A financial analysis of laparoscopic and open cholecystectomy

Minimally invasive: minimally reimbursed? An examination of six laparoscopic surgical procedures

It is generally believed that minimally invasive surgery (MIS) results in less postoperative pain, fewer complications, and shorter recovery periods compared with open procedures. Yet despite these benefits, the level of reimbursement assigned to the surgeon by United States health-care payers is often lower than that for open procedures. Furthermore, the cost of performing a MIS may be higher vs an open procedure because specialized equipment, increased surgical time, or both may be required. In this report, we examine the issue by comparing reimbursements for MIS with open procedures, summarizing the medical literature on MIS vs open surgical procedures, and offering recommendations for payers who establish reimbursement policies. The review is focused on six MIS procedures where outcomes data exist: laparoscopic cholecystectomy (lap chole), laparoscopic colectomy (LC), laparoscopic fundoplication (LF), laparoscopic hysterectomy (LH), laparoscopic ventral hernia repair (LVHR), and laparoscopic appendectomy (LA). Outcomes summarized were length of hospital stay (LOS), operating room time, operating room costs, complications, and return to work or normal activities. The level of scientific evidence was assigned to each study using predetermined criteria. A total of 112 articles were reviewed: 14 for lap chole, 26 for LC, 7 for LF, 19 for LH, 9 for LVHR, and 37 for LA. The data demonstrate that these procedures result in reduced hospital stay, reduced hospital costs, and faster return to work or normal activities. Yet, the operating room time and costs are frequently higher for MIS. These findings suggest that as both the outcomes value and level of operating room resources are greater, MIS warrants reimbursement that meets or exceeds that of open procedures.

Is laparoscopic cholecystectomy cheaper?

As laparoscopic cholecystectomy is being used more and more frequently, a cost analysis was aimed to be performed to evaluate cost effectiveness in Turkey. Records of 376 patients who underwent cholecystectomy by various methods were analyzed retrospectively. Mean duration of postoperative hospital stay was 5.1 +/- 2.6 days for the open cholecystectomy group (OC group), composed of 177 patients; 5.6 +/- 2.1 days for the converted open cholecystectomy group (CC group) composed of 15 patients; and 2.5 +/- 1.8 days for the laparoscopic cholecystectomy group (LC group), which included 184 patients. The mean cost per patient was 778 dollars +/- 75, 1964 dollars +/- 82, and 2357 dollars +/- 80 for the OC, LC, and CC groups, respectively. It was concluded that laparoscopic cholecystectomy will gain economic feasibility over conventional cholecystectomy in our country only when costs of laparoscopic equipment lower and personnel wages increase sufficiently.

The Surgical Recovery Index

BACKGROUND

We developed a tool, the Surgical Recovery Index (SRI), specifically to measure surgical recovery. We then tested the ability of the SRI to discriminate between patients undergoing laparoscopic (L) operations and patients undergoing open (O) operations.

METHODS

We surveyed 50 patients drawn from the practice of a single surgeon to establish the types of activities that define recovery from surgery. Their responses were used to construct the SRI, a self-administered questionnaire using a numerical rank-order scale format. A total score and two subscale scores (pain and activity resumption) were calculated for each patient. Mean and median scores were calculated for each patient group. Chi-square tests were used to evaluate group differences for individual questions; t-tests and Kruskal-Wallis tests were used to evaluate group differences for summary scores.

RESULTS

In all, 149 patients completed the SRI (60 L, 89 O). Cronbach's alphas were 0.91 for pain questions and 0.97 for activity resumption questions. The scores for pain level with time (L vs O, 1-10 scale) at week 1 (mean, 4.42 vs 6.06, p = 0.03), week 2 (mean, 3.08 vs 4.38, p = 0.04), week 3 (mean, 2.03 vs 3.16, p = 0.02), and week 4 (mean, 1.18 vs 2.28, p = 0.00) all favored laparoscopy. The scores for pain level with activity (L vs O, 1-3 scale) for getting out of bed (mean, 1.62 vs 1.85, p = 0.04), hygiene activities (mean, 1.38 vs 1.65, p = 0.04), and computer work (mean, 1.15 vs 1.56, p = 0.00) were all significant, although pain with exertion (mean, 1.87 vs 2.10, p = 0.13) was not. Delay until return to activity (L vs O, 1-4 scale) was significant, favoring L for 13 activities (all p < 0.02), but it was not significant for three activities. The scores for subscales for pain (L vs O, mean, 20.7 vs 34.4, respectively) and activity resumption delay (mean, 44.3 vs 62.0), as well as total scores (mean, 33.0 vs 49.0), were also significant (all p = 0.00). The same differences were observed when median scores were considered instead of mean scores, suggesting the robustness of the group difference.

CONCLUSIONS

Reduction in time to full recovery (i.e., pain resolution and activity resumption) is a fundamental advantage of laparoscopic surgery, yet there are no tools designed to specifically measure recovery. These data provide preliminary evidence of the reliability and validity of the new SRI as a measure of recovery in patients undergoing laparoscopic operations.

