Cost of Major Complications after Liver Resection in the United States: Are High-volume Centers Cost-effective?

Objective: The aim of the study was to estimate the cost of major complications after liver resection and determine whether high-volume (HV) centers are cost-effective. Methods: From 2002 to 2011, 96,107 cases of liver resection performed in the United States were identified using Nationwide Inpatient Sample. Hospitals were categorized as HV (150+ cases/yr), medium-volume (51-149 cases/yr), and low-volume (LV) (1-50 cases/yr) centers. Multivariable regression analysis identified predictors of cost. Propensity score matching comparing cases with versus without complications and costs of specific complications were estimated. Cost-effectiveness of HV centers was determined by calculating the incremental cost-effectiveness ratio. Results: After propensity score matching, the occurrence of a major complication added $33,855 extra cost, increased mean length of stay by 8.7 [95% confidence interval (CI), 8.4-9] days and increased risk of death by 9.3% (all P < 0.001). The cost of most common complications was wound infection (3.8%, $21,995), renal failure (2.8%, $19,201), respiratory failure (2.7%, $25,169), and hemorrhage (3.3%, $9,180), whereas sepsis (0.8%, $33,009), gastrointestinal bleeding (0.5%, $32,835), fistula (0.2%, $27,079), and foreign body removal (0.1%, $29,404) were most costly, but less frequent. Compared with LV centers, liver resection at HV centers was associated with $5109 (95% CI, 4409-5809, P < 0.001) more cost per case, yet on average 0.54 years (95% CI, 0.23-0.86) longer survival for an incremental cost-effectiveness ratio of $9392. Conclusions: HV centers were cost-effective at performing liver resection compared with LV centers. After liver resection, complications such as surgical site infection, respiratory failure, and renal failure contributed the most to annual cost burden.