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Surgical Costs Associated with Smoking in Veterans Undergoing General Surgery

Kamath AS, Vaughan-Sarrazin MS, Vander Weg MW, Cullen J, Katz DA. Surgical Costs Associated with Smoking in Veterans Undergoing General Surgery. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2011 May 6; Phoenix, AZ.


BACKGROUND: Approximately 30% of general surgery patients undergoing elective surgery smoke cigarettes, and an estimated 10 million procedures are performed on smokers every year in the US. Smoking has been shown to be associated with poor wound healing as well as increased postoperative pulmonary and cardiovascular complications. The objectives of this study are: 1) to compare total inpatient costs in current smokers, former smokers, and never smokers undergoing general surgical procedures in VA hospitals, and 2) to determine whether the relationship between smoking and costs is mediated by postoperative complications. METHODS: This study was performed using two data sources: First, general surgical patients were identified in the VA Surgical Quality Improvement Program data set (VASQIP), which includes abstracted medical record data (including smoking status) for VA surgical patients. Second, inpatient costs of care were identified in the VA Decision Support System (DSS), which provides the costs of individual patient encounters on the basis of the relative values assigned to medical services. Relative to never smokers (reference category), surgical costs for current and former smokers were estimated using generalized linear regression models with adjustment for preoperative variables (demographics, comorbidities, functional status, and laboratory values), operative variables (urgency of surgery, complexity of surgery), and hospital-level variation. Costs included those incurred during the index hospitalization and during readmissions within 30 days of surgery. RESULTS: the 14,853 general surgical patients, 34% were current smokers, 39% were former smokers, and 27% were never smokers. Unadjusted costs were significantly higher for current and former smokers relative to never smokers: relative costs (95% CI) were 1.11 (1.06- 1.15) and 1.15 (1.10-1.19), respectively. After controlling for patient covariates, current smokers still had significantly higher costs compared to never smokers: relative cost was 1.04 (1.00-1.07); costs for former smokers did not differ significantly from those of never smokers: relative cost was 1.02 (0.99-1.06). The relationship between smoking and surgical costs was partially mediated by surgical complications. Relative costs for current smokers were no longer statistically significant after accounting for any surgical complications: 1.02 (0.99-1.05). CONCLUSION: Smokers undergoing elective general surgery have modestly increased surgical costs compared to never smokers, in part related to increased postoperative complications. Our results suggest that efforts to improve surgical outcomes and reduce hospital costs in general surgery patients should place greater emphasis on helping patients quit smoking preoperatively.

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