Costs Associated with Postoperative Sepsis in VHA Hospitals

Sepsis is a complication that can arise from bacterial, viral, or fungal infections; severe sepsis, which includes organ failure, is associated with extremely high mortality rates. Approximately 30% of patients with severe sepsis die within 1 month of diagnosis and 50% die within 6 months. Ineffective treatment may leave patients vulnerable to additional complications, including kidney failure or depressed heart rate. Approximately 30% of inpatient cases of severe sepsis are associated with postoperative complications. Sepsis is costly to treat, and the costs increase significantly as dysfunction develops in vital organs; estimates have varied from $10,500 to >$40,000 per case in previous studies, depending on patient characteristics, country, and inclusion criteria. According to researchers, there were no studies that specifically examined the incremental cost associated with sepsis as a complication of general surgery. With efforts to control rising healthcare costs, creating a business case for quality to sustain quality improvement efforts has become increasingly important; reducing the incidence of postsurgical sepsis offers an opportunity to create such a business case for quality. In that context, researchers recently conducted a study to estimate the incremental costs associated with general surgery postoperative sepsis in 118 acute care Veterans Health Affairs (VHA) hospitals. The study was designed to control for patient risk factors with potential cost impact (eg, surgical complexity and comorbidity) and variations in costs at the hospital level. Study results were reported in Archives of Surgery [2011;146(8):944-951]. The study cohort included 13,878 patients who underwent a general surgical procedure at one of the VHA hospitals in the study from October 1, 2005, through September 30, 2006. Of those patients, 4.1% (n=564) developed postoperative sepsis; 365 had severe sepsis and 199 had septic shock. The rate of sepsis increased with age: for patients <55 years of age, the rate was 2.3% compared with a rate of 6.1% for patients ≥85 years of age. There was variation in the sepsis rate by type of surgery: 8.0% for procedures involving the stomach, 13.5% for those involving the pancreas, 8.6% for rectum repair, 8.3% for total colon removal, and 10.2% for other intestine operations. Other factors associated with increased risk for sepsis were moderate-to-severe dyspnea, American Society of Anesthesiologists class indicating a moribund patient, and preoperative presence of diabetes mellitus, weight loss, bleeding disorder, wound infection, blood transfusion, pneumonia, chronic obstructive pulmonary disease, acute renal failure or current receipt of dialysis, and being ventilator dependent within 48 hours before the surgery. The average unadjusted cost for the patients who developed sepsis was $88,747 compared with $24,923 for those who did not develop sepsis (P<.001). For the patients with septic shock, the cost was $6300 higher compared with patients with severe sepsis ($92,829 vs $86,522). In risk-adjusted analyses, the relative costs for patients with sepsis were 2.28 times higher than for patients without sepsis (95% confidence interval, 2.19-2.38); the difference was estimated at $26,972. Analyses found that sepsis occurred most frequently with failure to wean the patient from mechanical ventilation within 48 hours (35.8%), postoperative pneumonia (30.9%), reintubation for respiratory or cardiac failure (28.7%), and urinary tract infection (18.8%). In risk-adjusted analyses, among the patients with sepsis, costs were highest when sepsis occurred with pneumonia or failure to wean the patient from mechanical ventilation within 48 hours. Limitations cited by the authors included a variation across VHA hospitals in cost estimates, a potential inability to generalize the results to the private sector, not including other costs to society (eg, lost wages and disability compensation), unmeasured confounders that may have produced misleading results, the possible invalidity of the assumption that there is a direct relationship between the rate of postoperative sepsis and costs, and finally, nuances associated with the identification of sepsis that were not addressed in the study. In conclusion, the researchers summarized, “given the high cost of treating sepsis, a business case can be made for quality improvement initiatives that reduce the likelihood of postoperative sepsis.”