Cost-effectiveness analysis of weekday and weeknight or weekend shifts for assessment of appendicitis

A population-based cohort examining factors affecting all-cause morbidity and cost after pediatric appendectomy: Does annual adult procedure volume matter?

BACKGROUND

The purpose of this study was to examine factors affecting morbidity and cost after pediatric appendectomy and particularly the role of adult surgical volume.

MATERIALS AND METHODS

This was population-based study including all pediatric patients who underwent appendectomy for appendicitis in Canada (excluding Quebec) from 2008 to 2015. All-cause morbidity was the main outcome of interest. Cost of the index admission (in 2014 Canadian dollars) was a secondary outcome. Hierarchal linear and logistic regressions were used to model the outcomes.

RESULTS

Overall, 41,512 patients were identified. After adjustment, younger patients (OR = 0.98/year, 95%CI 0.97-0.99, p < 0.001), patients with comorbidities (OR = 2.20, 95%CI 1.96-2.46, p < 0.001), and those with perforated appendicitis (OR = 5.95, 95%CI 5.44-6.50, p < 0.001) were more susceptible to morbidity. Annual pediatric appendectomy volume was a significant predictor of reduced morbidity (OR = 0.85/20 cases, 95%CI 0.76-0.93, p < 0.001) as was the use of laparoscopy (OR = 0.81, 95%CI 0.72-0.91, p = 0.001). Conversely, annual adult appendectomy volume conferred no benefit nor did pediatric surgery specialty training.

CONCLUSION

Outcomes after pediatric appendectomy are influenced by pediatric case volume, regardless of specialty training, but extra adult surgical volume confers no benefit.

Predictors and Outcomes of Nondiagnostic Ultrasound for Acute Appendicitis in Children

Ultrasound assessments of children with possible acute appendicitis (AA) are often nondiagnostic. We aimed to identify the predictors of nondiagnostic ultrasound and to investigate the outcomes. A retrospective review was conducted on children aged 4 to 17 years evaluated in 2013 for AAwith ultrasound at a tertiary hospital pediatric emergency department. Demographics, clinical data, and outcomes were analyzed. Of 528 children, 194 (36.7%) had diagnostic ultrasounds and 334 (63.3%) had nondiagnostic ultrasounds. Nondiagnostic ultrasounds were more common after-hours (7 pm–7 am weekdays and on weekends, 70.7%) than during business hours (7 am–7 pm weekdays; 29.3%). After-hours timing and female sex were identified as independent predictors of non-diagnostic ultrasounds (P < 0.05 for both). AA was diagnosed in 35 children with a nondiagnostic ultrasound (10.5%; P < 0.05). No child who underwent a nondiagnostic ultrasound was found to have AA with laboratory values of white blood cell < 11 x 103/μL and c-reactive protein (CRP) < 5 mg/dL. Children with nondiagnostic ultrasounds have a low likelihood of AA if white blood cell < 11 and CRP < 5. We propose a management algorithm that we hope will help reduce admissions and decrease the use of computed tomography scans.

No weekend effect on outcomes of severe acute pancreatitis in Japan: data from the diagnosis procedure combination database

BACKGROUND

In the early phase of severe acute pancreatitis, timely multidisciplinary management is required to reduce mortality. The aim of this observational study was to evaluate the impact of weekend hospital admission on outcomes using population-based data in Japan.

METHODS

Data on adult patients (≥20 years) with severe acute pancreatitis were extracted from a nationwide Japanese administrative database covering over 1000 hospitals. In-hospital mortality, length of stay, and total costs were compared between weekend and weekday admissions, with adjustment for disease severity according to the current Japanese severity scoring system for acute pancreatitis, and other potential risk factors.

