ORIGINAL ARTICLE
Incremental Cost of Emergency Versus Elective Surgery Adil H. Haider, MD, MPH,∗ Augustine Obirieze, MBBS, MPH,† Catherine G. Velopulos, MD, MHS,‡ Patrick Richard, PhD,§ Asad Latif, MD, MPH,|| Valerie K. Scott, MSPH,‡ Cheryl K. Zogg, MSPH, MHS,∗ Elliott R. Haut, MD,‡ David T. Efron, MD,‡ Edward E. Cornwell III, MD,† Ellen J. MacKenzie, PhD,∗∗ and Darrell J. Gaskin, PhD∗∗
Objective: To determine hospital costs and the adjusted risk of death associated with emergent versus elective surgery. Background: Emergency surgery has a higher cost and worse outcomes compared with elective surgery. However, no national estimates of the excess burden of emergency surgery exist. Methods: Nationwide Inpatient Sample (NIS) data from 2001 to 2010 were analyzed. Patients aged 18 years or older who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, or colon resection for neoplasm were included. Using generalized linear models with propensity scores, cost differences for emergent versus elective admission were calculated for each procedure. Multivariable logistic regression was performed to investigate the adjusted odds of mortality comparing elective and emergent cases. Dischargelevel weights were applied to analyses. Results: A total of 621,925 patients, representing a weighted population of 3,057,443, were included. The adjusted mean cost difference for emergent versus elective care was $8741.22 (30% increase) for abdominal aortic aneurysm repair, $5309.78 (17% increase) for coronary artery bypass graft, and $7813.53 (53% increase) for colon resection. If 10% of the weighted estimates of emergency procedures had been performed electively, the cost benefit would have been nearly $1 billion, at $996,169,160 (95% confidence interval [CI], $985,505,565–$1,006,834,104). Elective surgery patients had significantly lower adjusted odds of mortality for all procedures. Conclusions: Even a modest reduction in the proportion of emergent procedures for 3 conditions is estimated to save nearly $1 billion over 10 years. Preventing emergency surgery through improved care coordination and screening offers a tremendous opportunity to save lives and decrease costs. Keywords: cost, elective, emergency, mortality, surgery (Ann Surg 2015;262:260–266)
R
ising costs pose a serious threat to the economic viability of the United States health care system. In 2011, US health care expenditures reached $2.7 trillion,1 and these expenses are increasing
From the ∗ Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School & Harvard School of Public Health, Boston, MA; †Department of Surgery, Howard University College of Medicine, Washington, DC; ‡Center for Surgical Trials and Outcomes Research, The Johns Hopkins School of Medicine, Baltimore, MD; §Department of Preventive Medicine & Biometrics (PMB), Uniformed Services University, Bethesda, MD; ||Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD; and ∗∗ Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Disclosure: None of the authors has any conflicts of interest. Sources of funding include the National Institutes of Health/NIGMS K23GM093112-01 and the American College of Surgeons C. James Carrico Fellowship for the study of Trauma and Critical Care and Hopkins Center for Health Disparities Solutions (Dr Haider). Reprints: Adil H. Haider, MD, MPH, Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins School of Medicine, 1800 N Orleans St, Zayed 6107, Baltimore, MD 21287. E-mail: [email protected]. C 2014 Wolters Kluwer Health, Inc. All rights reserved. Copyright ISSN: 0003-4932/14/26202-0260 DOI: 10.1097/SLA.0000000000001080
260 | www.annalsofsurgery.com
at twice the rate of the gross domestic product. Nearly 30% of these costs are related to surgical care, with projections for a 60% increase to more than $900 billion in surgical expenditures by 2025.2 Several strategies have been adopted to curb costs and improve surgical quality and outcomes, including global reimbursement packages with bundled payments,3 pay-for-performance measures, and incentives to decrease hospital readmission rates. One important contributor to increased hospital costs and worse surgical outcomes is the performance of emergency, rather than elective, surgery. It is well known that an elective operation has better outcomes and lower costs compared with the same procedure performed emergently.4–10 Emergency surgery can be prevented for many conditions through better access to primary care and screening services. Unfortunately, referral patterns for surgery vary widely across the United States, with factors such as payer status, region, age, sex, obesity, comorbidities, and health care provider networks significantly influencing timely access to surgical care.11,12 These variations may contribute to well-documented health care disparities in surgical outcomes among minority and low socioeconomic status patients. For instance, access to subspecialty services and nonemergency admission to high-quality hospitals is worse among primary care physicians who care for predominantly minority populations.13 Strategies that better align primary care, screening programs, and surgical intervention to decrease the proportion of emergent versus elective surgery may be the next major opportunity to improve surgical outcomes and decrease costs. The Affordable Care Act (ACA), in fact, mandates that participating plans in the