Impact of the case payment reimbursement method on the utilization and costs of laparoscopic cholecystectomy

The purpose of this study was to examine the relationship between adoption of case payment for laparoscopic cholecystectomy (LC) and the growth rate of LC, outcomes of patients undergoing LC, and total healthcare expenditures on cholecystectomy. We used the claims data from Bureau of National Health Insurance (BNHI) to identify patients who underwent LC and open cholecystectomy (OC). Data were available from January 1996 to October 1997 and from January 1998 to October 1999, enabling use to compare data from before and after the introduction of the new case payment system. Results showed that the volume and the proportion of LCs increased after adoption of the new payment method. We did not find a sharp increase in the cholecystectomy rate during the study period. In terms of outcomes, the admission rate for emergencies decreased; the surgery mortality rate decreased, but the readmission rate increased. The average cost and length of hospital stay for LC subjects decreased; however, the total cost of cholecystectomy increased. The impact on LC of the introduction of a case payment method failed to reduce total health expenditures for cholecystectomy.

In-line image projection accelerates task performance in laparoscopic appendectomy

BACKGROUND

In laparoscopy, the monitor usually is placed at or above eye level across from the operating surgeon. Position of the endoscopic image at hand level has been shown in a laboratory model to facilitate task performance. The authors tested the hypothesis that in-line image projection reduced operating time for a standardized procedure.

METHODS

Children undergoing laparoscopic appendectomy were assigned randomly according to video image position: (1) at the top of the laparoscopy tower in front of the surgeon ("overhead") or (2) on a screen placed on the patient's abdomen ("in-line"). Operating time was recorded for each operation, and patients were stratified according to severity of appendicitis and training level of the operating surgeon. Statistical analysis was performed using Student's t, chi2 tests, and analysis of variance with post-hoc Fisher test (P <.05. significant).

RESULTS

One hundred eight children, aged 2 to 17 years, underwent a laparoscopic appendectomy during a 26-month period. Fifty-four were assigned to the in-line projection screen and 54 to the overhead monitor. Operating time was significantly shorter (P =.013) when in-line projection was used (46.8 +/- 10.2 v. 52.2 +/- 15.1 minutes with overhead monitor). By analysis of variance (ANOVA) the only factors that significantly affected operating time were use of in-line projection (P =.030), severity of appendicitis (P =.002), and training level of the operating surgeon (P =.047).

CONCLUSIONS

Placing the endoscopic image in the same field as the surgeon's hands decreases operating time by 10%, even for procedures that, like appendectomy, do not require complex suturing skills. This decrease in operating time occurs independently of the surgeon's level of proficiency or the degree of difficulty of the operation.

Evaluation of the cost for laparoscopic-assisted Billroth I gastrectomy

BACKGROUND

Despite the rapid spread of laparoscopic gastric surgery in Japan, no one has yet evaluated the costs for this new technique. The aim of this study was to analyze and compare the hospital charges for laparoscopic-assisted gastrectomy with those for conventional open gastrectomy.

METHODS

The study included 48 consecutive patients who underwent laparoscopic-assisted Billroth I gastrectomy and 43 who had a conventional open Billroth I gastrectomy for cure of early gastric cancer between May 1994 and April 2000. Hospital charges covered all costs incurred during the hospital stay; they were divided into charges for consultation, prescription, injection, nursing care, operating theater, laboratory, radiology, ward and meal, and others.

RESULTS

The patients who underwent laparoscopic gastrectomy were similar to those who had open gastrectomy in terms of symptoms, concurrent illness, operation time, proximal resection margin, number of harvested lymph nodes, and stage of the disease. Hospital stay after laparoscopic gastrectomy was shorter than that after open gastrectomy (16.1 vs 20.5 days, p < 0.01). Charges for nursing care, charges for ward and meal, and total hospital charges were less in the laparoscopic group than in the open group ( yen5800 vs yen8010, p < 0.01; yen461 x 10(3) vs yen512 x 10(3), p < 0.05; yen1336 x 10(3) vs yen1411 x 10(3), p = 0.072). When we compared laparoscopic gastrectomies performed during 1994-96 with those done during 1997-2000, we found a decrease in charges for ward and meal and total hospital charges ( yen498 x 10(3) vs yen421 x 10(3), p < 0.01; yen1390 x 10(3) vs yen1277 x 103, p < 0.01).

CONCLUSION

Laparoscopic-assisted Billroth I gastrectomy is less expensive than conventional open Billroth I gastrectomy because both the postoperative recovery period and the hospital stay are shorter. In patients who undergo gastrectomy, the additional costs of the disposable instruments can be fully offset by the lower charges for ward and meal and nursing care associated with laparoscopic gastrectomy.

Laparoscopic retroperitoneal lymph node dissection

PURPOSE

Retroperitoneal lymph node dissection is the most sensitive and specific diagnostic modality for detecting occult lymph node metastases in clinical stage I testicular tumor. In stage II disease, residual tumors after chemotherapy have to be removed surgically. To reduce the morbidity of these procedures we have replaced open surgery by laparoscopy.

