Ann Thorac Surg 2008;85:1986-1987. doi:10.1016/j.athoracsur.2008.02.089
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Hari R. Mallidi, MD
Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk Building, CVRB MC: 5407, Stanford, CA 94305
(Email: mallidi{at}stanford.edu).
The literature is replete with evidence that complications after cardiac surgery are costly. They are costly in terms of decreasing the benefit of surgery in those patients who experience a complication (ie, shortened life-expectancy and decreased quality of life), and they are costly in terms of greatly increasing the financial burden of providing cardiac surgical care. As surgeons, we have known for a long time that the patients who sail through surgery without any negative outcome do better in both the short-term and the long-term. We also know that patients with a complication (regardless as to how trivial it may seem) do not have the same benefit of surgery. Although our focus has largely remained on the individual patient that is receiving our treatment, the financial implications of these complications on the global health care budget have remained largely in the background. The costs of providing medical care in the United States have been skyrocketing. At the present rate of growth, it is estimated that by the year 2050 the cost of funding the Medicare program will be equal to the entire current federal annual budget. This is clearly a situation that is untenable. In light of this estimate, the recent announcement by the Centers for Medicare and Medicaid Services (CMS) in the fall of 2007 that Medicare would no longer pay hospitals for care that is necessary due to the occurrence of preventable complications is understandable. The CMS has highlighted eight complications that will no longer be taken into account when calculating the reimbursements that hospitals will receive. Among these eight complications are several that will be of great relevance to cardiac surgery patients: (1) mediastinitis after coronary artery bypass grafting (CABG), (2) line infections, (3) ABO blood group incompatible transfusions, (4) object(s) left in patients during surgery, 5) air embolism, and 6) pressure ulcers.
The analysis of the hospital survivors of complications after isolated CABG in the Medicare population published by Brown and colleagues [1] demonstrates that the costs of complications after surgery are not trivial. The average cost of a patient undergoing isolated CABG without a complication was just under $30,000. The average incremental cost of experiencing any complication was $19,968. A complication was experienced by 15,579 patients, which translates into a total cost to Medicare of $311,081,472. This is just an estimate of the costs in patients undergoing isolated CABG (ie, the patient population in cardiac surgery who are least at risk of experiencing any complication). The two most expensive complications were septicemia and other postoperative infection. Although many factors associated with these infectious complications are out of the control of the surgeon (ie, diabetes mellitus, severe chronic obstructive pulmonary disease, and emergency operation, and so forth), there remain many interventions that might be instituted to decrease the occurrence of these infectious complications. These interventions include: (1) appropriate preoperative preparation of the patients with respect to shower, scrub, and bowel preparation; (2) correct timing of the dose and selection of the choice of prophylactic antibiotics; (3) strict adherence to sterile technique during the conduct of the operation; (4) strict glucose control in the perioperative period; and (5) measures to ensure that lines are placed and taken care of in an appropriate manner. If a concerted effort is made by the hospital to ensure that compliance with evidence-based approaches to decreasing perioperative infections are implemented for every cardiac surgical patient, then a decrease in infection rate might be realized.
Also, as CMS attempts to further reduce costs in the future, there may be implications for payment with respect to the noninfectious complications that occur after cardiac surgery. This, in turn, could stimulate interest in better defining the risks associated with postoperative ventilator failure, postoperative renal failure, and postoperative stroke, and stimulate interest in identifying ways to minimize this risk (ie, preoperative smoking cessation programs, initiation of bronchodilator therapy, and so forth). The ultimate silver-lining is that the changes to the CMS reimbursements may provide the impetus to improve the care for all patients undergoing cardiac surgery by intensely studying and preventing complications.
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References
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- Brown PP, Kugelmass AD, Cohen DJ, et al. The frequency and cost of complications associated with coronary artery bypass grafting surgery: results from the United States Medicare program Ann Thorac Surg 2008;85:1980-1987.[Abstract/Free Full Text]
Related Article
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The Frequency and Cost of Complications Associated With Coronary Artery Bypass Grafting Surgery: Results from the United States Medicare Program
- Phillip P. Brown, Aaron D. Kugelmass, David J. Cohen, Matthew R. Reynolds, Steven D. Culler, Ansley D. Dee, and April W. Simon
Ann. Thorac. Surg. 2008 85: 1980-1986.
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