Bile duct injury (BDI) is a rare but devastating technical complication of cholecystectomy, occurring in around 0.2% of cases.1 Although infrequent, its impact is substantial given the high volume of cholecystectomies performed annually in the United States. While mortality and need for liver transplant have been evaluated, we currently lack contemporary data on costs and resources needed to manage BDI after cholecystectomy, which was the aim of our study.2–4
METHODS
We performed a retrospective cohort study using inpatient Medicare claims data from the Medicare Provider Analysis and Review file and the American Hospital Association Annual Survey to examine resource utilization and price-standardized Medicare spending among beneficiaries who experienced BDI requiring subsequent definitive surgical repair following cholecystectomy between 2010 and 2021.5,6 Beneficiaries aged 65–99 years with continuous Medicare fee-for-service coverage for 12 months postoperatively were included. We excluded patients with incomplete claims data or a diagnosis of gallbladder, bile duct, or liver malignancy. See eMethods Supplement, Supplemental Digital Content 1, http://links.lww.com/SLA/F674 for coding strategy. Beneficiary comorbidities were identified and categorized using the Elixhauser method.
Outcomes included 1-year total and component Medicare spending (eg, hospital, physician, and postacute care), readmissions (inpatient and outpatient), and 90-day complications (eMethods Supplement, Supplemental Digital Content 1, http://links.lww.com/SLA/F674). We performed multivariable regression analyses adjusting for demographics (age, sex, race) and 29 Elixhauser comorbidities. Binary outcomes (eg, complications, readmissions) were modeled using logistic regression. Continuous outcomes (eg, number of readmissions, days hospitalized), and Medicare spending were modeled using generalized linear models with a gamma distribution and log link to account for right-skewed data. Standard errors were clustered at the hospital level to account for within-hospital correlation.
Analyses were conducted using Stata version 18 (StataCorp). Statistical significance was defined as P < 0.05. This study was deemed exempt by our Institutional Review Board due to use of deidentified data.
RESULTS
We identified 68,974 beneficiaries whose cholecystectomies were complicated by BDI. Mean age was 73 years, and 56.3% of beneficiaries had ≥ 3 Elixhauser comorbidities (Table 1). Average adjusted total episode spending was $61,503 (95% CI: 60,705–62,301) (Table 2). While much of the spending was accounted for by the index hospitalization, substantial variation can be attributed for some beneficiaries to outlier payments [42.6%, 31,660 (95% CI: 30,233–33,087)], readmissions [60.9%, $28,429 (95% CI: 27,929–28,940)], and postacute care utilization [86.7%, $16,514 (95% CI: 16,385–17,025)] (Table 2).
TABLE 1.
Patient and Hospital Characteristics Among Beneficiaries With Bile Duct Injuries Following Cholecystectomy
| Patient characteristics | N (%) |
|---|---|
| No. patients | 68,974 |
| Age at index admission, mean (SD) | 73.0 (11.0) |
| Female sex | 31,537 (45.7) |
| White race | 57,210 (82.9) |
| No. elixhauser comorbidities | |
| 0 | 4626 (6.7) |
| 1 | 10,872 (15.8) |
| 2 | 14,633 (21.2) |
| 3 or more | 38,843 (56.3) |
| Approach | |
| Robotic-assisted | 1149 (1.7) |
| Laparoscopic | 34,754 (50.4) |
| Open | 33,071 (47.9) |
| Hospital characteristics | |
| Geographic region | |
| Northeast | 11,219 (16.3) |
| West | 14,398 (21.0) |
| Midwest | 15,573 (22.7) |
| South | 27,482 (40.0) |
| No. beds | |
| < 250 | 25,194 (36.7) |
| 250–499 | 25,034 (36.5) |
| > = 500 | 18,444 (26.9) |
| Profit status | |
| For-profit | 9,987 (14.5) |
| Nonprofit | 51,272 (74.7) |
| Other | 7413 (10.8) |
| CBSA urban location | 67,083 (97.7) |
| Teaching hospital | 43,196 (62.9) |
| Technology hospital | 50,549 (82.1) |
| Nurse to census ratio, mean (SD) | 8.3 (3.1) |
CBSA indicates core-based statistical area.
TABLE 2.
