Influence of Patient Age and Co-Morbidity on Outcome of a Collaborative Care Pathway After Radical Prostatectomy and Cystoprostatectomy

Early Postoperative Oral Feeding After Total Gastrectomy in Gastric Carcinoma Patients: A Retrospective Before-After Study Using Propensity Score Matching

BACKGROUND

Despite its clinical benefits, early oral nutrition after total gastrectomy is not widely implemented because of concerns about tolerability and safety. We investigated the feasibility and safety of early oral nutrition after total gastrectomy in gastric carcinoma patients.

METHODS

This is a retrospective before-after study. From 2008-2016, 301 patients received conventional oral feeding (COF) before May 2012, and 454 patients, early oral feeding (EOF) after May 2012. The EOF group received oral diet on postoperative day 1, and the COF group was maintained nil-by-mouth until patients demonstrated gas passage. After balancing potential confounders using propensity score matching, 203 patients were selected in each group.

RESULTS

Both matched groups demonstrated well-balanced baseline characteristics. The EOF group demonstrated significantly earlier first flatus time (2.9 vs 3.1 days, P = .013) and hospital discharge (8.9 vs 12.6 days, P < .001) than the COF group. No significant differences were observed for overall morbidity and mortality, but the EOF group demonstrated lower incidence of abdominal infection (3.0% vs 7.4%, P = .044) and anastomosis leakage (1.5% vs 4.9%, P = .048). Subgroup analyses by age, sex, operative approach, lymph node dissection, and tumor stage demonstrated no increased risk of morbidity, anastomosis leakage, and short hospital stay in the EOF group.

CONCLUSION

Early oral nutrition may be feasible and safe after total gastrectomy, with no increase in postoperative complications. Large, randomized, controlled trials are warranted to further investigate the clinical benefits of early oral nutrition after total gastrectomy.

Feasibility of a Clinical Pathway With Early Oral Intake and Discharge for Laparoscopic Gastrectomy

BACKGROUND AND AIMS

Although some studies have reported the safety of early oral intake after gastrectomy, it still remains controversial. This study focused on the feasibility of a clinical pathway with early oral intake and discharge setting for exclusively laparoscopic distal gastrectomy.

MATERIALS AND METHODS

A clinical pathway was applied to 403 patients until December 2014. In the protocol, patients are allowed to take a sip of water and a soft diet on the first and second days after the operation, respectively, and the discharge day is set as the fifth to seventh day after the operation. Clinicopathological variables were prospectively collected, and risk factors for discharge variances were analyzed.

RESULTS

The completion rate of the clinical pathway was 76.9%. There were five re-admissions (1.2%). The overall morbidity rate was 18% ( n = 72), and major complications (Clavien-Dindo IIIa or greater) occurred in 13 patients (3%). Complications were the causes for discharge variances in 68 cases (73%), while the attending surgeons' judgment was the cause in 25 cases (27%). On multivariate analysis, age (odds ratio = 2.23, 95% confidence interval = 1.38-3.60, p = 0.001) and operative time (odds ratio = 2.38, 95% confidence interval = 1.45-3.98, p = 0.001) were independent risk factors for discharge variances.

CONCLUSION

A high completion rate of a clinical pathway with early oral intake and discharge setting for laparoscopic distal gastrectomy was achievable with an acceptably low re-admission rate. Laparoscopic distal gastrectomy is recommended as a first step for a clinical pathway with an early oral intake and discharge protocol.

Integrated Care Planning for Cancer Patients: A Scoping Review

Introduction

There has been a growing emphasis on the use of integrated care plans to deliver cancer care. However little is known about how integrated care plans for cancer patients are developed including featured core activities, facilitators for uptake and indicators for assessing impact.

Methods

Given limited consensus around what constitutes an integrated care plan for cancer patients, a scoping review was conducted to explore the components of integrated care plans and contextual factors that influence design and uptake.

Results

Five types of integrated care plans based on the stage of cancer care: surgical, systemic, survivorship, palliative and comprehensive (involving a transition between stages) are described in current literature. Breast, esophageal and colorectal cancers were common disease sites. Multi-disciplinary teams, patient needs assessment and transitional planning emerged as key features. Provider buy-in and training alongside informational technology support served as important facilitators for plan uptake. Provider-level measurement was considerably less robust compared to patient and system-level indicators.

Conclusions

Similarities in design features, components and facilitators across the various types of integrated care plans indicates opportunities to leverage shared features and enable a management lens that spans the trajectory of a patient's journey rather than a phase-specific silo approach to care.

