Pay for obesity? Pay-for-performance metrics neglect increased complication rates and cost for obese patients

Rates of surgical complications are increasingly being used for pay-for-performance reimbursement structures. We hypothesize that morbid obesity has a significant effect on complication rates and costs following commonly performed general surgical procedures.

We studied 30,502 patients who underwent cholecystectomy for cholecystitis and 6,390 patients who underwent appendectomy for acute appendicitis using administrative claims data from seven Blue Cross and Blue Shield Plans over a 7-year period (2002-2008). We compared 30-day complications as well as total 30-day direct medical costs for obese and non-obese patients. Multivariate regressions were performed to determine the relationship of morbid obesity to complications and cost.

Obese patients were more likely to have a complication within 30 days after surgery than non-obese patients (19.2% vs. 15.7% for cholecystectomy, p < 0.0001; 20.2% vs. 15.2%, p < 0.0001, for appendectomy). The mean total 30-day postoperative cost for obese patients were $1,109 higher following a cholecystectomy (p < 0.0001) and $666 higher following an appendectomy (p = 0.09).

Morbid obesity is associated with a higher rate of complications for two commonly performed general surgical procedures and is associated with higher costs for cholecystectomy. Pay-for-performance metrics should account for the increased risk of complications and higher cost in this population.