new marketplace provide several preventive services rated A or B by the US Preventive Services Task Force without requiring a co-pay/coinsurance.14,15 These directly address screening and intervention for the following 3 potentially surgical diseases: abdominal aortic aneurysm (AAA), colorectal cancer, and heart disease. Currently, no national estimates of the burden of emergency surgery exist. This study determines hospital costs for the emergent and elective treatment of 3 major surgeries—AAA repair, coronary artery bypass graft (CABG), and colon resection for neoplasm— which could be affected by increased access to preventive care and screening, and estimates the cost savings that could be achieved at a national level if a modest proportion (10%) of emergent surgical patients had received their procedure electively. In addition, the adjusted risk of death associated with emergent versus elective procedures for these 3 conditions is calculated. Quantifying the potential health and economic benefits of elective versus emergency surgery is a key step toward improving quality of care, and the solvency and effectiveness of our health care system.
METHODS Data Source The Nationwide Inpatient Sample (NIS) database is the largest all-payer inpatient care database that is publicly available in the United States. The data are a 20% stratified sample of discharges from US hospitals, representing 95% of the US population, which is weighted Annals of Surgery r Volume 262, Number 2, August 2015
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 262, Number 2, August 2015
to permit researchers to calculate national population estimates.16 The Nationwide Inpatient Sample subfiles, including the hospital weight and cost-to-charge ratio (CCR) files, were merged to the core file to obtain information on cost, hospital characteristics, and patientlevel data.17 Data from 2001 through 2010 were queried. Over this 10-year period the number of states contributing to the NIS has grown, such that in 2010 only 4 states (Delaware, North Dakota, Idaho, and Alabama) and the District of Columbia did not participate in the NIS. As mentioned above, the NIS sampling strategy ensures that each year of data presents a nationally representative sample.
Study Population Three common surgical procedures that treat major causes of morbidity and mortality in the United States, cardiovascular disease and cancer, were selected. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure codes were used to identify patients aged 18 years or older who had undergone AAA repair (ICD-9-CM codes 39.71, 39.73, 39.54, 38.44, 38.45, 38.46), coronary artery bypass graft (CABG) (36.1x), or colon resection for neoplasm, including cecectomy (45.72, 17.32), transverse colon resection (45.74, 17.34), left hemicolectomy (45.75, 17.35), right hemicolectomy (45.73, 17.33), and sigmoidectomy (45.76, 17.36). Patients with primary or secondary diagnosis of trauma (ICD-9-CM codes 800-959) were excluded. Patient records with missing information on cost and other variables of interest were excluded. The final study cohort included 621,925 discharge records.
Definitions The primary outcome variable was associated with costs incurred for the hospital stay, calculated by multiplying total charge by the hospital-specific all-payer CCR. Hospital-specific CCRs are developed using standardized information on all-payer inpatient cost and charge reported by hospitals to the Centers for Medicare and Medicaid. The independent variable of interest was type of admission. Patients were grouped as emergent (including those coded as urgent) or elective admission. Other information retrieved included patient demographics, median household income of residence zip code, primary diagnosis (using ICD-9-CM codes on first diagnosis position), hospital characteristics, area wage index, length of stay, comorbidities (using the Charlson Comorbidity Index),18–20 and mortality.
Statistical Analyses Univariate and bivariate analyses were performed to provide descriptive statistics. On bivariate analyses, the Pearson χ 2 test was used to test distribution of categorical variables, whereas the Student t test was used to test difference in means. Given the likely differences in characteristics between emergently and electively admitted patients, propensity scoring21 was used to assess the probability of being emergently versus electively admitted, adjusting for age, sex, race/ethnicity, primary payer, the Charlson Comorbidity Index, income quartile of residential zip code, and primary diagnosis. The incremental cost between elective and emergent patients was estimated using generalized linear models with log link (to derive arithmetic means) and gamma family (given the skewed distribution of the costs data). These models adjusted for the above propensity score quintiles and year of admission, local wage index, inpatient death, hospital’s bed size, rural/urban location, hospital ownership, teaching status, and US state. Using appropriate consumer price indices, costs in prior years (2001–2009) were then adjusted for inflation and converted to 2010 US dollars. Estimates of mean per-patient costs for emergent and elective admissions of AAA repair, CABG, and colon resection for neoplasm, together with corresponding mean cost differences, were derived. C 2014 Wolters Kluwer Health, Inc. All rights reserved.