Fast-Track Programs for Liver Surgery: A Meta-Analysis

BACKGROUND AND OBJECTIVES

Plentiful publications have inspected the feasibility of fast-track surgery programs during hepatic surgery, but the potency of these studies has not been discussed profoundly so far. Our goal was to assess the effects of fast-track programs on surgical outcomes compared with traditional surgical plans for liver surgery.

METHODS

The following databases were searched: PubMed, Cochrane library, Embase, Science Citation Index Expanded, etc. Studies meeting our inclusion criteria were included. All interrelated data and the methodological quality of included studies were extracted and assessed. We applied risk ratio and weighted mean difference as the estimated effect measures. Sensitivity analysis was performed to perceive the reliability of our findings.

RESULTS

Altogether, 14 studies with 1400 patients were analyzed. Meta-analysis of randomized controlled trials demonstrated that implementation of fast-track surgery programs could observably decrease the total length of hospital stay, complication rate, postoperative first flatus time, and hospitalization expense, and did not compromise mortality and readmission rate. The above findings were also in line with the results of case-control studies.

CONCLUSIONS

Fast-track surgery programs are feasible and effective for liver surgery. Future studies should optimize fast-track surgery programs catering to liver surgery.

Enhanced recovery programmes in hepatobiliary and pancreatic surgery: a systematic review

INTRODUCTION

The terms ‘enhanced recovery after surgery’, ‘enhanced recovery programme’ (ERP) and ‘fast track surgery’ refer to multimodal strategies aiming to streamline peri-operative care pathways, to maximise effectiveness and minimise costs. While the results of ERP in colorectal surgery are well reported, there have been no reviews examining if these concepts could be applied safely to hepatopancreatobiliary (HPB) surgery. The aim of this systematic review was to appraise the current evidence for ERP in HPB surgery.

METHODS

A MEDLINE® literature search was undertaken using the keywords ‘enhanced recovery’, ‘fast-track’, ‘peri-operative’, ‘surgery’, ‘pancreas’ and ‘liver’ and their derivatives such as ‘pancreatic’ or ‘hepatic’. The primary endpoint was length of post-operative hospital stay. Secondary endpoints were morbidity, mortality and readmission rate.

RESULTS

Ten articles were retrieved describing an ERP. ERP protocols varied slightly between studies. A reduction in length of stay was a consistent finding following the incorporation of ERP when compared with historical controls. This was not at the expense of increased rates of readmission, morbidity or mortality in any study.

CONCLUSIONS

The introduction of an ERP in HPB surgery appears safe and feasible. Currently, many of the principles of the multimodal pathway are derived from the colorectal ERP and distinct differences exist, which may impede its implementation in HPB surgery.

Implementation of a fast-track clinical pathway decreases postoperative length of stay and hospital charges for liver resection

A fast-track clinical pathway is designed to streamline patient care delivery and maximize cost effectiveness. It has decreased postoperative length of stay (LOS) and hospital charges for many surgical procedures. However, data on clinical pathways after liver surgery are sparse. This study examined whether use of a fast-track clinical pathway for patients undergoing elective liver resection affected postoperative LOS and hospital charges. A fast-track clinical pathway was developed and implemented by a multidisciplinary team for patients undergoing liver resection. Between July, 2007 and May, 2008, a total of 117 patients underwent elective liver resection: the fast-track clinical pathway (education of patients and families, earlier oral feeding, earlier discontinuation of intravenous fluid, no drains or nasogastric tubes, early ambulation, use of a urinary catheter for less than 24 h and planned discharge 6 days after surgery) was studied prospectively in 56 patients (postpathway group). These patients were compared with the remainder who had usual care (prepathway group). Outcome measures were postoperative LOS, perioperative hospital charges, intraoperative and postoperative complications, mortality, and readmission rate. Among all patients, 69 (59%) had complicating diseases and/or a history of surgery and 24 patients belonged to American Society of Anesthesiologists grade III–IV. Compared with the prepathway group, the postpathway group had a significantly shorter postoperative LOS (7 vs. 11 days, P < 0.01). The average perioperative hospital charges were RMB 26,626 for patients in the prepathway group and only RMB 21,004 for those in the postpathway group (P < 0.05), with no differences in intraoperative and postoperative complications (P = 0.814), mortality (P = 0.606), and readmission rate (P = 0.424). Implementation of the fast-track clinical pathway is an effective and safe method for reducing postoperative LOS and hospital charges for high-risk patients undergoing elective liver resection. The result supports the further development of fast-track clinical pathways for liver surgical procedures.

Is the critical pathway effective for the treatment of gastric cancer?

Purpose

The present study was conducted to investigate the low compliance rate of the critical pathway (CP) and whether CP is effective for treatment of gastric cancer in radical gastrectomy.

