Association of reintubation and hospital costs and its modification by postoperative surveillance: A multicenter retrospective cohort study

Maíra I Rudolph; Omid Azimaraghi; Elie Salloum; Luca J Wachtendorf; Aiman Suleiman; Tobias Kammerer; Maximilian S Schaefer; Matthias Eikermann; Michael E Kiyatkin

doi:10.1016/j.jclinane.2023.111264

Association of reintubation and hospital costs and its modification by postoperative surveillance: A multicenter retrospective cohort study

J Clin Anesth. 2023 Dec:91:111264. doi: 10.1016/j.jclinane.2023.111264. Epub 2023 Sep 16.

Authors

Maíra I Rudolph¹, Omid Azimaraghi², Elie Salloum³, Luca J Wachtendorf⁴, Aiman Suleiman⁵, Tobias Kammerer⁶, Maximilian S Schaefer⁷, Matthias Eikermann⁸, Michael E Kiyatkin⁹

Affiliations

¹ Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Department for Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany. Electronic address: mrudolph@montefiore.org.
² Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA. Electronic address: oazimaragh@montefiore.org.
³ Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA. Electronic address: esalloum.md@gmail.com.
⁴ Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, MA, USA. Electronic address: lucawachtendorf@gmail.com.
⁵ Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Anesthesia and Intensive Care, Faculty of Medicine, The University of Jordan, Amman, Jordan. Electronic address: asuleima@bidmc.harvard.edu.
⁶ Department for Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany. Electronic address: tobias.kammerer@uk-koeln.de.
⁷ Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Anesthesiology, Dϋsseldorf University Hospital, Dϋsseldorf, Germany. Electronic address: msschaef@bidmc.harvard.edu.
⁸ Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany. Electronic address: meikermann@montefiore.org.
⁹ Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA. Electronic address: mkiyatkin@montefiore.org.

PMID: 37722150
DOI: 10.1016/j.jclinane.2023.111264

Abstract

Objective: We estimated hospital costs associated with postoperative reintubation and tested the hypothesis that prolonged surveillance in the post-anesthesia care unit (PACU) modifies the hospital costs of reintubation.

Design: Retrospective observational research study.

Setting: Two tertiary care academic healthcare networks in the Bronx, New York and Boston, Massachusetts, USA.

Patients: 68,125 adult non-cardiac surgical patients undergoing general anesthesia between 2016 and 2021.

Interventions: The exposure variable was unplanned reintubation within 7 days of surgery.

Measurements: The primary outcome was direct hospital costs associated with patient care related activities. We used a multivariable generalized linear model based on log-transformed costs data, adjusting for pre- and intraoperative confounders. We matched our data with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS). In the key secondary analysis, we examined if prolonged postoperative surveillance, defined as PACU utilization (≥4 h) modifies the association between reintubation and costs of care.

Main results: 1759 (2.6%) of patients were re-intubated within 7 days after surgery. Reintubation was associated with higher direct hospital costs (adjusted model estimate 2.05; 95% CI: 2.00-2.10) relative to no reintubation. In the HCUP-NIS matched cohort, the adjusted absolute difference (AD_adj) in costs amounted to US$ 18,837 (95% CI: 17,921-19,777). The association was modified by the duration of PACU surveillance (p-for-interaction <0.001). In patients with a shorter PACU length of stay, reintubation occurred later (median of 2 days; IQR 1, 5) versus 1 days (IQR 0, 2; p < .001), and was associated with magnified effects on hospital costs compared to patients who stayed in the PACU longer (AD_adj of US$ 23,444, 95% CI: 21,217-25,799 versus AD_adj of US$ 17,615, 95% CI: 16,350-18,926; p < .001).

Conclusion: Postoperative reintubation is associated with 2-fold higher hospital costs. Prolonged surveillance in the recovery room mitigated this effect. The cost-saving effect of longer PACU length of stay was likely driven by earlier reintubation in patients who needed this intervention.

Keywords: Hospital costs; PACU; Postoperative reintubation; Surveillance.

Publication types

Multicenter Study
Observational Study

MeSH terms

Adult
Anesthesia, General*
Hospital Costs*
Humans
Length of Stay
Postoperative Period
Recovery Room
Retrospective Studies