Adjusted Medicare Spending and Resource Utilization Among Beneficiaries With Bile Duct Injuries Following Cholecystectomy
| Variable (proportion of beneficiaries with payment) | Adjusted 1-year episode payments when present, mean USD (95% CI) |
|---|---|
| Medicare spending | |
| Total 1-year episode payment (100%) | 61,503 (60,705–62,301) |
| Hospital payment (100%) | 43,314 (42,680–43,949) |
| Index hospitalization (100%) | 31,107 (30,606–31,607) |
| DRG payment (100%) | 26,131 (25,882–26,380) |
| Outlier (42.6%) | 31,660 (30,233–33,087) |
| Readmission (60.9%) | 28,429 (27,929–28,940) |
| Physician services (100%) | 5,913 (5825–6000) |
| Postacute care (86.7%) | 16,705 (16,385–17,025) |
| Outpatient (80.6%) | 4517 (4380–4655) |
| Home health agency (57.5%) | 5184 (5101–5267) |
| Subacute nursing facility (48.1%) | 17,382 (17,062–17,701) |
| Inpatient rehabilitation facility (33.3%) | 23,786 (22,899–24,673) |
| Nursing (35.3%) | 50,627 (49,134–52,120) |
| Outcomes and resource utilization | Adjusted, estimated rate (95% CI) |
| Variable | |
| 90-day inpatient hospital readmissions after index hospitalization discharge | 26.24 (25,86–26.63) |
| 1-year inpatient hospital readmissions after index hospitalization discharge | 41.60 (41.15–42.06) |
| Any complication within 90 days of index hospitalization discharge | 49.24 (48.75–49.73) |
| Serious complications within 90 days of index hospitalization discharge | 31.69 (21.21–32.17) |
| Any reoperation after bile duct injury repair within 90 days of index hospitalization discharge | 7.14 (6.90–7.38) |
| 1-year outpatient visit to hospital facility | 50.74 (49.91–51.58) |
| 1-year outpatient visit to clinic or other outpatient facility | 52.13 (51.29–52.97) |
| 1-year inpatient admission to hospital or outpatient visit to hospital, clinic, or other outpatient facility | 68.68 (68.08–69.27) |
| Total number of days of health system touchpoints within 1 year following index hospitalization discharge | |
| Among all patients | 26.87 (26.41–27.34) |
| Among patients with any readmission | 33.67 (33.09–34.24) |
| Among patients with no readmissions | 11.98 (11.77–12.20) |
DRG indicates diagnosis-related group; USD, United States dollars.
From a resource utilization standpoint, 41.5% had an inpatient hospital readmission within one year following discharge. A smaller minority of beneficiaries (10.1%) had 3 or more inpatient hospital readmissions within one year following their index hospitalization. When all 1-year inpatient and outpatient encounters occurring after discharge from the index hospitalization were combined, the average number of days each beneficiary touched the health care system was nearly one month (26.87 days, 95% CI: 26.41–27.34). Other resource utilization data are summarized in Table 2.
DISCUSSION
This Medicare claims evaluation among beneficiaries with BDI following cholecystectomy found high levels of spending and resource utilization in the year following index hospitalization, with beneficiaries spending an average of one month in that year interacting with the health care system. These data suggest that BDI imposes a sustained clinical and economic burden, which are driven by a combination of prolonged recovery, high rates postacute care utilization, readmissions, and multiple outpatient encounters.
This study has important limitations, including reliance on administrative data, which may lack clinical granularity. However, we evaluated outcomes reliably coded in claims data using previously validated methods and were able to leverage actual payer spending information, providing a robust assessment of the economic implications of BDI.
Together, these findings highlight that even rare surgical complications, such as BDI after cholecystectomy, can impose large aggregate costs and substantial resource utilization. These data underscore the importance of ongoing initiatives to improve the safety of cholecystectomy and prevent occurrence of BDI.1
Supplementary Material
Supplemental Digital Content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website, www.annalsofsurgery.com.
Acknowledgments
C.L.M. reports receiving unrelated grant funding from the National Institute on Minority Health and Health Disparities (award number: L60MD020984) and Frederick A. Coller Surgical Society during the conduct of this study. S.L.S. receives unrelated research and grant funding from the National Cancer Institute on a T32 training grant (award number: 2T32-CA236621-06A1). Unrelated to this work. J.B. D. reports receiving personal fees from ArborMetrix Inc and being an equity owner in ArborMetrix Inc. No other disclosures were reported.
This work was supported by grant R01-DK131584-01 from the National Institute of Diabetes and Digestive and Kidney Diseases to Drs. Dimick and Sheetz.
Footnotes
The authors report no conflicts of interest.
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