Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients

Abstract

Importance: Postoperative neurocognitive disorders (PNDs) after surgical procedures are common and may be associated with increased health care expenditures.

Objective: To quantify the economic burden associated with a PND diagnosis in 1 year following surgical treatment among older patients in the United States.

Design, setting, and participants: This retrospective cohort study used claims data from the Bundled Payments for Care Improvement Advanced Model from 4285 hospitals that submitted Medicare Fee-for-service (FFS) claims between January 2013 and December 2016. All Medicare patients aged 65 years or older who underwent an inpatient hospital admission associated with a surgical procedure, did not experience a PND before index admission, and were not undergoing dialysis or concurrently enrolled in Medicaid were included. Data were analyzed from October 2019 and May 2020.

Exposures: PND, defined as an International Classification of Diseases, Ninth or Tenth Revision, diagnosis of delirium, mild cognitive impairment, or dementia within 1 year of discharge from the index surgical admission.

Main outcomes and measures: The primary outcome was total inflation-adjusted Medicare postacute care payments within 1 year after the index surgical procedure.

Results: A total of 2 380 473 patients (mean [SD] age, 75.36 (7.31) years; 1 336 736 [56.1%] women) who underwent surgical procedures were included, of whom 44 974 patients (1.9%) were diagnosed with a PND. Among all patients, most were White (2 142 157 patients [90.0%]), presenting for orthopedic surgery (1 523 782 patients [64.0%]) in urban medical centers (2 179 893 patients [91.6%]) that were private nonprofits (1 798 749 patients [75.6%]). Patients with a PND, compared with those without a PND, experienced a significantly longer hospital length of stay (mean [SD], 5.91 [6.01] days vs 4.29 [4.18] days; P < .001), were less likely to be discharged home (9947 patients [22.1%] vs 914 925 patients [39.2%]; P < .001), and had a higher incidence of mortality at 1 year after treatment (4580 patients [10.2%] vs 103 767 patients [4.4%]; P < .001). After adjusting for patient and hospital characteristics, the presence of a PND within 1 year of the index procedure was associated with an increase of $17 275 (95% CI, $17 058-$17 491) in cost in the 1-year postadmission period (P < .001).

Conclusions and relevance: The findings of this cohort study suggest that among older Medicare patients undergoing surgical treatment, a diagnosis of a PND was associated with an increase in health care costs for up to 1 year following the surgical procedure. Given the magnitude of this cost burden, PNDs represent an appealing target for risk mitigation and improvement in value-based health care.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Sites reported serving as the editor-in-chief of Regional Anesthesia and Pain Medicine. No other disclosures were reported.

Figures

Figure 1.. Assembly of the Cohort

Data from the Bundled Payment for Care Improvement-Advanced (BPCI-A) data set were used to assess patients presenting for surgery between 2013 and 2016.

Figure 2.. Unadjusted and Multivariable Models Predicting Health Care Costs

HCC indicates Hierarchical Condition Category.

Figure 3.. Adjusted Payments by Neurocognitive Disorder Subtype

No patients were categorized as having both dementia and mild cognitive impairment in the first year following the index surgical admission and are thus not reported.