitted by hospitals for services provided to Medicare beneficiaries. For each hospitalization, the Medicare Provider Analysis and Review record includes patient information on age, sex, race, date of admission, date of discharge, the principal diagnosis code, eight secondary diagnosis codes, six procedure codes, discharge status, total charges, and total reimbursement.

Study Population Inclusion and Exclusion Criteria
The population in this study consisted of all hospitalizations in which a Medicare beneficiary survived a CABG procedure without concomitant valve operation in a hospital that performed at least 52 CABG surgeries (average of < 1 per week) on Medicare beneficiaries during fiscal year 2005. There were a total of 118,099 hospital admissions (in 798 hospitals) for Medicare beneficiaries with an International Classification of Diseases, 9th Clinical Modification (ICD-9-CM) procedure code indicating that the patient underwent a CABG procedure (36.10 to 36.19 or 36.2) during that admission without any ICD-9-CM procedure codes indicating concomitant valve surgery (35.00 to 35.04, 35.10 to 35.14, 35.20 to 35.28, or 35.31 to 35.39). The study excluded 3,804 admissions because the Medicare beneficiary died during the CABG hospitalization. An additional 62 admissions were excluded because of missing information needed to calculate costs. The final study cohort consisted of 114,233 Medicare beneficiary hospitalizations.

Definitions of Complications, Demographics, and Comorbidities
Seven complications of interest were defined for this study. These complications included hemorrhage or postoperative shock, reoperation, postoperative adult respiratory distress syndrome, new-onset hemodialysis, postoperative stroke, postoperative infection and septicemia. These complications were selected because there are specific ICD-9-CM codes that differentiate complications from a condition existing before operation; CABG most likely would not have been performed if the condition existed preoperatively; or because of the frequency with which they occurred in the study population, or both. Appendix A lists the ICD-9-CM procedure and diagnosis codes used to identify each complication.


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  		Appendix International Classification of Disease, 9th Clinical Modification, Codes Used to Identify Each of the Study Complications
 
Demographic variables of interest were age, sex, and race. Comorbidities and cardiac risk factors of interest included previous CABG, previous percutaneous coronary intervention (PCI), previous myocardial infarction (MI); primary admission diagnosis of acute ST-elevation MI, non-ST-elevation MI, or acute MI in an unspecified site; heart failure, cardiomyopathy, cardiogenic shock, chronic obstructive pulmonary disease, chronic renal failure, chronic liver disease, peripheral vascular disease, hypertension, diabetes mellitus (type I or II), history of hemodialysis, history of cerebrovascular disease, unstable angina, valve disease, heart block, atrial fibrillation/flutter, ventricular fibrillation/flutter, paroxysmal tachycardias, obesity, and current smoking. All comorbidities were defined according to ICD-9-CM diagnosis codes contained in the Medicare Provider Analysis Review file.

Hospital Resource Utilization
This study examined two alterative measures of the hospital resources consumed in treating the selected complication of interest: LOS and total hospital cost. This study measures resources consumed from the perspective of the entire hospital admission. The LOS was defined as the number of days from admission to discharge. Postsurgical LOS was not calculated because privacy issues associated with the public use version of the Medicare Provider Analysis and Review file prohibit the use of any actual dates associated with a patient's hospitalization. Hospital cost was estimated by multiplying the total charges that were found in the Medicare Provider Analysis and Review file by the appropriate hospital's overall cost-to-charge ratio, obtained from the fiscal year 2005 Medicare Cost Report. This method of estimating total hospital cost has been discussed and used previously in the literature [12–14].

Statistical Analysis
Univariate differences in baseline demographic data, comorbidities, and cardiac risk factors between patients who experienced any complication and those who did not were assessed with {chi}2 analysis or the Fisher exact test for discrete variables and the Student t test for continuous variables. Observed complication rates are reported as the proportion of hospitalizations with a selected complication out of all study hospitalizations. Mean hospital cost and mean hospital LOS for all patients experiencing selected complications are presented as mean ± SD. All multivariate regression models were estimated using the linear and log-linear forms of the estimated resource equation. However, this article only reports the results from the linear regression models. Differences between study groups were considered statistically different at a value of p ≤ 0.05. All analyses were performed with SAS 9.1 software (SAS Institute, Cary, NC).