Cost of Emergency Versus Elective Surgery
Healthcare Cost and Utilization Project-NIS discharge-level weights were applied to all fitted models to derive national patient estimates. Subset analyses were performed separately on records of patients aged 18 to 64 years and those 65 years or older to further assess potential cost differences in these subgroups. Using national (weighted) estimates of numbers of cases and the mean cost differences calculated previously, the cost savings that would accrue if 10% of emergent procedures were performed electively were then calculated. The association between admission status and mortality was also investigated by performing logistic regression, adjusting for propensity score quintiles, discharge year, hospital bed size, teaching status, rural versus urban location, and ownership/control. All statistical analyses were performed using STATA/MP version 11.0 (StataCorp LP, College Station, TX). Statistical significance was defined as P < 0.05.
RESULTS The final study cohort included 621,925 patients, representing a weighted population of 3,057,443. The majority of these patients (61.5%) underwent CABG, whereas 26.1% had colon resections for neoplasms and 12.4% had AAA repairs. Tables 1 and 2 show the patient and hospital characteristics of those who underwent emergent or elective AAA repair, CABG, or colon resection for neoplasm. Among patients who underwent AAA repair and colon resection for neoplasm, 73% and 70% were performed electively, respectively, whereas only 46% of CABG patients were admitted electively. The top 3 primary diagnoses for patients who underwent AAA repair were AAA without mention of rupture (73.3%), ruptured AAA (7.2%), and thoracic aortic aneurysm (without mention of rupture) (4.7%). Coronary atherosclerosis of native artery (71.5%), subendocardial infarction (first episode of care) (14.2%), and acute myocardial infarction of the inferior wall (3.0%) were the 3 most frequent primary diagnoses for patients undergoing CABG. Among patients who underwent colon resection, 77.4% had a malignant and 19.7% a benign neoplasm of colon. Missing data across the data set were low, ranging between 0.05% and 2% for various variables included in the models. After adjusting for potential confounding factors, and propensity score quintiles, in the generalized linear models, patients undergoing emergent procedures had $7383.74 (95% confidence interval [CI], 7304.70–7462.79) higher mean per-patient hospitalization costs compared with elective patients, representing a 29% increase. The mean cost difference was $8741.22 (95% CI, 8597.60–8884.84; 30% increase) for AAA repair, $5309.78 (95% CI, 5234.42–5385.14; 17% increase) for CABG, and $7813.53 (95% CI, 7746.33–7880.72; 53% increase) for colon resection for neoplasm (Fig. 1). Subset analyses were performed for patients aged 18 to 64 years and those 65 years or older, and similarly higher associated costs were noted for emergency surgery (Table 3). Expected cost benefits were calculated in the scenario that 10% of emergent procedures had been performed electively. Among patients who underwent AAA repair, CABG, and colon resection for neoplasm, this would result in $89,181,422 (95% CI, 87,716,154– 90,646,691), $535,522,640 (95% CI, 527,922,140–543,123,141), and $186,395,664 (95% CI, 184,792,575–187,998,516) in accrued cost savings, respectively (Table 4). On a national level, if 10% of the weighted estimates of patients who underwent emergency procedures had instead been performed electively, the associated cost benefits were nearly $1 billion at $996,169,160 (95% CI, 985,505,565– 1,006,834,104). Across all surgery categories, and overall, patients undergoing surgery after elective admissions had significantly lower adjusted odds of mortality (odds ratio [OR] [95% CI]: 0.45 [0.43–0.47]; 0.32 [0.29–0.35]; 0.71 [0.67–0.75]; and 0.32 [0.29–0.34]) for all patients, AAA repair, CABG, and colon resection for neoplasm, respectively) www.annalsofsurgery.com | 261
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 262, Number 2, August 2015
Haider et al
TABLE 1. Patient Characteristics Overall (n = 621,925) Emergent 274,512 (44) Age group, yr, %
Incremental Cost of Emergency Versus Elective Surgery Adil H. Haider, MD, MPH,∗ Augustine Obirieze, MBBS, MPH,† Catherine G. Velopulos, MD, MHS,‡ Patrick Richard, PhD,§ Asad Latif, MD, MPH,|| Valerie K. Scott, MSPH,‡ Cheryl K. Zogg, MSPH, MHS,∗ Elliott R. Haut, MD,‡ David T. Efron, MD,‡ Edward E. Cornwell III, MD,† Ellen J. MacKenzie, PhD,∗∗ and Darrell J. Gaskin, PhD∗∗
