The process of estimating the cost of surgery: Providing a practical framework for surgeons

Comparing Costs: Does Extreme Oncoplastic Breast-Conserving Surgery Confer a Cost Benefit When Compared with Mastectomy and Reconstruction?

INTRODUCTION

Extreme oncoplastic breast-conserving surgery (eOBCS) describes the application of OBCS to patients who would otherwise need a mastectomy, and its safety has been previously described.

OBJECTIVE

We aimed to compare the costs of eOBCS and mastectomy.

METHODS

We reviewed our institutional database to identify breast cancer patients treated surgically from 2018 to 2023. We included patients with a large disease span (≥5 cm) and multifocal/multicentric disease. Patients were grouped by their surgical approach, i.e. eOBCS or mastectomy. The direct costs of care were determined and compared; however, indirect costs were not included.

RESULTS

Eighty-six patients met the inclusion criteria, 10 (11.6%) of whom underwent mastectomy and 76 (88.4%) who underwent eOBCS. Six mastectomy patients (60%) had reconstruction and 6 (60%) underwent external beam radiation therapy (EBRT). Reconstructions were completed in a staged fashion, and the mean cost of the index operation (mastectomy and tissue expander) was $17,816. These patients had one to three subsequent surgeries to complete their reconstruction, at a mean cost of $45,904. The mean cost of EBRT was $5542. Thirty-four eOBCS patients (44.7%) underwent 44 margin re-excisions, including 6 (7.9%) who underwent mastectomy. Sixty (78.9%) of the eOBCS patients had EBRT. The mean cost of their index operation was $6345; the mean cost of a re-excision was $3615; the mean cost of their mastectomies with reconstruction was $49,400; and the mean cost of EBRT was $6807. The cost of care for eOBCS patients remained lower than that for mastectomy patients, i.e. $17,318 versus $57,416.

CONCLUSION

eOBCS is associated with a lower cost than mastectomy and had a low conversion rate to mastectomy.

Cost-effectiveness of the ADVISE trial: An intraoperative OCT protocol in DMEK surgery

The intraoperative optical coherence tomography (iOCT) is recently introduced in Descemet membrane endothelial keratoplasty (DMEK) surgery, which aims to increase clinical performance and surgery safety. However, the acquisition of this modality is a substantial investment. The objective of this paper is to report on the cost-effectiveness of an iOCT-protocol in DMEK surgery with the Advanced Visualization in Corneal Surgery Evaluation (ADVISE) trial. This cost-effectiveness analysis uses data 6 months postoperatively from the multicentre prospective randomized clinical ADVISE trial. Sixty-five patients were randomized to usual care (n = 33) or the iOCT-protocol (n = 32). Quality-Adjusted Life Years (EQ-5D-5L), Vision-related Quality of Life (NEI-VFQ-25) and self-administered resources questionnaires were administered. Main outcome is the incremental cost-effectiveness ratio (ICER) and sensitivity analyses. The iOCT protocol reports no statistical difference in ICER. For the usual care group compared with the iOCT protocol, respectively, the mean societal costs are €5027 compared with €4920 (Δ€107). The sensitivity analyses report the highest variability on time variables. This economic evaluation learned that there is no added value in quality of life or cost-effectiveness in using the iOCT protocol in DMEK surgery. The variability of cost variables depends on the characteristics of an eye clinic. The added value of iOCT could gain incrementally by increasing surgical efficiency, and aiding in surgical decision-making.

What are the observed procedural costs of vascular access surgery? Protocol for a systematic review

INTRODUCTION

A central component in the introduction of a novel surgical procedure or technique is an evaluation of its cost efficiency when compared with a benchmark standard of care. Accurate assessment of costs is thus essential in ensuring appropriate allocation of resources within a healthcare system. The treatment of kidney failure requires a significant volume of resources, and vascular access provision is the main modifiable cost. The costs of providing this service are obscured by generic NHS reference costs, which lack adequate granularity to allow meaningful comparisons between treatments. The aim of this systematic review will be to assess the reporting of procedural costs in all published economic analyses of vascular access surgery and perform a comparison of the reported procedural costs involved in arteriovenous fistula (AVF) and arteriovenous graft (AVG) creation. This will provide an estimate as to the accuracy of the NHS reference costs in this field.

METHODS AND ANALYSIS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines will be followed. A systematic search will be performed of the MEDLINE, Embase and Cochrane databases to identify full-text economic analyses of vascular access for haemodialysis in which the procedural cost of AVF or AVG creation is reported. Publications in English from 1 January 2000 to 30 August 2023, will be eligible for inclusion. Studies will be selected by title and abstract review, followed by a full-text review using inclusion and exclusion criteria. Studies not reporting the procedural costs of surgery will be excluded. Data collected will pertain to procedural costs of AVF and AVG creation. Costs will be adjusted to a common currency using a gross domestic product (GDP) deflator index and conversion rates based on purchasing power parities for GDP. Comparison with NHS reference costs will indicate their reliability for use in future economic analyses in this field.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review. Findings will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42023458779.

Challenges involved in the application of artificial intelligence in gastroenterology: The race is on!