RESULTS

In total, 8328 patients hospitalized during the study period 2010-2013 were analyzed (2242 admitted at weekends and 6086 on weekdays). In-hospital mortality rates were not significantly different: 5.9 vs. 5.4 % for weekend and weekday admissions, respectively (multivariate-adjusted odds ratio, 1.06; 95 % confidence interval, 0.83-1.35). The impact of weekend admission was not significant either for length of hospitalization (median, 18 vs. 19 days) and total costs (median, 6161 vs. 6233 US dollars) (both p > 0.19 in multivariate-adjusted linear regression). The rates of, and time to, specific treatments were also similar between patients with weekend and weekday admissions.

CONCLUSIONS

A weekend effect in severe acute pancreatitis admissions was not evident. Adjustments to weekend staffing and selective hospital referral of patients admitted at weekends are not indicated for severe acute pancreatitis in current clinical practice in Japan.

Cost-Effectiveness of Integrating a Clinical Decision Rule and Staged Imaging Protocol for Diagnosis of Appendicitis

OBJECTIVE

To evaluate the cost-effectiveness of a diagnostic protocol for appendicitis in children, the use of a validated clinical decision rule (CDR) and a staged imaging protocol, compared with usual care.

METHODS

We estimated the cost-effectiveness of the three competing strategies using parameters from existing literature as well as a Markov model developed to simulate the effects of exposure to ionizing radiation from a single computed tomography (CT) study in the course of diagnosis. The simulation model was applied to a hypothetical cohort of 100,000 boys and girls, age 10 years, presenting with acute abdominal pain to emergency departments in the United States.

RESULTS

The integrated strategy, the CDR followed by staged imaging, was found to be the most cost-effective approach. Cost savings accrued from the reduction in CT utilization for low-risk patients compared with the other two strategies. The addition of ultrasound (US) to the CDR strategy reduced CT utilization by an additional 10.9%, its main cost advantage, with negligible change in net health benefits from false-negative US results, and associated morbidity or mortality.

CONCLUSIONS

Results suggest that the integration of staged imaging with the CDR for the diagnosis of appendicitis in children is a cost-effective and cost-saving approach. The model estimates a further 10.9% reduction in the number of CTs from the incorporation of US for patients scoring high or medium risk, in excess of the 19.5% reduction estimated in the CDR validation study.

Outcomes variability in non-emergent esophageal foreign body removal: Is daytime removal better?

OBJECTIVE

The objective of this study is to investigate differences between esophageal foreign body removal performed during standard operating room hours and those performed after-hours in asymptomatic patients.

METHODS

A retrospective chart review at a tertiary children's hospital identified 264 cases of patients with non-emergent esophageal foreign bodies between 2006 and 2011. Variables pertaining to procedure and recovery times, hospital charges, complications, length of stay, American Society of Anesthesiology (ASA) classification, and presence of mucosal injury were summarized and compared between cases performed during standard operating hours and those performed after-hours.

RESULTS

Cases performed during standard hours had significantly longer average wait times compared with after-hours cases (13.1h versus 9.0h, p<0.001). No other clinical characteristics or outcomes were significantly different between groups. Longer wait times are not associated with mucosal injury or postoperative complications.

CONCLUSION

There were no significant differences in procedure time, charges, or safety in after-hours removal of non-emergent esophageal foreign bodies compared to removal during standard operating hours. OR wait time was about 4h longer during standard hours compared with after-hours. This study could not assess the factors to determine the impact in differences in hospital resource utilization or work force, which may be significant between these two groups.