Methods

The medical records of 631 patients who had undergone radical gastrectomy with D2 lymph node dissection were reviewed. This study compared data from patients in early gastric cancer (EGC) and advanced gastric cancer (AGC) groups, which were further subdivided into general care (non-CP) and CP groups.

Results

The mean length of preoperative hospital stays were significantly different between the EGC and AGC patients (P < 0.05). However, there was no difference in the mean length of postoperative hospital stays between non-CP and CP groups among either EGC patients or AGC patients (P > 0.05). The postoperative and total cost of hospitalization was not statistically different between either of the groups (P > 0.05); however, the mean preoperative costs were significantly different (P < 0.05).

Conclusion

We conclude that use of the CP following gastrectomy is unnecessary. To decrease the length of hospital stay and associated costs, preoperative examination and consultation should be performed before admission.

The economics of robotic cystectomy: cost comparison of open versus robotic cystectomy

OBJECTIVE

• To assess and compare the economic burden of open radical cystectomy (OC) vs robotic-assisted laparoscopic radical cystectomy (RC) with pelvic lymph node dissection and urinary diversion.

PATIENTS AND METHODS

• A series of 103 and 83 consecutive patients undergoing OC and RC, respectively, were prospectively studied at a tertiary care institution from April 2002 to February 2009. • Data were collected on patient demographics, perioperative parameters and length of stay (LOS) in hospital. Cohorts were subdivided into ileal conduit (IC), continent cutaneous diversion (CCD) and orthotopic neobladder (ON) subgroups. • A linear cost model was created to simulate treatment with OC vs RC. Procedural costs were derived from the Medicare Resource Based Relative Value Scale. Materials costs were obtained from the respective suppliers. The indirect costs of complications were considered. • Sensitivity analyses were performed.

RESULTS

• Despite a higher cost of materials, RC was less expensive than OC for IC and CCD, although the cost advantage deteriorated for ON. • The per-case costs of RC with IC, CCD and ON were $20,659, $22,102 and $22,685, respectively, compared to $25,505, $22,697 and $20,719 for their OC counterparts. • The largest cost driver in the study was LOS in hospital. • RC showed a shorter LOS compared to OC, although this effect was insufficient to offset the higher cost of robotic surgery. • Complications materially affected cost performance.

CONCLUSIONS

• Despite a higher cost of materials, RC can be more cost efficient than OC as a treatment for bladder cancer at a high-volume, tertiary care referral centre, particularly with IC. • Complications significantly impact cost performance.

Radical cystectomy in the elderly patient: a contemporary comparison of perioperative complications in a single institution series

PURPOSE

To report on our recent experience with peri- and postoperative morbidity of radical cystectomy in patients 75 years and older compared to younger patients.

PATIENTS AND METHODS

Medical records of 326 consecutive patients undergoing radical cystectomy from May 2004 through April 2008 were reviewed.

RESULTS

Eighty-five of 326 patients (26%) were > or =75 years (75-95) old. ASA score was equal 3 or greater in 51% of patients > or =75 years and 32% of patients <75 years. Ileal conduit was performed in 83% of patients > or =75, 16% received an ileal neobladder compared to 46 and 51%, respectively, in patients <75. A total of 33 patients (39%) in the older patient group received blood transfusions intraoperatively compared to 76 patients (32%) in the younger age group. In 6 patients > or =75 years (7.1%) and 17 patients <75 (7.1%) open surgical revision was necessary, perioperative complication rate was 22 and 21%, respectively. The most common complications were wound dehiscence (5.9 vs. 7.5%), infections (4.7 vs. 4.6%), and pulmonary embolism (3.5 vs. 2.1%). Perioperative mortality was 1.2% (1 patient) in the elderly versus 0.4% (1 patient) in the younger age group.

CONCLUSION

Our data show that radical cystectomy can be offered to the elderly patient with acceptable morbidity. Because of higher comorbidity rate in the elderly, therapeutic decision for radical cystectomy in elderly patients should be made carefully and individually. Nevertheless our results demonstrate that age itself is not a main criterion which has to be considered strongly in decision making for radical cystectomy.

Understanding differences between high and low volume hospitals for radical prostatectomy

OBJECTIVES

We evaluated the impact of the specialized medical and ancillary services available at low vs. high volume prostatectomy centers on prolonged length of stay (LOS) outcomes after radical prostatectomy.

METHODS

Using the Nationwide Inpatient Sample, we identified patients who underwent prostatectomy (n = 9,266) for prostate cancer in 2003 using ICD-9 codes. Hospital characteristics were ascertained using the American Hospital Association file. Differences in health services availability according to hospital prostatectomy volume were estimated using logistic regression. Logistic models were fitted to measure the effect of available health services on a prolonged LOS (>90 percentile for sample was 5 days).