Strategy for Estimating for Adjusted Resource Use
Adjusted resources, both cost and LOS, consumed in treating each acute complication of interest were estimated using multivariate linear regression models, controlling for differences in patient demographic characteristics, comorbidities, and cardiac risk factors, as defined previously. This approach defined the incremental resources consumed by patients experiencing a specific complication as the estimated coefficient on the dichotomous variable that was set equal to 1 if the patient had a complication of interest and to 0 for all other patients. For comparison, we also report the observed, average incremental resources consumed in treating a selected complication, which was defined as the difference between the average hospital resources consumed by all patients who experience a selected complication and those who did not develop that specific complication within the study population.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Table 1 presents baseline demographic and clinical characteristics for the study cohort according to whether one or more complications developed in the Medicare beneficiary during the hospitalization for CABG. In general, patients who experienced complications were more likely to be older than 75 years, women, and nonwhite. Patients with complications were significantly more likely to have heart failure, chronic obstructive pulmonary disease, preoperative cardiogenic shock, cardiomyopathy, atrial fibrillation/flutter, ventricular fibrillation/flutter, paroxysmal tachycardia, chronic renal failure, a primary diagnosis of acute MI (ST-elevation, non-ST-elevation, or unspecified site), valve disease, or type I diabetes. In contrast, patients experiencing no complications were significantly more likely to have had a previous CABG, previous PCI, or previous MI, have unstable angina, hypertension, heart block, type II diabetes, history of cerebrovascular disease, peripheral vascular disease, obesity, or be a current smoker.


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  		Table 1 Baseline Demographic and Cardiac Risk Factors of all Hospitalizations and Study Complications That Occurred During the CABG Hospitalization
 
A total of 13.64% of all Medicare beneficiaries who survived their CABG procedure experienced one or more of the prespecified complications; 10.99% of patients experienced only one of the study complications, and 2.64% of patients experienced two or more of the seven study complications (Table 2). The three most common study complications were postoperative adult respiratory distress syndrome, hemorrhage or postoperative shock, and any reoperation. Less than 1.5% of all Medicare beneficiaries undergoing CABG operations experienced any one of the other four study complications. For comparison, Table 2 also presents the incidence (number and percentage of study population) of the seven study complications among the 10.99% of the patients who experienced only one study complication.


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  		Table 2 Observed Study Complication Rates by Study Complication Category for Entire Study Population
 
Table 3 presents the observed mean hospital cost/LOS and the incremental cost/LOS for patients experiencing each of the study complications. The mean cost of a CABG hospitalization for all study patients was $32,201 ± $23,059, with an observed mean LOS of 9.9 ± 7.8 days. Patients who did not experience any study complications during their hospitalization had significantly lower observed mean costs ($29,477 ± $17,358 vs $49,445 ± $40,578) and significantly shorter mean LOS (9.0 ± 5.8 vs. 15.9 ± 13.9 days) than patients experiencing at least one study complication. The three study complications with the highest observed incremental cost to treat were septicemia ($59,204), postoperative infection ($35,307), and any postoperative adult respiratory distress syndrome ($22,222). These three complications all resulted in observed incremental LOS that exceeded 7.5 days. Multiple study complications occurred in 2.64% of all admissions and were particularly expensive to treat, with an observed incremental hospital cost of $31,503 for those beneficiaries experiencing exactly two study complications and $58,827 for those beneficiaries experiencing three or more study complications, compared with beneficiaries not experiencing any study complications.


