Improving surgical outcomes

If you’ve ever received a bill for a surgery, you know it’s expensive. Unsurprisingly, it’s also one of the top cost drivers for employers, accounting for roughly 34% of total healthcare spend.

One thing that can drive those costs up even further? Complications. These unplanned events during or after surgery affect recovery, can extend a person’s hospital stay, and might even require additional treatment—all of which have a big impact on costs.

While we’d all like to think surgical complications are few and far between, they’re more common than most people realize. According to one study, adverse surgical outcomes (such as reactions to anesthesia, unintended lacerations or punctures, or wound issues) occurred in more than one in three patients who were admitted for surgery.

Surgery can be unpredictable, and there’s always the potential for problems to crop up. However, plenty of research shows that complication rates vary (often significantly) depending on where the operation was performed and who performed it.

That might sound scary, but it’s actually good news. It means employers have a little more control over quality and surgical outcomes (and, as a result, costs) than they might initially think.

What causes surgery complications?

Many times, surgical outcomes aren’t random or left to chance. The same procedure can have dramatically different results depending on two main factors: the facility and the surgeon.

The Facility

Where a surgery takes place has a big impact on outcomes. Two things are particularly influential: how often a facility performs a given procedure and the quality of the infrastructure supporting that care.

Hospital volume—that’s the term for how often a hospital performs a specific procedure in a given year—is one of the most consistently studied predictors of surgical outcomes. Here’s a quick look at some of the research:

• For bariatric surgery specifically, one study found that higher hospital volume was associated with fewer postoperative complications.
• In a study of total joint arthroplasty (TJA)—a surgery that replaces a damaged or arthritic joint with artificial implants—high-volume centers had significantly lower risks of mortality and major complications.
• In another study, patients at low-volume facilities had more than twice the risk of wound complications in the first month following knee replacement surgery, compared to those treated at high-volume facilities.

Put simply, the more frequently a hospital performs a type of surgery, the better a person’s chances of avoiding complications.

But while volume carries a lot of weight, it’s not the only thing that matters. Studies show that a hospital’s infrastructure—that includes things like staffing levels, care protocols, and specialist resources—also shapes surgical outcomes:

• One study of more than 232,000 surgical patients found that each additional patient added to a nurse’s workload was associated with a 7% increase in the likelihood of dying within 30 days. It was also associated with a 7% increase in the odds of “failure to rescue,” meaning an inability to prevent death after a patient develops a complication.
• Standardized care protocols are effective, too. When hospitals in one study introduced a 19-item World Health Organization (WHO) surgical safety checklist designed to improve team communication and consistency of care, postoperative complication rates fell by 36% on average, and death rates fell by a similar amount.

Surgical outcomes aren’t just about what happens in the procedure room. The facility itself—how experienced it is, how it’s staffed, and how it operates—plays a major role in whether a patient recovers smoothly or faces setbacks.

The Surgeon

Understandably, who performs the actual procedure also has a large impact on surgical outcomes—and there are a couple of things worth considering when deciding whether or not a surgeon is the right choice.

Just as with facilities, studies show that volume (meaning how many times a surgeon performs a specific procedure) is important in minimizing the risk of complications.

For many procedures, patients can substantially improve their chances of survival by selecting surgeons who perform the operation frequently. In a study of nearly 475,000 patients, surgeons who performed a procedure more frequently had lower patient death rates—and that held true across all eight cardiovascular and cancer procedures studied.

Keep in mind that just because a facility itself is high-volume or high-quality doesn’t automatically guarantee the individual surgeon is. It’s smart for patients to ask thoughtful questions about both the facility and the surgeon to make their most informed choices.

Of course, it’s hard to overstate the importance of the surgeon’s technical skills. These can vary pretty substantially, and research shows this variation has a direct, measurable impact on surgical outcomes:

• In one NEJM study, researchers had peer surgeons anonymously rate video recordings of 20 bariatric surgeons performing laparoscopic gastric bypass.
• Surgeons rated in the lowest quartile of skill had complication rates of 14.5% compared with 5.2% among those in the highest quartile.
• Lower-skill surgeons also had longer operating times (137 minutes vs. 98 minutes) and higher rates of reoperation and readmission.

It proves that a surgeon’s skill affects the full journey of a patient’s recovery, and not just what happens inside the OR.

How complication rates impact employer costs

Surgical complications obviously have the biggest impact on the patient. But, as an employer, they also affect you—especially your bottom line.

When a patient develops a complication after surgery, hospital costs skyrocket. In one study, any surgical complication resulted in an average 1.5-fold increase in direct hospital costs. Serious complications (like septic shock, as one example) drove costs four times higher than uncomplicated costs.

Complications also extend how long a patient needs to stay in the hospital. That same study found patients who experienced complications had average hospital stays of 6.5 days, compared with 3.2 days for patients without complications—and they were nearly 10 times more likely to be readmitted.

And unfortunately, those readmissions carry a hefty price tag. The average cost of an inpatient surgical admission for people with large employer coverage is $47,345. If a complication triggers a readmission, it can effectively double that bill.

There’s the productivity cost, too. Complications extend the timeline for recovery, meaning more time away from work, reduced capacity when the employee returns, and, in some cases, permanent changes to their ability to do their job.

In short, reducing surgical complications is a clinical priority and an effective way for employers to control healthcare spend.

How employers can steer employees toward high-quality surgery care

You don’t make healthcare decisions for your employees, but the access you offer through your benefits packages shapes which options employees can realistically consider. Here are a few things you can do:

• Offer access to value-based Centers of Excellence (COEs): Best-in-class COE programs connect employees to vetted networks of high-performing hospitals and surgeons, selected based on outcomes data, volume, and care coordination. It’s the most direct way employers can influence surgical quality.
  • An independent RAND study found that patients using Carrum Health’s COE network experienced 80% fewer readmissions for joint replacement, spinal fusion, and bariatric surgery.
• Use benefit design to incentivize better care: Structuring benefits so employees pay less out-of-pocket at COE facilities (or nothing at all) encourages them to choose higher-quality options without feeling pressured.
  • Bundled payment arrangements, which cover the full episode of care at a single transparent price, also remove the billing unpredictability that leads employees to default to the nearest option rather than the best one.
• Invest in care navigation: Surgery can be overwhelming. Carrum provides your employees with a dedicated care navigator who helps them understand their options, coordinates scheduling, and supports them through recovery. This improves both outcomes and the overall experience.
• Look for outcome guarantees: Some of Carrum’s offerings include post-surgical warranties. If a complication or readmission occurs within 30 days (the most common window for complications and readmissions), the cost falls on the provider, and not on the patient or employer.

The difference between a smooth surgical recovery and a costly, complicated one often comes down to where the operation happens and who performs it. Fortunately, employers have more influence over these factors than they might think.

Investing in high-quality surgical access is the right thing to do for your employees, and it’s one of the most effective ways to achieve optimal surgical outcomes and manage your healthcare spend.