Utility of CT after sonography for suspected appendicitis in children: integration of a clinical scoring system with a staged imaging protocol

To improve diagnosis of pediatric appendicitis, many institutions have implemented a staged imaging protocol utilizing ultrasonography (US) first and then computed tomography (CT). A substantial number of children with suspected appendicitis undergo CT after US, and the efficient and accurate diagnosis of pediatric appendicitis continues to be challenging. The objective of the study is to characterize the utility of CT following US for diagnosis of pediatric appendicitis, in conjunction with a clinical appendicitis score (AS). Imaging studies of children with suspected appendicitis who underwent CT after US in an imaging protocol were retrospectively reviewed by three radiologists in consensus. Chart review derived the AS (range 0-10) and obtained the patient diagnosis and disposition, and an AS was applied to each patient. Clinical and radiologic data were analyzed to assess the yield of CT after US. Studies of 211 children (mean age 11.3 years) were included. The positive threshold for AS was determined to be 6 out of 10. When AS and US were concordant (N = 140), the sensitivity and specificity of US were similar to CT. When AS and US were discordant (N = 71) and also when AS ≥ 6 (N = 84), subsequent CT showed superior sensitivity and specificity to US alone. In the subset where US showed neither the appendix nor inflammatory change in the right lower quadrant (126/211, 60 % of scans), when AS < 6 (N = 83), the negative predictive value (NPV) of US was 0.98. However, when AS ≥ 6 (N = 43), NPV of US was 0.58, and the positive predictive value of subsequent CT was 1. There was a significant decrease in depiction of the appendix on US with patient weight-to-age ratio of >6 (kg/year, P < 0.001) and after-hours (1700 -0730 hours) performance of US (P < 0.001). Results suggest that the appendicitis score has utility in guiding an imaging protocol and support the contention that non-visualization of the appendix on US is not intrinsically non-diagnostic. There was little benefit to additional CT when AS < 6 and US did not show the appendix or evidence of inflammation; this would have avoided CT in 140/211 (66 %) patients. CT demonstrated benefit when AS ≥ 6, suggesting that cases with AS ≥ 6 and features that limit depiction of the appendix on US may be triaged to CT.

Acute variceal hemorrhage in patients with liver cirrhosis: weekend versus weekday admissions

PURPOSE

Little is known about the impact of weekend admission on acute variceal hemorrhage (AVH). Thus, we investigated whether day of admission due to AVH influenced in-hospital mortality.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 294 patients with cirrhosis admitted between January 2005 and February 2009 for the management of AVH. Clinical characteristics were compared between patients with weekend and weekday admission, and independent risk factors for in-hospital mortality were determined by multivariate binary logistic regression analysis.

RESULTS

No demographic differences were observed between patients according to admission day or in the clinical course during hospitalization. Seventeen (23.0%) of 74 patients with weekend admission and 48 (21.8%) of 220 with weekday admission died during hospitalization (p=0.872). Univariate and subsequent multivariate analysis showed that initial presentation with hematochezia [p=0.042; hazard ratio (HR), 2.605; 95% confidence interval (CI), 1.038-6.541], in-patient status at the time of bleeding (p=0.003; HR, 4.084; 95% CI, 1.598-10.435), Child-Pugh score (p<0.001; HR, 1.877; 95% CI, 1.516-2.324), and number of endoscopy sessions for complete hemostasis (p=0.001; HR, 3.864; 95% CI, 1.802-8.288) were independent predictors for in-hospital mortality.

CONCLUSION

Weekend admission did not influence in-hospital mortality in patients with cirrhosis who presented AVH.

Glowing in the dark: time of day as a determinant of radiographic imaging in the evaluation of abdominal pain in children

BACKGROUND/PURPOSE

Although ultrasound is often the preferred pediatric imaging study, many institutions lack ultrasound access at night; and computerized tomography (CT) becomes the only radiological method available for evaluation of appendicitis in children. The purpose of this study was to characterize patterns of daytime and nighttime use of ultrasound or CT for evaluation of pediatric appendicitis and to measure consequent differences in radiation exposure and cost.

METHODS

A retrospective chart review of patients evaluated for appendicitis from October 2004 to October 2009 (N = 535) was performed to evaluate daytime and nighttime use of ultrasound and CT for pediatric patients.

