Postoperative pulmonary complications in adult elective surgery patients in the US: severity, outcomes and resources use

Introduction

Postoperative pulmonary complications (PPCs) are associated with adverse outcomes and added resource use. However, PPCs vary in severity, and so may have very different outcomes.

Methods

We selected adult elective surgical cases from the Premier database for 2008. The PPC conditions identified were: pneumonia; respiratory failure; bronchospasm; tracheobronchitis; pleural effusion; pulmonary collapse; ARDS; and pneumothorax. We stratified PPC cases into levels: those with bronchospasm and no other PPC (BS), those with respiratory failure (RF) and all remaining (NRF). We examined incidence, length of stay, hospital mortality, and total cost. US national projections were made using Premier supplied projection weights. We calculated incremental resource use and outcomes by comparing cases with and without PPCs for each surgical condition and summarizing across all conditions.

Results

There were 738,039 cases in our cohort. At least one PPC was identified in 85,435. BS occurred on 6.4% of cases (45,005), NRF in 3.8% (27,796) and RF in 1.7% of cases (12,634). BS was not associated with an increase in the risk of death (one added death per 5611 cases), but had significant increases in resource use: one added ICU admission per 14 cases; one added ICU day per five cases; and one added hospital day and $1,563 added cost per case. NRF was associated with a modest increase in risk of death (one added death per 157 NRF cases) and substantial increases in resource use: one added ICU admission for every six cases; 0.66 ICU days per case; and three hospital days and $5,771 added cost per NRF case. RF was associated with greatly increased risk of death (one added death per 10 cases) and larger increases in resource use: one added ICU admission per two cases; 5 ICU days, 8 hospital days and $24,000 in added cost per RF case. Projecting to the US population there were 583,300 PPC cases, associated with 9,500 added deaths, 92,200 added ICU admissions, 584,200 added ICU days, 867,400 added floor days and $3.42 billion US in added costs. PPC add $717 to the average cost of elective surgery in the US.

Conclusions

PPCs are very common, occurring in one in eight elective postoperative patients. While BS was not associated with added deaths, all three PPC strata were associated with substantial increase in resource use. Better strategies for the prevention and management of PPCs could lead to greatly improved outcomes and substantial savings.