Gastroenterology is a particularly data-rich field, generating vast repositories of data that are a fruitful ground for artificial intelligence (AI) and machine learning (ML) applications. In this opinion review, we initially elaborate on the current status of the application of AI/ML-based software in gastroenterology. Currently, AI/ML-based models have been developed in the following applications: Models integrated into the clinical setting following real-time patient data flagging patients at high risk for developing a gastrointestinal disease, models employing non-invasive parameters that provide accurate diagnoses aiming to either replace, minimize, or refine the indications of endoscopy, models utilizing genomic data to diagnose various gastrointestinal diseases, computer-aided diagnosis systems facilitating the interpretation of endoscopy images, models to facilitate treatment allocation and predict the response to treatment, and finally, models in prognosis predicting complications, recurrence following treatment, and overall survival. Then, we elaborate on several challenges and how they may negatively impact the widespread application of AI in healthcare and gastroenterology. Specifically, we elaborate on concerns regarding accuracy, cost-effectiveness, cybersecurity, interpretability, oversight, and liability. While AI is unlikely to replace physicians, it will transform the skillset demanded by future physicians to practice. Thus, physicians are expected to engage with AI to avoid becoming obsolete.

The unmet surgical needs of global refugee populations: A perspective review

The global refugee community, including those forced to flee due to persecution, conflict, or violence, faces significant challenges in accessing healthcare, resulting in a higher prevalence of surgical disease. These challenges have a profound impact on morbidity and mortality rates, particularly in low- and middle-income countries where many immigrants seek refuge. Limited availability of medical facilities, an inadequate surgical workforce, financial constraints and linguistic and cultural barriers all contribute to reduced access to healthcare. Limited access to competent healthcare leads to poor health outcomes, increased morbidity and mortality rates and suboptimal surgical results for refugees. To address these challenges, a multifaceted approach is necessary. This includes increased funding for healthcare initiatives, workforce recruitment and training and improved coordination between aid organisations and local healthcare systems. Strategies for managing surgical conditions in the global refugee community encompass the development of targeted public health programmes, removing legal barriers, establishing healthcare facilities to enhance surgical access and prioritising disease prevention among refugees.

Leveraging machine learning and prescriptive analytics to improve operating room throughput

Successful days are defined as days when four cases were completed before 3:45pm, and overtime hours are defined as time spent after 3:45pm. Based on these definitions and the 460 unsuccessful days isolated from the dataset, 465 hours, 22 minutes, and 30 seconds total overtime hours were calculated. To reduce the increasing wait lists for hip and knee surgeries, we aim to verify whether it is possible to add a 5th surgery, to the typical 4 arthroplasty surgery per day schedule, without adding extra overtime hours and cost at our clinical institution. To predict 5th cases, 301 successful days were isolated and used to fit linear regression models for each individual day. After using the models' predictions, it was determined that increasing performance to a 77% success rate can lead to approximately 35 extra cases per year, while performing optimally at a 100% success rate can translate to 56 extra cases per year at no extra cost. Overall, this shows the extent of resources wasted by overtime costs, and the potential for their use in reducing long wait times. Future work can explore optimal staffing procedures to account for these extra cases.

[Economics of operating room use at a university eye hospital]

BACKGROUND

In ophthalmologic surgery, there are usually short operation times and thus many changes between the individual operations, which are not subject to remuneration. As in maximum care hospitals consecutive different operations with different durations are often performed, emergency operations have to be inserted and further training of colleagues is practiced, it is particularly important to generate the shortest possible transfer times in order to have both sufficient operation time and to be able to treat as many cases as possible. The aim of this work is to evaluate the efficiency of the surgical performance of a university eye hospital.

MATERIAL AND METHOD

The surgeries performed in 2021 at the MHH Eye Clinic were evaluated with respect to the spectrum, number, surgery duration, transfer times and process times. In terms of personnel, each operating room was staffed with one assistant anesthesiologist, one nurse anesthetist, two operating room nurses, one surgeon, and 20% senior anesthesiologist supervision. Based on a theoretical concept, which provides an increased staffing ratio while maintaining the same infrastructure, it was calculated how many more surgeries could be performed if the transfer time was halved and whether the additional financial expense could be compensated.

RESULTS

With a total of n = 2712 surgeries performed during regular duty hours (244 working days) in 2 operating rooms (average daily n = 11.1; weekly n = 53.6 and monthly n = 237.1), the average surgery duration was 37 min and the transition time 43 min. This means that the operating rooms were used for surgery for 51% of the total operating time. Main procedures were vitrectomy with n = 1350 and cataract surgery with n = 1308. The new personnel concept provided one additional operating room nurse per operating room and one additional anesthesiologist for both operating rooms. The additional costs for this personnel expenditure were calculated at approx. 300,000 € per year. The halving of the transfer time from 43 min to about 21 min through possible overlapping induction and parallel work, which was not possible until now, results in an additional operation time of about 100 min per operating room, so that at least 4 additional operations can be planned and performed. In this way, with stringent implementation and the same spatial structures with stable fixed costs, n = 976 more operations could be performed, which, minus the personnel costs, the additional material costs for surgery and anesthesia of 557,042 € and the inpatient hotel costs of 600,663 €, with an average length of stay of 2.8 days, would result in an additional revenue of about 2.4 times the additional personnel costs at the current flat rate of 3739.40 € and an average case mix index of the MHH Eye Hospital of 0.649 (total revenue: 2,155,449 €; profit margin II: 701,389 €) for the considered surgical patient collective in 2021.

CONCLUSION

An increase of the personnel expenditure in the operating room for surgical subjects such as ophthalmology with shorter interventions and many changes is economically worthwhile also for a large hospital in order to enable and optimize overlapping transfers of anesthesia and surgical care. This should therefore also be considered separately, contrary to standardized staffing of the overall hospital, in order to use existing resources with their fixed costs as optimally as possible.