Objective: To determine hospital costs and the adjusted risk of death associated with emergent versus elective surgery. Background: Emergency surgery has a higher cost and worse outcomes compared with elective surgery. However, no national estimates of the excess burden of emergency surgery exist. Methods: Nationwide Inpatient Sample (NIS) data from 2001 to 2010 were analyzed. Patients aged 18 years or older who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, or colon resection for neoplasm were included. Using generalized linear models with propensity scores, cost differences for emergent versus elective admission were calculated for each procedure. Multivariable logistic regression was performed to investigate the adjusted odds of mortality comparing elective and emergent cases. Dischargelevel weights were applied to analyses. Results: A total of 621,925 patients, representing a weighted population of 3,057,443, were included. The adjusted mean cost difference for emergent versus elective care was $8741.22 (30% increase) for abdominal aortic aneurysm repair, $5309.78 (17% increase) for coronary artery bypass graft, and $7813.53 (53% increase) for colon resection. If 10% of the weighted estimates of emergency procedures had been performed electively, the cost benefit would have been nearly $1 billion, at $996,169,160 (95% confidence interval [CI], $985,505,565–$1,006,834,104). Elective surgery patients had significantly lower adjusted odds of mortality for all procedures. Conclusions: Even a modest reduction in the proportion of emergent procedures for 3 conditions is estimated to save nearly $1 billion over 10 years. Preventing emergency surgery through improved care coordination and screening offers a tremendous opportunity to save lives and decrease costs. Keywords: cost, elective, emergency, mortality, surgery (Ann Surg 2015;262:260–266)
R
ising costs pose a serious threat to the economic viability of the United States health care system. In 2011, US health care expenditures reached $2.7 trillion,1 and these expenses are increasing
From the ∗ Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School & Harvard School of Public Health, Boston, MA; †Department of Surgery, Howard University College of Medicine, Washington, DC; ‡Center for Surgical Trials and Outcomes Research, The Johns Hopkins School of Medicine, Baltimore, MD; §Department of Preventive Medicine & Biometrics (PMB), Uniformed Services University, Bethesda, MD; ||Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD; and ∗∗ Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Disclosure: None of the authors has any conflicts of interest. Sources of funding include the National Institutes of Health/NIGMS K23GM093112-01 and the American College of Surgeons C. James Carrico Fellowship for the study of Trauma and Critical Care and Hopkins Center for Health Disparities Solutions (Dr Haider). Reprints: Adil H. Haider, MD, MPH, Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins School of Medicine, 1800 N Orleans St, Zayed 6107, Baltimore, MD 21287. E-mail: [email protected]. C 2014 Wolters Kluwer Health, Inc. All rights reserved. Copyright ISSN: 0003-4932/14/26202-0260 DOI: 10.1097/SLA.0000000000001080
260 | www.annalsofsurgery.com
at twice the rate of the gross domestic product. Nearly 30% of these costs are related to surgical care, with projections for a 60% increase to more than $900 billion in surgical expenditures by 2025.2 Several strategies have been adopted to curb costs and improve surgical quality and outcomes, including global reimbursement packages with bundled payments,3 pay-for-performance measures, and incentives to decrease hospital readmission rates. One important contributor to increased hospital costs and worse surgical outcomes is the performance of emergency, rather than elective, surgery. It is well known that an elective operation has better outcomes and lower costs compared with the same procedure performed emergently.4–10 Emergency surgery can be prevented for many conditions through better access to primary care and screening services. Unfortunately, referral patterns for surgery vary widely across the United States, with factors such as payer status, region, age, sex, obesity, comorbidities, and health care provider networks significantly influencing timely access to surgical care.11,12 These variations may contribute to well-documented health care disparities in surgical outcomes among minority and low socioeconomic status patients. For instance, access to subspecialty services and nonemergency admission to high-quality hospitals is worse among primary care physicians who care for predominantly minority populations.13 Strategies that better align primary care, screening programs, and surgical intervention to decrease the proportion of emergent versus elective surgery may be the next major opportunity to improve surgical outcomes and decrease costs. The Affordable Care Act (ACA), in fact, mandates that participating plans in the new marketplace provide several preventive services rated A or B by the US Preventive Services Task Force without requiring a co-pay/coinsurance.14,15 These directly address screening and intervention for the following 3 potentially surgical diseases: abdominal aortic aneurysm (AAA), colorectal cancer, and heart disease. Currently, no national estimates of the burden of emergency surgery exist. This study determines hospital costs for the emergent and elective treatment of 3 major surgeries—AAA repair, coronary artery bypass graft (CABG), and colon resection for neoplasm— which could be affected by increased access to preventive care and screening, and estimates the cost savings that could be achieved at a national level if a modest proportion (10%) of emergent surgical patients had received their procedure electively. In addition, the adjusted risk of death associated with emergent versus elective procedures for these 3 conditions is calculated. Quantifying the potential health and economic benefits of elective versus emergency surgery is a key step toward improving quality of care, and the solvency and effectiveness of our health care system.
