J. J. Idrees1, C. Schmidt1, M. Dillhoff1, J. Cloyd1, E. Ellison1, T. M. Pawlik1 1The Ohio State University, Wexner Medical Center,Department Of Surgery,Columbus, OH, USA
Introduction: Major complications after liver resection can increase costs, as well as be associated with higher mortality. Failure to rescue (FTR) has been inversely correlated with hospital volume. We sought to determine whether high or medium volume centers were more cost-effective at rescuing patients from major complications relative to low volume centers following hepatic resection.
Methods: The Nationwide Inpatient Sample (NIS) was used to identify 96,107 liver resections that occurred between 2011-2011. Hospitals were categorized into high (HV) (150+ cases/year), medium (MV)(51-149 cases/year), and low (LV) (1-49 cases/year) volume centers. Cost-effectiveness analyses were performed using propensity score matched cohorts adjusted for patient co-morbidities among HV vs. LV (8,924 pairs), as well as MV vs. LV (18,158 pairs) centers. Incremental cost effectiveness ratio (ICER) was calculated to assess cost-effectiveness of HV and MV centers relative to LV centers. ICER was calculated at the willingness to pay threshold of $50,000. Sensitivity analyses were performed using the bootstrap method with 10,000 replications.
Results: The overall incidence of complications following hepatectomy was 14.9% (n=14,313), which was roughly comparable among centers regardless of volume (HV 14.2 % vs. MV 14.3% vs. LV 15.4%; p<0.001). In contrast, while overall FTR was 11.2%, the FTR rate was substantially lower among HV centers (HV: 7.7%, MV: 11.2%, LV: 12.3%, p<0.001). Both HV and MV centers were more cost-effective at rescuing patients from a major complication relative to LV centers. Specifically, the incremental cost per year of life gained was $3,296 at HV versus $4,182 at MV centers compared with LV hospitals. HV were particularly cost-effective at managing certain complications. For example, compared to LV centers, HV hospitals had lower costs with a higher survival benefit in managing bile duct complications (ICER: -$1,580) and sepsis (ICER: -$2,760).
Conclusion: Morbidity following liver resection was relatively common as 1 in 7 patients experienced a complication. Not only was FTR lower at HV hospitals, but the management of most major complications was also more cost-effective at HV centers.