The association between intraoperative low driving pressure ventilation and perioperative healthcare-associated costs: A retrospective multicenter cohort study

Study objective

A low dynamic driving pressure during mechanical ventilation for general anesthesia has been associated with a lower risk of postoperative respiratory complications (PRC), a key driver of healthcare costs. It is, however, unclear whether maintaining low driving pressure is clinically relevant to measure and contain costs. We hypothesized that a lower dynamic driving pressure is associated with lower costs.

Design

Multicenter retrospective cohort study.

Setting

Two academic healthcare networks in New York and Massachusetts, USA.

Patients

46,715 adult surgical patients undergoing general anesthesia for non-ambulatory (inpatient and same-day admission) surgery between 2016 and 2021.

Interventions

The primary exposure was the median intraoperative dynamic driving pressure.

Measurements

The primary outcome was direct perioperative healthcare-associated costs, which were matched with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP–NIS) to report absolute differences in total costs in United States Dollars (US$). We assessed effect modification by patients' baseline risk of PRC (score for prediction of postoperative respiratory complications [SPORC] ≥ 7) and effect mediation by rates of PRC (including post-extubation saturation < 90%, re-intubation or non-invasive ventilation within 7 days) and other major complications.

Main results

The median intraoperative dynamic driving pressure was 17.2cmH₂O (IQR 14.0–21.3cmH₂O). In adjusted analyses, every 5cmH₂O reduction in dynamic driving pressure was associated with a decrease of −0.7% in direct perioperative healthcare-associated costs (95%CI −1.3 to −0.1%; p = 0.020). When a dynamic driving pressure below 15cmH₂O was maintained, -US$340 lower total perioperative healthcare-associated costs were observed (95%CI −US$546 to −US$132; p = 0.001). This association was limited to patients at high baseline risk of PRC (n = 4059; −US$1755;97.5%CI −US$2495 to −US$986; p < 0.001), where lower risks of PRC and other major complications mediated 10.7% and 7.2% of this association (p < 0.001 and p = 0.015, respectively).

Conclusions

Intraoperative mechanical ventilation targeting low dynamic driving pressures could be a relevant measure to reduce perioperative healthcare-associated costs in high-risk patients.