RESULTS

Average age was 10.2 years (range, 3-17 years). During the day, 6 times as many ultrasounds were performed as CTs (230 vs 35). At night, half as many ultrasounds were performed (50 vs 110). Average radiation dose per child during the day was significantly lower than at night (day, 0.52 mSv per patient; night, 2.75 mSv per patient). Average radiology costs were lower for daytime patients ($2491.06 day vs $4045.00 night; P < .05).

CONCLUSIONS

Dependence on CT at night results in higher average radiation exposure and cost. Twenty-four-hour ultrasound availability would decrease radiation exposure and cost of evaluation of children presenting with appendicitis.

Dollars and sense of interval appendectomy in children: a cost analysis

PURPOSE

Although initial nonoperative management of focal, perforated appendicitis in children is increasingly practiced, the need for subsequent interval appendectomy remains debated. We hypothesized that cost comparison would favor continued nonoperative management over routine interval appendectomy.

METHODS

Decision tree analysis was used to compare continued nonoperative management with routine interval appendectomy after initial success with nonoperative management of perforated appendicitis. Outcome probabilities were obtained from literature review and cost estimates from the Kid's Inpatient Database. Sensitivity analyses were performed on the 2 most influential variables in the model, the probability of successful nonoperative management and the costs associated with successful observation. Monte Carlo simulation was performed using the range of cost estimates.

RESULTS

Costs for continued nonoperative observation were estimated at $3080.78 as compared to $5034.58 for the interval appendectomy. Sensitivity analysis confirms a cost savings for nonoperative management as long as the likelihood of successful observation exceeds 60%. As the cost of nonoperative management increased, the required probability for its success also increased. Using wide distributions for both probability estimates as well as costs, Monte Carlo simulation favored continued observation in 75% of scenarios.

CONCLUSION

Continued nonoperative management has a cost advantage over routine interval appendectomy after initial success with conservative management in children with focal, perforated appendicitis.

Imaging of acute appendicitis in children: EU versus U.S. ... or US versus CT? A North American perspective

The timing, type, and technique of imaging evaluation of suspected appendicitis in children are all debated. This debate is both local and international. The fact is that choices in imaging evaluation will depend on both local and national influences, which are reasonable and to be expected. There still is a responsibility, though, for those involved with evaluation of patients with possible appendicitis to come to agreement about an appropriate diagnostic pathway that considers standards of care and available resources.

Optimizing the role of imaging in appendicitis

Acute appendicitis is the most common acute abdominal condition that requires surgical intervention in childhood. From the diagnostic performance perspective, computed tomography (CT) has a significantly higher sensitivity than does ultrasound (US) for diagnosing appendicitis in children; from the safety perspective, however, one should consider the radiation associated with CT, especially in children. There is strong evidence supporting improved patient outcomes in children with suspected acute appendicitis who undergo CT scanning. Nevertheless, we should keep in mind that for a single abdominal CT study in a 5-year-old child, the lifetime risk of radiation-induced cancer would be 26.1 per 100,000 in female and 20.4 per 100,000 in male patients, based on probabilistic models designed with data from atomic bomb survivors. An integrated clinical-imaging approach, applying clinical scores that are able to predict which children with acute abdominal pain do or do not have a high probability of presenting with appendicitis may improve the effectiveness of the imaging diagnosis of appendicitis at the hospital level. Such an approach could avoid exposure of children who at low risk for appendicitis to unnecessary diagnostic tests and eventually, to radiation.

Outcomes of weekend admissions for upper gastrointestinal hemorrhage: a nationwide analysis

BACKGROUND & AIMS

Previous studies have identified a weekend effect in outcomes of patients with various medical conditions suggesting worse outcomes for weekend admissions. The aim of our study was to analyze if weekend admissions for upper gastrointestinal hemorrhage (UGIH) have higher mortality and longer hospital stay compared with those admitted on weekdays, and to examine if this effect differs by hospital teaching status.

