title: Hospital charges associated with "never events": comparison of anterior cervical discectomy and fusion, posterior lumbar interbody fusion, and lumbar laminectomy to total joint arthroplasty.
abstract: OBJECTIVE Beginning in 2008, the Centers for Medicare and Medicaid Service (CMS) determined that certain hospital-acquired adverse events such as surgical site infection (SSI) following spine surgery should never occur. The following year, they expanded the ruling to include deep vein thrombosis (DVT) and pulmonary embolism (PE) following total joint arthroplasty. Due to their ruling that "never events" are not the payers' responsibility, CMS insists that the costs of managing these complications be borne by hospitals and health care providers, rather than billings to health care payers for additional care required in their management. Data comparing the expected costs of such adverse events in patients undergoing spine and orthopedic surgery have not previously been reported. METHODS The California State Inpatient Database (CA-SID) from 2008 to 2009 was used for the analysis. All patients with primary procedure codes indicating anterior cervical discectomy and fusion (ACDF), posterior lumbar interbody fusion (PLIF), lumbar laminectomy (LL), total knee replacement (TKR), and total hip replacement (THR) were analyzed. Patients with diagnostic and/or treatment codes for DVT, PE, and SSI were separated from patients without these complication codes. Patients with more than 1 primary procedure code or more than 1 complication code were excluded. Median charges for treatment from primary surgery through 3 months postoperatively were calculated. RESULTS The incidence of the examined adverse events was lowest for ACDF (0.6% DVT, 0.1% PE, and 0.03% SSI) and highest for TKA (1.3% DVT, 0.3% PE, 0.6% SSI). Median inpatient charges for uncomplicated LL was $51,817, compared with $73,432 for ACDF, $143,601 for PLIF, $74,459 for THR, and $70,116 for TKR. Charges for patients with DVT ranged from $108,387 for TKR (1.5 times greater than index) to $313,536 for ACDF (4.3 times greater than index). Charges for patients with PE ranged from $127,958 for TKR (1.8 times greater than index) to $246,637 for PLIF (1.7 times greater than index). Charges for patients with SSI ranged from $168,964 for TKR (2.4 times greater than index) to $385,753 for PLIF (2.7 times greater than index). CONCLUSIONS Although incidence rates are low, adverse events of spinal procedures substantially increase the cost of care. Charges for patients experiencing DVT, PE, and SSI increased in this study by factors ranging from 1.8 to 4.3 times those for patients without such complications across 5 common spinal and orthopedic procedures. Cost projections by health care providers will need to incorporate expected costs of added care for patients experiencing such complications, assuming that the cost burden of such events continues to shift from payers to providers.
authors.affiliation: Department of Orthopedics, Adult Spinal Deformity Service, Brown University, Warren Alpert Medical School, Providence, Rhode Island;
authors.forename: Alan H
authors.initials: AH
authors.lastname: Daniels
authors.affiliation: Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon;
authors.forename: Satoshi
authors.initials: S
authors.lastname: Kawaguchi
authors.affiliation: Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon;
authors.forename: Alec G
authors.initials: AG
authors.lastname: Contag
authors.affiliation: Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon;
authors.forename: Farbod
authors.initials: F
authors.lastname: Rastegar
authors.affiliation: Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon;
authors.forename: Garrett
authors.initials: G
authors.lastname: Waagmeester
authors.affiliation: Department of Orthopedics, University of Wisconsin, Madison, Wisconsin; and.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Anderson
authors.affiliation: Department of Humanities and Social Sciences, Oregon Institute of Technology, Klamath Falls, Oregon.
authors.forename: Melanie
authors.initials: M
authors.lastname: Arthur
authors.affiliation: Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon;
authors.forename: Robert A
authors.initials: RA
authors.lastname: Hart
mesh_terms: D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects* / Q000191:economics; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects* / Q000191:economics; D002140:California / Q000453:epidemiology; D002574:Cervical Vertebrae / Q000601:surgery; D017586:Diskectomy / Q000009:adverse effects* / Q000191:economics / Q000379:methods; D017722:Hospital Charges / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D007796:Laminectomy / Q000009:adverse effects* / Q000191:economics / Q000379:methods; D008159:Lumbar Vertebrae / Q000601:surgery; D011183:Postoperative Complications / Q000191:economics* / Q000453:epidemiology / Q000628:therapy; D011655:Pulmonary Embolism / Q000191:economics / Q000453:epidemiology / Q000209:etiology / Q000628:therapy; D013123:Spinal Fusion / Q000009:adverse effects* / Q000191:economics / Q000379:methods; D020246:Venous Thrombosis / Q000191:economics / Q000453:epidemiology / Q000209:etiology / Q000628:therapy
keywords: ACDF = anterior cervical discectomy and fusion; CA-SID = California State Inpatient Database; CMS = Centers for Medicare and Medicaid Service; DVT = deep vein thrombosis; HCUP = Healthcare Cost and Utilization Project; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; LL = lumbar laminectomy; PE = pulmonary embolism; PLIF = posterior lumbar interbody fusion; SSI = surgical site infection; THR = total hip replacement; TKR = total knee replacement; adverse event; anterior cervical discectomy and fusion; complication; cost; deep vein thrombosis; hospital charge; infection; lumbar; never event