UI Hospitals and Clinics

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Kick the Habit to Cut Cost

A special note to smokers needing general surgery: not only will your recovery likely take longer than your nonsmoking counterparts, but your wallet may take a harder hit, as well.

"We know the complications that come with smoking related to our health," says Aparna Kamath, clinical assistant professor of internal medicine with University of Iowa Health Care. "We know wound complications are higher, cardiovascular complications are higher, and respiratory complications are higher."

Now, thanks to a study Kamath authored with fellow UI researchers, we also know that hospital costs are an average 4 percent, or roughly $900, higher for general surgery patients who smoke than they are for their nonsmoking counterparts. In fact, even those former smokers who haven’t smoked in a year saw smaller hospital bills than those still smoking.

"This research just strengthens our belief that we should encourage patients to quit smoking before their operations because of respiratory complications, in order to improve their surgical outcomes," Kamath says. "In addition, it provides health care stakeholders and decision makers with data to make a business case for preoperative smoking cessation interventions."

Kamath and her associates estimate that approximately 30 percent of patients undergoing elective general surgery procedures smoke. Although an abundance of research associates smoking with an increased risk of numerous postoperative complications, especially those related to pulmonary, cardiovascular, and wound-healing outcomes, little information is available comparing surgical costs for smokers versus nonsmokers, Kamath says.

In this study, published in the June issue of Journal of American College of Surgeons, Kamath and colleagues analyzed data on 14,853 patients who had undergone a general surgery operation in 123 Veterans Affairs (VA) Medical Centers during a one-year period. The patients, mostly white males, were classified into one of three groups: 34 percent were current smokers (patients who smoked within the year before their operation), 39 percent were former smokers (patients with a history of smoking, but who did not smoke during the year before their operation), and 27 percent were never smokers.

Researchers then examined hospital costs in three areas: the operation, subsequent readmission within 30 days of discharge, and length of hospital stay. Because smokers often have coexisting health conditions such as hypertension, chronic obstructive pulmonary disease, diabetes, and coronary artery disease—all of which can drive up health care costs—the researchers controlled for these factors as well as other factors, including age and urgency of surgical procedure.

Study results showed that total inpatient costs were 4 percent higher for current smokers compared with patients who never smoked. That finding translated into a higher cost of approximately $900 for each patient who underwent a surgical procedure, Kamath says. The same was not true for former smokers, for whom the difference in costs were not statistically significant compared with patients who never smoked. After factoring in the complexity of the operation, researchers found that hospital costs for smokers who had more complex procedures were 6 percent higher compared with hospital costs for patients who never smoked.

Another aim of the current study was to determine if the increased costs found for smokers were primarily the result of respiratory complications. Upon further analysis, the researchers found that, in fact, postoperative respiratory complications partially account for the added expense for smokers undergoing elective general surgery operations ."It wasn’t a surprise, but it’s important to actually prove this expectation," Kamath says.

Importantly, even short periods of abstinence may be beneficial. "Although our research did not directly address this issue, evidence suggests that quitting smoking before an operation, even as little as four to six weeks prior to the procedure, improves postoperative outcomes and decreases complications in patients," Kamath says. "I think it’s important to use the time before a surgical procedure as a teachable moment."

This study was conducted using two data sources, the National VA Surgical Quality Improvement Program (VASQIP) and Decision Support System (DSS). VASQIP was established in 1994 as a statistically reliable, risk-adjusted tool to help the Department of Veteran’s Affairs measure its quality of care. This data-driven initiative served as the basis for the development of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®), which now is used in hundreds of hospitals across the nation to reduce complications, improve outcomes, and decrease costs.

The U.S. Department of Veterans Affairs funded the research.