METHODS

This was a cross-sectional study using the Nationwide Inpatient Sample 2004. A total of 28,820 discharges with acute variceal hemorrhage (AVH) and 391,119 discharges with acute nonvariceal UGIH (NVUGIH) were identified through appropriate International Classification of Diseases, ninth edition codes. Admissions were considered to be weekend admissions if they were admitted between midnight on Friday through midnight on Sunday. In-hospital mortality, frequency, and timing of endoscopy were measured.

RESULTS

On multivariate analysis, NVUGIH patients admitted on weekends had higher adjusted in-hospital mortality (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.09-1.35) and were less likely to undergo early endoscopy within 1 day of hospitalization (OR, 0.64; 95% CI, 0.61-0.68). Weekend admission was not predictive of in-hospital mortality in patients with AVH (OR, 0.94; 95% CI, 0.75-1.18), but was associated with lower likelihood of early endoscopy in nonteaching hospitals (OR, 0.65; 95% CI, 0.51-0.82). Early endoscopy was associated with significantly shorter hospital stays (NVUGIH, -1.08 days; AVH, -2.35 days) and lower hospitalization charges (NVUGIH, -$1958; AVH, -$8870).

CONCLUSIONS

Patients with NVUGIH admitted on the weekend had higher mortality and lower rates of early endoscopy. Patient with AVH admitted to nonteaching hospitals also had lower utilization of early endoscopy, but no difference in survival. There is a need for research into identifying the reasons for the weekend effect.

Acute appendicitis in young children: cost-effectiveness of US versus CT in diagnosis--a Markov decision analytic model

PURPOSE

To compare the cost-effectiveness of different imaging strategies in the diagnosis of pediatric appendicitis by using a decision analytic model.

MATERIALS AND METHODS

Approval for this retrospective study based on literature review was not required by the institutional Research Ethics Board. A Markov decision model was constructed by using costs, utilities, and probabilities from the literature. The risk of radiation-induced cancer was modeled by using the Biological Effects of Ionizing Radiation VII report, which is based primarily on data from atomic bomb survivors. The three imaging strategies were ultrasonography (US), computed tomography (CT), and US followed by CT if the initial US study was negative. The model simulated the short-term and long-term outcomes of the patients, calculating the average quality-adjusted life span and health care costs.

RESULTS

For a single abdominal CT study in a 5-year-old child, the lifetime risk of radiation-induced cancer would be 26.1 per 100,000 in female and 20.4 per 100,000 in male patients. In the base-case analysis, US followed by CT was the most costly and most effective strategy, CT was the second-most costly and second-most effective strategy, and US was the least costly and least effective strategy. The incremental cost-effectiveness ratios (ICERs) of CT to US and of US followed by CT to US were both well below the societal willingness-to-pay threshold of $50,000 (in U.S. dollars). The ICER of US followed by CT to CT was less than $10,000 in both male and female patients.

CONCLUSION

In a Markov-based decision model of pediatric appendicitis, the most cost-effective method of imaging pediatric appendicitis was to start with a US study and follow each negative US study with a CT examination.

CT utilization: the emergency department perspective

CT scan utilization in the pediatric emergency department (ED) has dramatically increased in recent years. This likely reflects the improved diagnostic capability of CT, as well as its wider availability. However, the utility of CT is tempered by the high radiation exposure to patients as well as cost. In this review we will consider the magnitude of changes in CT use in the pediatric ED, and we will examine some of the driving forces behind these increases. In addition, we will consider strategies to limit growth in CT scan utilization or even result in reductions in CT use in the future. These strategies include better physician and patient education, application of existing clinical decision rules to reduce CT utilization and development of new rules, technical alterations in CT protocols to reduce per-exam exposures, use of alternative imaging modalities such as US and MRI that do not expose patients to ionizing radiation, and expanded use of clinical observation in place of immediate diagnostic imaging. Reform of liability laws might alleviate another driving force behind high CT utilization rates. Protocols must be designed to maximize patient safety by limiting radiation exposures while preserving rapid and accurate diagnosis of time-sensitive conditions.