METHODS Data Source The Nationwide Inpatient Sample (NIS) database is the largest all-payer inpatient care database that is publicly available in the United States. The data are a 20% stratified sample of discharges from US hospitals, representing 95% of the US population, which is weighted Annals of Surgery r Volume 262, Number 2, August 2015
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 262, Number 2, August 2015
to permit researchers to calculate national population estimates.16 The Nationwide Inpatient Sample subfiles, including the hospital weight and cost-to-charge ratio (CCR) files, were merged to the core file to obtain information on cost, hospital characteristics, and patientlevel data.17 Data from 2001 through 2010 were queried. Over this 10-year period the number of states contributing to the NIS has grown, such that in 2010 only 4 states (Delaware, North Dakota, Idaho, and Alabama) and the District of Columbia did not participate in the NIS. As mentioned above, the NIS sampling strategy ensures that each year of data presents a nationally representative sample.
Study Population Three common surgical procedures that treat major causes of morbidity and mortality in the United States, cardiovascular disease and cancer, were selected. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure codes were used to identify patients aged 18 years or older who had undergone AAA repair (ICD-9-CM codes 39.71, 39.73, 39.54, 38.44, 38.45, 38.46), coronary artery bypass graft (CABG) (36.1x), or colon resection for neoplasm, including cecectomy (45.72, 17.32), transverse colon resection (45.74, 17.34), left hemicolectomy (45.75, 17.35), right hemicolectomy (45.73, 17.33), and sigmoidectomy (45.76, 17.36). Patients with primary or secondary diagnosis of trauma (ICD-9-CM codes 800-959) were excluded. Patient records with missing information on cost and other variables of interest were excluded. The final study cohort included 621,925 discharge records.
Definitions The primary outcome variable was associated with costs incurred for the hospital stay, calculated by multiplying total charge by the hospital-specific all-payer CCR. Hospital-specific CCRs are developed using standardized information on all-payer inpatient cost and charge reported by hospitals to the Centers for Medicare and Medicaid. The independent variable of interest was type of admission. Patients were grouped as emergent (including those coded as urgent) or elective admission. Other information retrieved included patient demographics, median household income of residence zip code, primary diagnosis (using ICD-9-CM codes on first diagnosis position), hospital characteristics, area wage index, length of stay, comorbidities (using the Charlson Comorbidity Index),18–20 and mortality.
Statistical Analyses Univariate and bivariate analyses were performed to provide descriptive statistics. On bivariate analyses, the Pearson χ 2 test was used to test distribution of categorical variables, whereas the Student t test was used to test difference in means. Given the likely differences in characteristics between emergently and electively admitted patients, propensity scoring21 was used to assess the probability of being emergently versus electively admitted, adjusting for age, sex, race/ethnicity, primary payer, the Charlson Comorbidity Index, income quartile of residential zip code, and primary diagnosis. The incremental cost between elective and emergent patients was estimated using generalized linear models with log link (to derive arithmetic means) and gamma family (given the skewed distribution of the costs data). These models adjusted for the above propensity score quintiles and year of admission, local wage index, inpatient death, hospital’s bed size, rural/urban location, hospital ownership, teaching status, and US state. Using appropriate consumer price indices, costs in prior years (2001–2009) were then adjusted for inflation and converted to 2010 US dollars. Estimates of mean per-patient costs for emergent and elective admissions of AAA repair, CABG, and colon resection for neoplasm, together with corresponding mean cost differences, were derived. C 2014 Wolters Kluwer Health, Inc. All rights reserved.