RESULTS

Among patients undergoing radical prostatectomy in 2003, 19.0% and 5.4% of patients had a prolonged LOS at low and high volume hospitals, respectively (unadjusted OR 4.2, 95% CI 2.5-6.9). After adjusting for differences in patients and availability of select health services, those treated at low volume centers were 3.3 times more likely to have a prolonged hospitalization compared with those treated at high volume hospitals (95% CI 1.9-5.6). Adjusting for hospital differences attenuated the volume effect by 14.8%.

CONCLUSIONS

There are substantial differences in the health care environment according to radical prostatectomy volume. Generally, high volume hospitals offer a much wider array of health care services specific to both post-prostatectomy and general medical care.

Prognostic impact of comorbidity in patients with bladder cancer

OBJECTIVE

To determine the impact of comorbidity on survival of bladder cancer patients.

METHODS

The population included 675 patients with newly diagnosed bladder cancer whose medical information was abstracted from a hospital cancer registry. Adult Comorbidity Evaluation-27, a validated instrument, was used to prospectively categorize comorbidity. Independent variables assessed include comorbidity, American Joint Committee on Cancer (AJCC) stage, grade, age, gender, and race. Outcome measure was overall survival. We analyzed the entire cohort, patients with noninvasive disease, and patients requiring cystectomy. Cox proportional hazards analysis was used to assess impact of independent variables on survival.

RESULTS

Median age at diagnosis for the entire cohort was 71 yr and median follow-up was 45 mo. Of 675 patients, 446 had at least one comorbid condition and 301 died during follow-up. On multivariable analysis for the entire cohort, comorbidity (p=0.0001), AJCC stage (p=0.0001), age (p=0.0001), and race (p=0.0045) significantly predicted overall survival. On subset analysis of noninvasive bladder cancer patients, comorbidity (p=0.0001) and age (p=0.0001) independently predicted overall survival, whereas stage, grade, race, and gender did not. On subset analysis of cystectomy patients, comorbidity (p=0.0053), stage (p=0.0001), and race (p=0.0449) significantly predicted overall survival.

CONCLUSIONS

Comorbidity is an independent predictor of overall survival in the entire cohort of bladder cancer patients, the subset with noninvasive disease, and the subset treated with cystectomy.

Standards for Surgical Complication Reporting in Urologic Oncology: Time for a Change

OBJECTIVES

No standards for reporting surgical morbidity exist in the urologic oncology literature, yet surgical outcomes are used to assess the success of surgical techniques and surgeon competency. This study analyzes the quality of complication reporting in the urologic literature.

METHODS

Reports identified by a MEDLINE search reporting surgical outcomes after radical prostatectomy, radical cystectomy, retroperitoneal node dissection, and radical/partial nephrectomy were analyzed using 10 established criteria for surgical complication reporting. Open (n = 73) and minimally invasive (n = 36) surgical series of 50 patients or more published from January 1995 to December 2005 were reviewed.

RESULTS

A total of 109 studies reporting the outcomes for 146,961 patients, including 95 retrospective (87%), 11 prospective (10%), 1 randomized (1%), and 2 population-based (2%) studies were analyzed. Of the 10 critical reporting elements, 2% met 9 to 10, 21% met 7 to 8, 43% met 5 to 6, 30% met 3 to 4, and 4% met 1 to 2 criteria. The most commonly underreported criteria were complication definitions in 79%, complication severity/grade in 67%, outpatient data in 63%, comorbidities in 59%, and the duration of the reporting period in 56%. Additionally, 47% of minimally invasive surgical series met fewer than 5 of the 10 reporting criteria compared with 28% of open series. Of the 36 studies reporting complication severity, a numeric grading system was used in 7 (19%), with 29 (81%) of 36 using a "major versus minor" categorization but using 26 different definitions of what constituted "major."

CONCLUSIONS

The disparity in the quality of surgical complication reporting in urologic oncology makes it impossible to compare the morbidity of surgical techniques and outcomes. Standard guidelines need to be established.

Advanced age is associated with poorer bladder cancer-specific survival in patients treated with radical cystectomy

OBJECTIVE

Bladder cancer (BCa) is a disease of older persons, the incidence of which is expected to increase as the population ages. There is controversy, however, regarding the outcomes of radical cystectomy (RC), the gold standard treatment of high-risk BCa, in patients of advanced chronological age. The aim of our study was to assess the impact of patient age on pathological characteristics and recurrence-free and disease-specific survival following RC.