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  		Table 3 Observed Average Unadjusted and Incremental Hospital Resource Utilization Associated With Treating Beneficiaries Who Experienced Selected Study Complications
 
Table 4 presents estimates of the adjusted incremental hospital cost and LOS associated with treating patients who had each of the study complications of interest. After adjusting for differences in demographics, comorbidities, and cardiac risk factors, those beneficiaries who experienced any study complication during the hospitalization associated with the CABG procedure consumed $15,468 more hospital resources and had a hospitalization that lasted 5.3 days longer than beneficiaries who did not experience a study complication. In addition, for each of the selected complications, beneficiaries experiencing that complication consumed significantly (p < 0.001) more hospital resources (higher cost and longer LOS) than did beneficiaries not experiencing that study complication, with an adjusted estimated incremental cost of more than $10,000 and an adjusted estimated incremental LOS that exceeded 3 days for all study complications except for patients experiencing any hemorrhage or postoperative stroke. The overall goodness of fit, as measured by the coefficient of determination for multivariate analysis (R 2), was between 0.15 and 0.22 for all the cost and the LOS equations.


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  		Table 4 Adjusted Incremental Hospital Resource Utilization Associated With Treating Patients With the Study Complication of Interest Obtained From Multivariate Regression Models
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Several important findings emerge from this analysis concerning the seven study complications associated with survivors of CABG procedures. First, of the 15,579 Medicare beneficiaries that experience one or more of the study complications, approximately 80% of the beneficiaries experience only one study complication, and less than 20% experience two or more study complications during their hospitalization. Second, the complication rate exceeds 2.0% for only the two most frequent postoperative complications (postoperative adult respiratory distress syndrome and hemorrhage or shock). Third, the reported complication rates, which were derived from administrative records, appear to be consistent with rates reported in other large data registries.

In addition, this analysis provides a set of nationally representative cost benchmarks for the mean incremental hospital resources consumed when treating one of seven complications that occur during Medicare beneficiaries' hospitalizations associated with CABG operations. First, among more than 100,000 hospitalizations, we found that the mean cost (in 2005 US dollars) of a hospitalization that was associated with a CABG surgery among Medicare beneficiaries was $32,201 ± $23,059, and the mean LOS was 9.9 ± 7.8 days. This implies that US hospitals consumed more than $3.6 billion of resources treating Medicare beneficiaries who survived CABG without concomitant valve repair during fiscal year 2005.

Second, the 13.64% of Medicare beneficiaries who experienced at least one study complication consumed significantly more hospital resources (adjusted incremental cost, $15,468 per hospitalization) and had a longer LOS (incremental LOS, 5.3 days) than did the 86.36% of Medicare beneficiaries who did not experience any complications during their CABG hospitalization. This suggests that Medicare beneficiaries who experienced any of the seven study complication consumed approximately $241 million of additional hospital resources to treat the complications. Finally, after controlling for patient's demographic characteristics and comorbidities, the incremental cost of treating two study complications (postoperative infection and septicemia) exceeded $30,000, and the incremental LOS required to treat these two complications exceeded 13 days.

Third, estimates of the total incremental resource cost of treating selected complications can be derived by combining the incremental hospital resource cost (Table 4) with the complication rates (Table 2). For example, hospitals used an additional $92.0 million of resources in treating Medicare beneficiaries who experienced septicemia and postoperative infection, the two most incrementally expensive complications to treat. On the other hand, hospitals used an additional $111 million of resources in treating Medicare beneficiaries who experienced postoperative adult respiratory distress syndrome, the most common complications in our study population. Our findings suggest that quality improvement efforts to reduce those complications that can be reduced by improving quality of care could have significant financial benefits (cost savings) for US hospitals.

This analysis has several limitations that warrant discussion. First, it applies only to Medicare beneficiaries. It should not be assumed that our findings on the incremental cost of complications can be extrapolated to other patient groups, especially younger patients who may be able to recover from a complication using fewer resources.

A second limitation is that the identification of study complications was dependent on ICD-9-CM coding reported in administrative data, not clinical medical records. In addition, the Medicare Provider Analysis and Review data file is truncated to include only nine diagnostic codes and six procedure codes. Mitigating this limitation is that specific ICD-9-CM codes differentiate between the diagnoses that existed on admission from those that occurred during or after the procedure for all but two of the study complications (septicemia and new-onset hemodialysis). In addition, the effect of underreporting complications because of the limited number of ICD-9-CM codes most likely results in understating the estimated incremental cost of treating complications reported here because the underreporting of complications most likely increases the average resources consumed for those patients who are observed as not experiencing the complications.

