New scoring system may help identify surgical patients at risk for pulmonary complications

Physicians at Thomas Jefferson University Hospital, Philadelphia, Penn., have developed an analytical tool to identify surgical patients at risk for costly respiratory complications. This tool may help hospitals avoid those complications and their related costs as Medicare and commercial payers exert increasing pressure on them by eliminating payment for patient complications that occur after operations and may extend hospital stays.

The investigators developed a scoring system to identify risk factors for ventilator dependence after major operations by using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®). Study coauthor Adam P. Johnson, MD, MPH, presented their findings today at the 2015 American College of Surgeons National Surgical Quality Improvement Program Conference. NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in hospitals.

Mechanical ventilation can cost up to $1,522 per day per patient in the intensive care unit.¹ "The need for artificial mechanical ventilation after operations is infrequent, but when it happens it does carry high costs," Dr. Johnson explained. "Ventilator dependence is highly associated with mortality, and in and of itself is a morbidity."

According to the study authors, the need for ventilation is not widespread. Previous reports have estimated approximately one to three percent of patients who have non-emergency surgical procedures require ventilation afterward. But the consequences are nonetheless significant, according to coauthor Scott W. Cowan, MD, FACS. "Even one percent of 220,000"--the incidence reported in a 2011 University of Michigan study2--"is still a significant number of patients who develop postoperative respiratory failure," Dr. Cowan said. "This outcome is a very big expense for our health care system."

The Jefferson researchers analyzed ACS NSQIP data on 7,473 patients who had elective general or vascular operations at the institution between 2006 and 2013. The scoring system assigned points for different factors, such as current smoker (1 point), age older than 60 years (2 points), and esophagus procedures (3 points). Total risk scores ranged from 0 to 7 for study subjects. The median risk score for patients who did not need the ventilator after operations was 2, while that for patients who did need the ventilator was 3. Those with a score above 3 comprised the 20 percent of patients who experienced 70 percent of adverse events.

Other risk factors for postoperative ventilator dependence were a diagnosis of severe chronic obstructive pulmonary disease; signs of active infection or inflammatory response; and low albumin counts, a sign of malnutrition. "Our goal was to quantify how each factor affects the risk of ventilator dependence," Dr. Johnson said.

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