PATIENTS AND METHODS

Between August 1992 and December 1999 125 patients underwent laparoscopic RPLND (stage I: 76 pts., stage II: 49 pts.)

RESULTS

Laparoscopic RPLND could be completed as planned in all but two patients in whom bleeding required conversion to open surgery. Once the learning curve had been overcome, mean operative time decreased significantly from 476 to 219 min for stage I and averaged 226 min in stage IIB disease. Only minor postoperative complications occurred such as asymptomatic lymphoceles (7 pts.) and chylous ascites (6 pts.). Mean post-op hospital stay was 3.3 and 3.5 days, respectively (stages I and II). Mean followup is currently 46 months for stage I and 35 months for stage II tumors. Over this period a single retroperitoneal recurrence was observed (stage I), which, however, was not due to surgical failure, but to false negative histologic findings. All other patients have remained free of relapse.

CONCLUSIONS

Laparoscopic RPLND is a demanding procedure with a long and steep learning curve. It has proved feasible also after chemotherapy. The diagnostic accuracy of laparoscopic RPLND was as good as that of the open procedure, while the morbidity is significantly lower. Tumor control was not compromised by the laparoscopic approach.

Treatment of acute cholecystitis. A comparison of open vs laparoscopic cholecystectomy

BACKGROUND

In this study, the clinical results and cost-effectiveness of open vs laparoscopic cholecystectomy in the treatment of acute cholecystitis were compared.

METHODS

Over a 5-year period (1994-98), 894 cholecystectomies were performed, 545 (60.96%) of them laparoscopically and 349 (39.04%) by the open method. The study included 209 patients with a clinical diagnosis of acute cholecystitis; 115 (55.02%) of them were operated on by the open method and 94 (44.98%) by the laparoscopic method.

RESULTS

A comparison analysis revealed that the mean postoperative treatment period was 8.40 days after open and 4.38 days after laparoscopic cholecystectomy. In the group operated on by the open method, 106 patients received an antibiotic, a mean of 5.09 ampules and 3.2 tablets or suppositories of an analgesic, and 2.91 dressings per patient; whereas in the group submitted to the laparoscopic method, the comparable figures were 43, 3.13, 2.1, and 1.47, respectively. In 31 (26.96%) employed patients operated on by the open method, the mean absenteeism from work was 42 days; whereas in 31 (32.98%) of those operated on by the laparoscopic method, it was 17 days. The mean operating times for the procedures were 89 and 115 min for the open and laparoscopic methods, respectively. Two patients submitted to open cholecystectomy died within 30 days postoperatively. Wound infection was recorded in 10 (8.7%), prolonged biliary secretion in two, and cicatricial hernia in five (4.35%) patients. In the group submitted to laparoscopic cholecystectomy, there were no deaths; nine (9.57%) conversions were required; four patients had to be reoperated on, two of them for bile lobe hemorrhage and two for massive biliary secretion from the open cystic duct; herniation at the site of supraumbilical incision developed in three patients, and infection developed at the same site in two (2.13%) patients. The hospital cost was significantly higher in laparoscopic patients ($1181 vs $873) USD), as was the total cost of treatment for acute cholecystitis ($1430 vs $1316). However, the cost for sick leave and rehabilitation was significantly lower in laparoscopically treated patients ($486 vs $1199).

CONCLUSIONS

Our comparison analysis of the results and cost-effectiveness of the surgical treatment of acute cholecystitis clearly pointed to the advantages of laparoscopic over open cholecystectomy-i.e., better clinical outcome and a more rapid resumption of daily activities. Hospital and total costs of treatment were on average higher in laparoscopic patients, except for the employed ones, where the lower sick leave cost translated into a significant reduction in total costs.

Convalescence in the first week after laparoscopic cholecystectomy: results from a detailed questionnaire on morbidity and recovery of daily activities

BACKGROUND

The aim of this study was to evaluate postoperative morbidity and return to daily activities after laparoscopic cholecystectomy.

METHODS

Thirty-five patients were asked to keep daily detailed structured diaries for 1 week.

RESULTS

Half of the patients were discharged from hospital on the 1st postoperative day (POD1); another third were released on POD2. Distressing pain subsided on POD2, but disturbing pain occurred in 10% of the patients on POD5-7. On POD7, mild pain at rest appeared in 30% of the patients and when moving in 60% of them. Although pain was the most common complaint, the mean consumption of analgesics was low. Even though one-fifth of the patients felt nauseated on POD2-3, and one-seventh again as late as POD7, drinking and eating did not pose problems. At the end of the week, one-third of the subjects experienced slight disorders in night rest and vigilance. Moving and walking were disturbed in one-third of the patients, and bending over and lifting objects were relatively difficult for 60% of the patients on POD7. Thirty percent of the 21 patients who were employed reported that they were capable of returning to work on POD7.

CONCLUSION

To account for the variability in the rate of convalescence, the length of sick leave after laparoscopic cholecystectomy should be individualized.