A third limitation is that hospital costs were estimated from billed charges. It is unlikely, however, that the approach used to estimate cost would consistently over- or underestimate the cost of treating patients in either study group. In this regard, it is reassuring that a similar pattern of resource utilization emerges from our analysis of LOS data, which is an alternative measure of hospital resource utilization.

A fourth limitation is that total LOS, instead of postoperative LOS, is used to calculate the incremental LOS associated with each study complication because our data set does not contain the information necessary to calculate postoperative LOS. As a result, our estimates of the incremental LOS associated with each complication most likely overstate the true time it takes the typical patients to recover from a study complication.

In conclusion, in fiscal year 2005, 13.64% of Medicare beneficiaries surviving CABG operations experienced one or more of the prespecified complications and the adjusted incremental hospital resources consumed in treating all but three of these complications exceeded $15,000 per episode. Hospitals are increasingly at financial risk for the incremental resources consumed in treating patients experiencing complications because of third-party payers' efforts to base hospital reimbursement on pay for performance measures, as well as payment exclusions and denials for specific complications. We suggest that the prevention of complications associated with CABG procedures could result in substantial cost savings to hospitals and these savings will be an important consideration in making the "business case" for patient safety initiatives and the implementation of best practices guidelines that can be shown to reduce selected complications.


   Appendix
 


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Eagle KA, Davidoff R, Edwards FH, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Surgery). American College of Cardiology Web site. http://www.acc.org/guidelines/cabg/cabg.pdfAccessed Sep 6, 2007.
  2. The VA Coronary Artery Bypass Surgery Cooperative Study Group Eighteen-year follow-up in the Veterans Affairs cooperative study of coronary artery bypass surgery for stable angina Circulation 1992;86:121-130.[Abstract/Free Full Text]
  3. In: Gersh BJ, editor. Mayo Clinic heart book. 2nd ed.. New York, NY: William Marrow & Company; 2000.
  4. In: Topol EJ, editor. Cleveland Clinic heart book. New York, NY: Cleveland Clinic Foundation; 2000.
  5. DeFrances CJ, Hall MJ. 2002 National hospital discharge survey: advance data from vital and health statisticsHyattsville, MD: National Center for Health Statistics; 2004No. 342.
  6. Hannan EL, Kilburn Jr H, Racz M, Shields E, Chassin MR. Improving the outcomes of coronary artery bypass surgery in New York state JAMA 1995;273:209-213.[Abstract/Free Full Text]
  7. Maziarz DM, Koutlas TC. Cost considerations in selecting coronary artery revascularization therapy in the elderly Am J Cariovasc Drugs 2004;4:219-225.
  8. Stroupe KT, Morrison DA, Hlatky MA, et al. Cost-effectiveness of coronary artery bypass grafts versus percutaneous coronary intervention for revascularization of high-risk patients Circulation 2006;114:1251-1257.[Abstract/Free Full Text]
  9. Cowper PA, DeLong ER, Peterson ED, et al. Variability in cost of coronary bypass surgery in New York State: Potential for cost savings Am Heart J 2002;143:130-139.[Medline]
  10. Weintraub WS, Becker ER, Mauldin PD, Culler S, Kosinski AS, King SP. Costs of revascularizations over eight years in the randomized and eligible patients in the Emory Angioplasty versus Surgery Trial (EAST) Am J Cardiol 2000;86:747-752.[Medline]
  11. Hall RE, Ash AS, Ghali WA, Moskowitz MA. Hospital cost of complications associated with coronary artery bypass graft surgery Am J Cardiol 1997;79:1680-1682.[Medline]
  12. Ashby J. The accuracy of cost measures derived from Medicare Cost Report data Hosp Cost Manag Account 1992;3:1-8.[Medline]
  13. Culler SD, Atherly A. Nonfederal US hospital costsIn: Weintraub WS, editor. Cardiovascular health care economics. Totowa, NJ: Humana Press; 2003. pp. 1-14.
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