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Cost of Individual Complications Following Coronary Artery Bypass Grafting
James H Mehaffey1, Robert B Hawkins1, Eric J Charles1, Clifford Fonner2, Irving L Kron1, Mohammed Quader3, Alan Speir4, Jeff Rich2, Gorav Ailawadi1
1University of Virginia, Charlottesville, VA;2Virginia Cardiac Surgery Quality Initiative, Falls Church, VA;3Virginia Commonwealth University, Richmond, VA;4INOVA Heart and Vascular Institute, Falls Church, VA

Objective: Given the fiscal challenges likely associated with the newly proposed bundled payment for coronary artery bypass surgery (CABG), it is critical to understand the financial implications of postoperative complications in cardiac surgery. The purpose of this study is to define the cost of perfect surgery (no complications) and demonstrate the incremental cost of each complication.
Methods: All (36,588) isolated CABG patients were evaluated (2006-2015) from a statewide Society of Thoracic Surgeons (STS) database collaborative. Patients were stratified by presence of postoperative complications including major morbidities as defined by the STS (prolonged ventilation, renal failure, reoperation, stroke, and deep sternal wound infection). Hierarchical modeling was used to identify the independent inflation-adjusted cost of each complication while controlling for hospital variation and time.
Results: The median age was 64, 74.3% were male and average predicted risk of mortality was 1.9%. A total of 24,738 (67.7%) patients experienced no complications at an average cost of $36,580. Each complication independently increases the cost of care (Table). The incidence of each additional major complication resulted in an exponential increase in cost (Figure). After accounting for incidence and incremental costs, institutions in our collaborative have spent an estimated $59.1 million on prolonged ventilation, $8.3 million on renal failure, $7.6 million on reoperation, $3.3 million on stroke, and $256,000 on deep sternal wound infections within the first 30 days after surgery over the past 10 years.
Conclusions: Perfect CABG without complication costs $36,580 on average. Major complications produce an exponential increase in costs and over the past ten years have totaled $78.6 million. As alternative payment models including bundled care are implemented, it is critical to understand the cost of adverse events to guide quality improvement projects, estimate true costs, and risk adjust payment models.


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