Financial Impact of Operative Stress and Physiologic Reserve in Surgical Patients
Timothy L. Fitzgerald 1, Laura Nicolais MD2, *Aurora Quaye MD2, *Janelle M. Richard BS2, *Peter Hubbs MD2
1Surgery, Maine Medical Center, Portland, ME; 2Anesthesia, Maine Medical Center, Portland, ME
Objective: The physiologic stress of a surgical procedure can be estimated by the operative stress score (OSS). Physiologic reserve can be estimated by deficit accumulation frailty scores such as a risk analysis index (RAI). This report utilized a single institutional dataset to analyze the intersection of stress and reserve.
Design: Patients from a single institution undergoing surgery from July 2021 to December 2022 were analyzed. OSS had five levels from lowest to highest, 1-5. Patients were classified pre-frail/frail with RAI > 31, normal 21-30, and robust < 20. Univariant analysis was performed utilizing Chi-square, student T-test, and one-way ANOVA. Multivariate analysis was performed with logistic regression.
Setting: Academic Medical Center
Outcome measures: Charges, cost, contribution margin, and income
Results: A total of 6,182 patients were included. When patients with an OSS score of 5 were compared to the mean, they were older (67 vs. 65.4, p < 0.001) with an increased likelihood of being male (70.2 vs 53.9, p < 0.0001), length of stay (9.7 days vs 3.3 days, p < 0.0001), and mortality (30 days- 3.9 vs. 0.7, 90 days- 6.27 vs. 1.37, and 120 days- 8.24 vs.1.8, p < 0.002). Prefrail/frail patients compared to the mean were older (76 versus 65.4 years, p < 0.0001) and had increased likelihood of being male (68.9 versus 53.9, p < 0.0001), mortality (30 days- 1.6 versus 0.7, 90 days- 4.4 versus 1.73, and 120 days- 4.7 versus 1.8, p < 0.0001), and length of stay (4.8 versus 3.3 days, < 0.0001). Total charges and total costs increased with OSS in a near-linear fashion. Although net income significantly differed between OSS categories, the highest was OSS of 4 (,350 vs. mean , p < 0.001). Total charges and cost also increased linearly with increasing frailty (p < 0.0001). In contrast, there is a near-linear decrease in contribution margin and net income with increasing frailty. Overall, for pre-frail/frail patients, there was a net negative income (03,658 versus the , p < 0.0001). When analyzed individually with frailty, trends were similar with each OSS category (1/2, 3, 4, and 5). Net income was negative for almost all OSS categories in prefrail/frail (1/2 03,658, 3 04,440, 4 , and 5 09,932). On multivariate analysis, the positive association between total charges and cost with increasing OSS persisted. Prefrailty/frailty was associated with increased total charges and total cost (p < 0.001) and decreased contribution margin and net income (p < 0.001).
Conclusion: Increased operative stress and decreased physiologic reserve have significant financial impacts. Increasing OSS was associated with increased charges/costs and profit (contribution margin and income). Frailty was associated with increased cost with decreased profit (contribution margins and net income). Most physically stressful operations on prefrail/frail patients were performed at a financial loss.
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