METHODS

The records of 888 consecutive patients who underwent RC for transitional cell carcinoma (TCC) were reviewed. Age at RC was analyzed both as a continuous (yr) and categorical (< or =60 yr old, n=240; 60.1-70 yr old, n=331; 70.1-80 yr old, n=266; >80 yr old, n=51) variable. Logistic regression and survival analyses were performed.

RESULTS

Higher age at RC, analyzed as a continuous or categorical variable, was associated with extravesical disease and pathological upstaging (all p<0.02). Older patients were less likely to receive postoperative chemotherapy (< or =60 yr: 32% vs. >80 yr: 14%, p=0.008). In both pre- and postoperative multivariate models, higher age at RC as a categorical variable was associated with BCa-specific survival (p<0.05). Patients >80 yr old had a significantly greater risk of disease recurrence than patients aged < or =60 yr (p<0.05).

CONCLUSION

Greater patient age at the time of RC for BCa is independently associated with adverse outcomes. Better understanding of factors associated with postoperative outcomes in this growing segment of the population is necessary. Prospective corroboration and further refinement of similar analyses in other large datasets is needed.

Radical cystectomy for invasive bladder cancer: long-term results of a standard procedure

Radical cystectomy with an appropriate lymphadenectomy remains the standard of therapy for high-grade invasive bladder cancer. This surgical approach provides the best survival rates with the lowest local recurrence rates and orthotopic diversion can be performed safely in most patients with an acceptable outcome and quality of life. Pathologic analysis of the bladder tumor and regional lymph nodes will help direct the need for adjuvant therapy in high-risk individuals. Equivalent long-term local control and survival are not seen with other forms of treatment including radiation therapy, chemotherapy, or a combination of the two. The rationale and clinical results of large, contemporary cystectomy series are presented, which provide a benchmark of outcomes with this form of surgical treatment.

The regionalization of radical cystectomy to specific medical centers

PURPOSE

Regionalization of high risk surgical procedures to larger teaching hospitals has been suggested as a means to improve the quality of care. We established a novel framework for characterizing regionalization, implemented it to determine the extent to which regionalization of radical cystectomy has occurred and delineated whether specific patient characteristics are associated with this phenomenon.

MATERIALS AND METHODS

We used the Nationwide Inpatient Sample to identify 22,088 patients who underwent radical cystectomy for bladder cancer from 1988 to 2000. Regionalization was assessed using 5 structural hospital measures, including teaching status, urban location, discharge volume, cystectomy volume and bed capacity. Adjusted models were developed to identify the significance of temporal trends and assess the association of demographic factors with structural qualities.

RESULTS

Compared with 1988 to 1990 subjects were more likely to undergo cystectomy at teaching hospitals (OR 1.8), high cystectomy volume hospitals (OR 1.2), high discharge volume hospitals (OR 1.7) and large bed capacity medical centers (OR 1.4) in 1998 to 2000. The concentration of cystectomy to urban medical centers during the study years was 90% to 92%. The proportion of subjects undergoing partial cystectomy decreased from 23.9% to 16.6% as regionalization occurred. Older subjects were less likely to be treated at these regionalized centers.

CONCLUSIONS

Without broad legislation from health care payers radical cystectomy has increasingly regionalized to specific medical centers. Despite this regionalization disparities in its use exist among specific, vulnerable patients. Addressing this may facilitate further concentration of this procedure.

Identifying risk factors for potentially avoidable complications following radical cystectomy

PURPOSE

Morbidity after radical cystectomy is common and associated with increased health care resource use. Accurate characterization of complications after cystectomy, associated patient specific risk factors, and perioperative processes of care are essential to directing changes in perioperative management that will reduce morbidity and improve the quality of patient care.

MATERIALS AND METHODS

The National Surgical Quality Improvement Program (NSQIP) is a prospective quality management initiative of 123 Veterans Affairs Medical Centers nationwide. The NSQIP collects clinical information, intraoperative data and outcomes on a wide variety of surgical procedures from multiple surgical disciplines. Since 1991, 2,538 radical cystectomy procedures have been captured by the NSQIP. Modeling using logistic regression was performed to identify patient specific risk factors and perioperative process measures associated with postoperative morbidity.

RESULTS

Of the 2,538 subjects at least 1 postoperative complication developed in 774 (30.5%). The most frequent complication was ileus (10%). Several factors were associated with the development of a complication, including age, dependent functional status, preoperative dyspnea, preoperative acute renal failure, chronic steroid use, preoperative alcohol consumption, American Society of Anesthesiology score, use of general anesthetic, operative time, intraoperative blood requirement and surgeon level of training.

