The value of routine ICU admission after elective surgery has been debated due to the lack of robust evidence supporting its benefit, as well as the increased incurred costs. We sought to analyze outcomes of patients undergoing hepatectomy who were routinely admitted to the intensive care unit (ICU) compared with surgical ward admission.
Patients were identified in the Truven Health Analytics MarketScan Commercial Claims and Encounters Database from 2010 to 2016. Routine postoperative ICU admission was defined as ICU admission for ≤ 24 h on postoperative day 0. Potential association between routine ICU admission with extended length-of-stay (LOS), failure-to-rescue, and total inpatient costs was analyzed.
In total 7970 patients underwent hepatectomy; 37.7% (n = 3001) had routine ICU admission and 62.3% (n = 4969) surgical ward admission. Among the 3001 patients who had routine ICU admission, 1137 (37.9%) had a major and 1864 (62.1%) had a minor hepatectomy. Routine ICU admission was not associated with lower failure-to-rescue (routine ICU 4.9% vs. ward 1.8%; p < 0.001). Patients routinely admitted to the ICU had longer median LOS (routine ICU 7 days, IQR 5–15 days vs. ward 5 days, IQR 4–7 days; p < 0.001). Median payments were higher for routine ICU admission than for surgical ward admission ($50,501, IQR $34,270–$80,459 vs. $39,774, IQR $28,555–$58,270, respectively).
Routine ICU admission was associated with longer LOS and higher hospital payments, yet did not translate into lower failure-to-rescue among patients undergoing hepatectomy.
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Short MN, Ho V, Aloia TA. Impact of processes of care aimed at complication reduction on the cost of complex cancer surgery. J Surg Oncol 2015; 112(6):610-5.
Centers for M, Medicaid Services HHS. Medicare program; Medicare Shared Savings Program: Accountable Care Organizations. Final rule. Fed Regist 2011; 76(212):67802-990.
CMS. Readmissions Reduction Program. Available at: https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html.
America. IoMUCoQoHCi. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US), 2001.
Medicine. Io. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press., 2006.
Internal Revenue Service DotT, Employee Benefits Security Administration DoL, Office of Consumer I, et al. Interim final rules for group health plans and health insurance issuers relating to internal claims and appeals and external review processes under the Patient Protection and affordable Care Act. Interim final rules with request for comments. Fed Regist 2010; 75(141):43329-64.
Coolsen MM, Wong-Lun-Hing EM, van Dam RM, et al. A systematic review of outcomes in patients undergoing liver surgery in an enhanced recovery after surgery pathways. HPB (Oxford) 2013; 15(4):245-51.
Melloul E, Hübner M, Scott M, et al. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg 2016; 40(10):2425-40.
Page AJ, Ejaz A, Spolverato G, et al. Enhanced recovery after surgery protocols for open hepatectomy--physiology, immunomodulation, and implementation. J Gastrointest Surg 2015; 19(2):387-99.
Taccone P, Langer T, Grasselli G. Do we really need postoperative ICU management after elective surgery? No, not any more! Intensive Care Med 2017; 43(7):1037-1038.
Gillies MA, Pearse RM. Intensive Care after High-risk Surgery: What’s in a Name? Anesthesiology 2016; 124(4):761-2.
Bagante F, Ruzzenente A, Beal EW, et al. Complications after liver surgery: a benchmark analysis. HPB (Oxford) 2019.
Buettner S, Gani F, Amini N, et al. The relative effect of hospital and surgeon volume on failure to rescue among patients undergoing liver resection for cancer. Surgery 2016; 159(4):1004-12.
Spolverato G, Ejaz A, Hyder O, et al. Failure to rescue as a source of variation in hospital mortality after hepatic surgery. Br J Surg 2014; 101(7):836-46.
Hansen L, Chang S. Health research data for the real world: the MarketScan databases. Ann Arbor, MI: Thomson Reuters 2012.
Stagg V. CHARLSON: Stata module to calculate Charlson index of comorbidity [Statistical Software Components S456719 web site]. 13 Sep 2017, 2006. Available at: https://ideas.repec.org/c/boc/bocode/s456719.html. Accessed 1/15/2019.
Iezzoni LI, Daley J, Heeren T, et al. Identifying complications of care using administrative data. Med Care 1994; 32(7):700-15.
Ghaferi AA, Osborne NH, Birkmeyer JD, et al. Hospital characteristics associated with failure to rescue from complications after pancreatectomy. J Am Coll Surg 2010; 211(3):325-30.
Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients. Ann Surg 2009; 250(6):1029-34.
Merath K, Chen Q, Bagante F, et al. Variation in the cost-of-rescue among medicare patients with complications following hepatopancreatic surgery. HPB (Oxford) 2018.
Krell RW, Girotti ME, Dimick JB. Extended length of stay after surgery: complications, inefficient practice, or sick patients? JAMA Surg 2014; 149(8):815-20.
Cerullo M, Gani F, Chen SY, et al. Routine intensive care unit admission among patients undergoing major pancreatic surgery for cancer: No effect on failure to rescue. Surgery 2019; 165(4):741-746.
Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol 2004; 159(7):702-6.
Firth D. Bias Reduction of Maximum Likelihood Estimates. Biometrika 1993; 80(1):27-38.
Heinze G, Schemper M. A solution to the problem of separation in logistic regression. Stat Med 2002; 21(16):2409-19.
Merath K, Hyer JM, Mehta R, et al. Use of perioperative epidural analgesia among Medicare patients undergoing hepatic and pancreatic surgery. HPB (Oxford) 2019.
Hicks CW, Alshaikh HN, Zarkowsky D, et al. Intensive care unit admission after endovascular aortic aneurysm repair is primarily determined by hospital factors, adds significant cost, and is often unnecessary. J Vasc Surg 2018; 67(4):1091-1101 e4.
Wunsch H, Gershengorn HB, Cooke CR, et al. Use of Intensive Care Services for Medicare Beneficiaries Undergoing Major Surgical Procedures. Anesthesiology 2016; 124(4):899-907.
Mogal HD, Levine EA, Fino NF, et al. Routine Admission to Intensive Care Unit After Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy: Not Always a Requirement. Ann Surg Oncol 2016; 23(5):1486-95.
Sobol JB, Wunsch H. Triage of high-risk surgical patients for intensive care. Crit Care 2011; 15(2):217.
Kahan BC, Koulenti D, Arvaniti K, et al. Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries. Intensive Care Med 2017; 43(7):971-979.
Merath K, Bagante F, Chen Q, et al. The Impact of Discharge Timing on Readmission Following Hepatopancreatobiliary Surgery: a Nationwide Readmission Database Analysis. J Gastrointest Surg 2018.
Nabhani J, Ahmadi H, Schuckman AK, et al. Cost Analysis of the Enhanced Recovery After Surgery Protocol in Patients Undergoing Radical Cystectomy for Bladder Cancer. Eur Urol Focus 2016; 2(1):92-96.
All patient data were de-identified and compliant with the Health Insurance Portability and Accountability Act of 1996. Patient consent was therefore waived; the study was approved by the Johns Hopkins University Institutional Review Board (Baltimore, MD).
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Merath, K., Cerullo, M., Farooq, A. et al. Routine Intensive Care Unit Admission Following Liver Resection: What Is the Value Proposition?. J Gastrointest Surg 24, 2491–2499 (2020). https://doi.org/10.1007/s11605-019-04408-5
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