The Cost of Failure: Assessing the Cost-Effectiveness of Rescuing Patients
from Major Complications After Liver Resection Using the National
Jay J. Idrees
Charles W. Kimbrough
Brad F. Rosinski
Mary E. Dillhoff
Eliza W. Beal
Jordan M. Cloyd
E. Christopher Ellison
Timothy M. Pawlik
Received: 14 February 2018 / Accepted: 17 May 2018
2018 The Society for Surgery of the Alimentary Tract
Objective To estimate the cost of rescue and cost of failure and determine cost-effectiveness of rescue from major complications
at high-volume (HV) and low-volume (LV) centers
Methods Ninety-six thousand one hundred seven patients undergoing liver resection were identified from the Nationwide
Inpatient Sample (NIS) between 2002 and 2011. The incremental cost of rescue and cost of FTR were calculated. Using
propensity-matched cohorts, a cost-effectiveness analysis was performed to determine the incremental cost-effectiveness ratio
(ICER) between HV and LV hospitals.
Results Ninety-six thousand one hundred seven patients were identified in NIS. The overall mortality was 2.3% and was lowest
in HV centers (HV 1.4% vs. MV 2.1% vs. LV 2.6%; p < 0.001). Major complications occurred in 14.9% of hepatectomies and
were comparable regardless of volume (HV 14.2% vs. MV 14.3% vs. LV 15.4%; p < 0.001). The FTR rate was substantially
lower among HV centers (HV 7.7%, MV 11%, LV 12%; p < 0.001). At a willingness to pay benchmark of $50,000 per year of
life saved, both HV (ICER = $3296) and MV (ICER = $4182) centers were cost-effective at rescuing patients from a major
complication compared to LV hospitals.
Conclusion Not only was FTR less common at HV hospitals, but the management of most major complications was cost-
effective at higher volume centers.
Keywords Failure to rescue
Quality of care
For many benign and malignant diseases of the liver, hepatic
resection represents the cornerstone of therapy. Hepatobiliary
surgery remains, however, a complex procedure with risk of
major complications and perioperative mortality.
incidence of major complications following many operations
may not be related to hospital volume, mortality has been
demonstrated to be lower in high-volume centers after com-
plex surgeries such as liver resection.
The increase in
mortality at some lower volume centers is due, at least in part,
to decreased recognition and timely management of major
complications, an occurrence known as failure-to-rescue
In turn, the relationship between better outcomes
and hospital volume has subsequently driven an emphasis to
concentrate or regionalize complex operations like hepatic
resection to high-volume centers.
While centralizing surgical procedures at high-volume cen-
ters may have a mortality benefit, the financial impact of con-
centrating complex procedures such as hepatic resection in
regional centers is unclear. While increased market consolida-
tion can create economies of scale that decrease total costs,
regionalization of care may also generate higher prices and
increase the use of expensive technologies.
complications are a major driver behind hospital costs, and
successful rescue from major complications may be more
* Timothy M. Pawlik
Department of Surgery, The Ohio State University, Wexner Medical
Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
Journal of Gastrointestinal Surgery