CONCLUSIONS

Morbidity remains high after cystectomy with 30.5% of subjects experiencing at least 1 complication. Measurable patient specific risk factors and perioperative processes associated with postoperative morbidity following cystectomy are now delineated which allows for improved risk stratification, patient counseling, and the development of novel processes that may incrementally reduce risk and improve outcomes.

Four Years Experience in Bladder Preserving Management for Muscle Invasive Bladder Cancer

OBJECTIVES

To evaluate the bladder preservation strategy in invasive bladder cancer particularly relapse, progression and complications.

MATERIALS AND METHODS

From January 2000 to May 2004 a total of 24 patients (mean age of 81 years; range 68-92) with muscle invasive bladder cancer who had refused or were not eligible for cystectomy were followed up for a period of up to four years.

RESULTS

24 (21 M/3 F) patients were followed up for a mean time of 680 (182-1253) days. All patients complained of frequency, urgency and severe nocturia. The second most frequent complication was bleeding which required a salvage cystectomy in 7 cases. Other major complications were intestinal occlusion in three cases, an enterovesical fistula, brain metastasis requiring neurosurgical intervention and radiation therapy of the brain, bone metastasis in the cervical spinal column and chronic renal failure. The mean re-admission rate was 8 per patient and the mean time spent at the hospital was 109 (range 13-253) days.

CONCLUSION

In our series the bladder preserving strategy does not confirm the optimistic results of other authors. The complications forced us to carry out a salvage cystectomy in nearly half of the cases. The other half of the patients complained of other severe complications reducing the quality of life of the remaining life span.

Two-surgeon versus single-surgeon radical cystectomy and urinary diversion: Impact on patient outcomes and costs

OBJECTIVES

To examine the difference in charges and outcomes between patients who underwent radical cystectomy and urinary diversion by a team of two surgeons versus a single surgeon.

METHODS

A total of 63 patients with bladder cancer who underwent the procedures were retrospectively analyzed. Two surgeons sequentially performed the cystectomy and ileal conduit (IC, n = 17) or neobladder (NBL, n = 18) or a single surgeon performed both the cystectomy and IC (n = 21) or NBL (n = 7). Procedure-related charges, hospital charges, operating room time, length of stay, and complications were compared between the two groups.

RESULTS

For the IC patients, the two-surgeon team had 60% greater mean surgeon charges (P <0.0001), 23% lower mean anesthesia charges (P <0.0001), 121 minutes shorter operating room time (P = 0.001), and 30% lower operating room charges (P = 0.001). For the NBL patients, the two-surgeon team had 32% greater surgeon charges (P <0.0001), 22% lower anesthesia charges (P = 0.003), 149 minutes shorter operating room time (P <0.0001), and 41% less operating room charges (P <0.0001). No differences were found in total hospital charges. The NBL patients who underwent surgery by two surgeons had a longer length of stay (P = 0.008). No differences were found in complications between the groups.

CONCLUSIONS

For IC patients, our data showed no differences in the average overall charges, whether a two-surgeon team or a single surgeon performed the procedure. Additional reductions in hospital charges could offset the greater physician charges in the NBL patients and allow full realization of the benefit from the shorter operative time with the two-surgeon team.

Radical cystectomy in the elderly

BACKGROUND

The authors report their experience with radical cystectomy for transitional cell carcinoma (TCC) of the bladder comparing clinical outcomes, including complication rates, among older patients versus younger patients in a high-volume center specializing in the treatment of patients with advanced carcinoma of the urinary bladder.

METHODS

A retrospective review was undertaken of 1054 patients who underwent radical cystectomy for bladder TCC from 1971 through 1997. Four age groups were compared; < 60 years at the time of cystectomy (n = 309 patients), age 60-69 years (n = 381 patients), age 70-79 years (n = 314 patients), and age > or = 80 years (n = 50 patients).

RESULTS

The median length of hospital stay in patients ages < 60 years, 60-69 years, 70-79 years, and > or = 80 years was 10 days, 10 days, 11 days, and 11 days, respectively (P < 0.001). The corresponding rates of overall early complications were 24%, 25%, 37%, and 30%, respectively (P = 0.002); whereas the corresponding late complication rates were 36%, 30%, 22%, and 14%, respectively (P < 0.001). The rate of early diversion-related complications did not differ significantly (11%, 8%, 12%, and 6%, respectively; P = 0.14). The operative mortality rates were 1%, 3%, 4%, and 0%, respectively (P = 0.14). There was no difference with respect to early complications, early diversion-related complications, late complications, or operative mortality comparing patients age > 70 years who underwent ileal conduit versus orthotopic urinary diversion (P = 0.20, P = 0.61, P = 0.53, and P = 0.78, respectively).

