Reply to the Letter “Discrepancies in Analysis of Frequency, Type of Complications and Economic Costs of Outlying Patients in General and Digestive Surgery”

To the Editor:

In reference to the controversy raised by our article,¹ we would like to thank Dr. De la Plaza's group for their interest and respond to their comments.²

It may not be clear in the methodology, but the minimum basic data set (MBDS) was used exclusively for a randomized sampling of all the non-outlying patients who, meeting the inclusion criterion, had the same DRG as the outlying patients, thereby balancing the samples in complexity, number and date. Each episode was evaluated individually, however, analyzing all clinical records and classifying the complications according to the internationally accepted Clavien-Dindo classification,³ as shown in Table 3, in addition to the categories proposed in the article (infectious, hemorrhagic, etc.). Precisely that is the reason why there are differences in complications between some patients and others, although they were not statistically significant. Therefore, we disagree on the interpretation that is made of the method. In any case, we should mention that, in our unit, we monitor the prospective recording of complications, as recommended,⁴ in a database prepared for this purpose with more than 17 000 record entries, which has been very helpful for the development of the study. However, due to its design we have had to retrospectively review the digital files, so it is not cited in the methodology.

As for the calculation of costs, we agree, and this is reflected in the discussion in the article about cost calculation⁵; there are other models such as direct imputation, which is more precise but also more expensive and complex to obtain in a public healthcare system. There is also the proposed model that uses the economic validation of the Comprehensive Complication Index,^6,7 although this had not been published when we submitted our manuscript. Our proposal for adjustment according to the hospital stay rate for each DRG attempts to adjust the cost so that it is closer to reality, although the calculations are somewhat generic and clearly limited when analyzing the cases individually. However, the main objective of the study is to analyze not the costs of complications but those of outlying patients, even though the complications certainly determine the cost of the episode, whether or not patients are outlying. Undoubtedly, this question is more commonly discussed “in the corridors” than in the scientific literature, and we believe that it should be analyzed in a more precise manner. However, as we have already said, it is tremendously difficult to design a prospective, randomized study due to the limitations of the admissions management system itself, hospital administration and, logically, the ever-changing availability of hospital beds.

Funding

The authors have received no funding for the development or publication of this project.