Cost of Emergency Versus Elective Surgery
Healthcare Cost and Utilization Project-NIS discharge-level weights were applied to all fitted models to derive national patient estimates. Subset analyses were performed separately on records of patients aged 18 to 64 years and those 65 years or older to further assess potential cost differences in these subgroups. Using national (weighted) estimates of numbers of cases and the mean cost differences calculated previously, the cost savings that would accrue if 10% of emergent procedures were performed electively were then calculated. The association between admission status and mortality was also investigated by performing logistic regression, adjusting for propensity score quintiles, discharge year, hospital bed size, teaching status, rural versus urban location, and ownership/control. All statistical analyses were performed using STATA/MP version 11.0 (StataCorp LP, College Station, TX). Statistical significance was defined as P < 0.05.
RESULTS The final study cohort included 621,925 patients, representing a weighted population of 3,057,443. The majority of these patients (61.5%) underwent CABG, whereas 26.1% had colon resections for neoplasms and 12.4% had AAA repairs. Tables 1 and 2 show the patient and hospital characteristics of those who underwent emergent or elective AAA repair, CABG, or colon resection for neoplasm. Among patients who underwent AAA repair and colon resection for neoplasm, 73% and 70% were performed electively, respectively, whereas only 46% of CABG patients were admitted electively. The top 3 primary diagnoses for patients who underwent AAA repair were AAA without mention of rupture (73.3%), ruptured AAA (7.2%), and thoracic aortic aneurysm (without mention of rupture) (4.7%). Coronary atherosclerosis of native artery (71.5%), subendocardial infarction (first episode of care) (14.2%), and acute myocardial infarction of the inferior wall (3.0%) were the 3 most frequent primary diagnoses for patients undergoing CABG. Among patients who underwent colon resection, 77.4% had a malignant and 19.7% a benign neoplasm of colon. Missing data across the data set were low, ranging between 0.05% and 2% for various variables included in the models. After adjusting for potential confounding factors, and propensity score quintiles, in the generalized linear models, patients undergoing emergent procedures had $7383.74 (95% confidence interval [CI], 7304.70–7462.79) higher mean per-patient hospitalization costs compared with elective patients, representing a 29% increase. The mean cost difference was $8741.22 (95% CI, 8597.60–8884.84; 30% increase) for AAA repair, $5309.78 (95% CI, 5234.42–5385.14; 17% increase) for CABG, and $7813.53 (95% CI, 7746.33–7880.72; 53% increase) for colon resection for neoplasm (Fig. 1). Subset analyses were performed for patients aged 18 to 64 years and those 65 years or older, and similarly higher associated costs were noted for emergency surgery (Table 3). Expected cost benefits were calculated in the scenario that 10% of emergent procedures had been performed electively. Among patients who underwent AAA repair, CABG, and colon resection for neoplasm, this would result in $89,181,422 (95% CI, 87,716,154– 90,646,691), $535,522,640 (95% CI, 527,922,140–543,123,141), and $186,395,664 (95% CI, 184,792,575–187,998,516) in accrued cost savings, respectively (Table 4). On a national level, if 10% of the weighted estimates of patients who underwent emergency procedures had instead been performed electively, the associated cost benefits were nearly $1 billion at $996,169,160 (95% CI, 985,505,565– 1,006,834,104). Across all surgery categories, and overall, patients undergoing surgery after elective admissions had significantly lower adjusted odds of mortality (odds ratio [OR] [95% CI]: 0.45 [0.43–0.47]; 0.32 [0.29–0.35]; 0.71 [0.67–0.75]; and 0.32 [0.29–0.34]) for all patients, AAA repair, CABG, and colon resection for neoplasm, respectively) www.annalsofsurgery.com | 261
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 262, Number 2, August 2015
Haider et al
TABLE 1. Patient Characteristics Overall (n = 621,925) Emergent 274,512 (44) Age group, yr, %