CONCLUSIONS

Elderly patients who underwent cystectomy for TCC had similar mortality and early diversion-related complication rates. Carefully selected elderly patients safely can be offered an orthotopic urinary diversion. Chronological age, per se, is not a contraindication for radical cystectomy in the setting of invasive bladder carcinoma.

Cost comparison of radical retropubic and radical perineal prostatectomy: single institution experience

OBJECTIVES

To perform a detailed comparison of the in-house hospital costs of patients undergoing radical perineal prostatectomy (RPP) and radical retropubic prostatectomy (RRP) performed with or without bilateral staging lymph node dissection (BPLND) for localized prostate cancer.

METHODS

A retrospective cost review was done of a cohort of 402 consecutive radical prostatectomies performed at our institution during a 21-month period. The procedure was performed as RPP in 279 (69.4%) and RRP in 123 (30.6%) patients, of whom 10.4% and 61.8%, respectively, underwent BPLND under the same anesthesia. The hospital costs were evaluated for each patient using the categories of surgical, nursing, laboratory/transfusion, and pharmacy. Surgical costs were further subdivided into operating room, anesthesia, and recovery room costs. Univariate and multivariate statistical analyses were applied to identify predictors of procedure-related costs.

RESULTS

The median hospital costs of patients undergoing RPP (7195 dollars, range 5052 dollars to 36,237 dollars) were substantially lower than those of patients undergoing RRP (9757 dollars, range 6935 dollars to 27,771 dollars; P = 0.001). The median costs for patients undergoing radical prostatectomy without BPLND were significantly lower in the RPP (7100 dollars, range 5052 dollars to 28,604 dollars) versus RRP (9169 dollars, range 6935 dollars to 16,705 dollars) patients (P = 0.001). The costs for RPP with BPLND (10,048 dollars, range 7529 dollars to 36,237 dollars) versus RRP with BPLND (9973 dollars, range 7658 dollars to 27,771 dollars) were not significantly different (P = 0.900). Patient age and nerve-preservation status did not significantly influence the procedure-related hospital costs.

CONCLUSIONS

RPP may result in lower in-house costs per patient than RRP in those patients who do not require BPLND. Total hospital costs depend largely on the factors of operating room time, length of stay, and laboratory and transfusion requirements, which may vary among institutions.

The impact of co-morbid disease on cancer control and survival following radical cystectomy

PURPOSE

We clarified the impact of concurrent medical disease on tumor control and survival following radical cystectomy.

MATERIALS AND METHODS

A total of 106 consecutive patients with clinically localized (cT2 or less) disease underwent radical cystectomy at the University of Michigan between 1997 and 1998. The Charlson Index, a validated risk adjustment index, was used to assess preoperative co-morbidity. The 3 primary end points were pathological stage, disease specific survival and overall survival. Logistic regression models were used to determine the relationship between Charlson Index and pathological stage, while Cox regression models were used for the 2 survival end points.

RESULTS

Of our study population 24% had a Charlson Index score of 2 or greater. Myocardial infarction, nonurothelial solid malignancies and cerebrovascular disease were the most common co-morbid conditions at 14%, 12% and 10%, respectively. On bivariate analysis the Charlson Index was significantly associated with decreased disease specific (p = 0.049) and overall (p = 0.016) survival. In a multivariate model the index was independently associated with decreased cancer specific survival (p = 0.049) and increased risk of extravesical disease (p = 0.033).

CONCLUSIONS

We demonstrated an association between co-morbid illness and adverse pathological and survival outcome following radical cystectomy. This finding underscores the value of assessing overall health before recommending and proceeding with surgery. Moreover, our results emphasize the need to adjust for co-morbidity when comparing outcomes following radical cystectomy.

The effectiveness of a "critical pathway" in the management of laryngectomy patients

BACKGROUND

This is a retrospective review of medical and financial records to test the hypothesis that the use of a critical pathway specifically designed for the management of laryngectomy patients will result in improved patient care, decreased length of hospitalization, and optimal allocation of resources.

METHODS

Thirty patients undergoing laryngectomy before the implementation of the laryngectomy critical pathway were compared with 30 patients after implementation of the pathway. Clinical outcomes, length of hospitalization, and cost analyses were performed.

RESULTS

Adjusting for two outliers, the average length of stay for pathway patients was 7.3 days vs 12 days for prepathway patients. A total estimated cost-savings of $204,000 was ultimately achieved.

CONCLUSIONS

Our laryngectomy critical pathway has resulted in improved patient care and optimized allocation of medical resources.

Three years' experience of collaborative care pathways on a maxillofacial ward

Collaborative care pathways (CCPs) provide a framework for multidisciplinary patient care. They provide guidelines and a mechanism for audit, and were first introduced at the Regional Unit, Walton Hospital, Liverpool, in November 1994. They have been designed for many surgical groups. Between August 1996 and 31 July 1997, 955 patients were admitted on to the nine established pathways: fractured mandible (n=213), fractured zygoma (n=117), minor oral surgery (n=244), abscess (n=18), examination under anaesthesia (n=73), nasal surgery (n=73), osteotomy (n=80), salivary (n=63), and temporomandibular joint (n=74). The purpose of this article is to report the introduction of CCP in a maxillofacial ward and give results from a one-year audit. CCP have proved to be an extremely useful tool and have several advantages over traditional documentation. They are more accurate, easily computerized, and facilitate audit. They promote the development of guidelines and standardized perioperative care, and this in turn facilitates training and raises standards of care.

The implementation of clinical paths for six common urological procedures, and an analysis of variances

OBJECTIVE

To evaluate the outcomes of treatment after implementing clinical paths for six common urological procedures, and analyse the variances from these paths.

PATIENTS AND METHODS

The study comprised 1006 consecutive patients treated according to the recommendations of the clinical path for six common urological procedures; the results of treatment were compared with those from 1006 patients treated by the same physicians before implementing the clinical paths. Total admission charges were divided into five categories, i.e. operation and anaesthesia, laboratory, radiology, pharmacy and other. The differences in these five categories before and after implementation were determined; the variance data were also tracked and analysed. Five quality indicators were monitored during implementation and compared with the data before implementation.

RESULTS

The mean length of hospital stay (LOS) and admission charges were significantly lower (P=0.03 and P<0.01) after implementation. The charges for laboratory, radiology, pharmacy and other were significantly decreased after the use of clinical paths. The common variations from the clinical paths were patient-related variance (33%) and discharge variance (26%). Variances affecting the LOS only or the admission charge only were more common than those affecting neither the LOS nor admission charges (both P<0.01), or both (both P<0.01). After implementation, the results of the five quality indicators were significantly improved and the number of patients with surgical complications was significantly reduced (P<0. 01), but the mortality and readmission rate did not increase.

CONCLUSIONS

The implementation of clinical paths for six common urological procedures decreased the LOS, admission charges and surgical complications, and improved the quality of care. During implementation, variances can affect the LOS and/or admission charges.

Impact of a clinical pathway for radical retropubic prostatectomy

OBJECTIVES

Cost containment has become an important issue in medical practice. With the implementation of collaborative care programs and critical pathways, substantial reduction in overall costs can be achieved while maintaining the quality of care and patient satisfaction.

METHODS

Our series consists of 856 consecutive patients treated with radical retropubic prostatectomy by 24 surgeons in a single hospital between January 1, 1994, and January 31, 1997. A clinical pathway for radical retropubic prostatectomy was implemented July 1, 1994. The patients were subdivided into three groups: (1) baseline: patients who underwent surgery in the 6 months immediately before the pathway onset (n = 113); (2) nonpathway: 75 patients treated off the clinical pathway; and (3) pathway: 668 men placed on the clinical pathway. We compare average length of stay and average hospital charges among the three groups. We also compare average length of stay among physician volume groups: high volume physicians performed at least 12 operations per year; low volume physicians performed less than 12 operations per year. Charges were further broken down by department. Patient satisfaction was recorded by an outside source after discharge. Postoperative complications were assessed in the clinical pathway and nonpathway groups.

RESULTS

Average hospital charges and average length of stay were $12,926 and 5.8 days for baseline patients, $11,795 and 5.0 days for nonpathway patients, and $10,042 and 4.0 days for pathway patients, respectively. Implementation of the clinical pathway was associated with lower charges and length of stay in the pathway group as well as the nonpathway group, with larger reductions in pathway patients. With continuous reassessment and modification of the clinical pathway, both average hospital charges and average length of stay have progressively decreased from $10,540 and 4.9 days in 1994 to $8766 and 2.7 days in January 1997. Charges were uniformly reduced in radiology, laboratory, pharmacy, operating room, anesthesia, and nursing or routine care. Patient satisfaction was similar in the pathway group and the nonpathway group. Incidence of postoperative complications did not differ significantly between the pathway and nonpathway groups. Length of stay and hospital charges were significantly lower for high than low volume surgeons, irrespective of the declines observed over time (P = 0.0001 and 0.0001, respectively).

CONCLUSIONS

Average hospital charges and average length of stay for all surgeons were lowered significantly with the implementation of a clinical pathway and continue to decrease with continuous reassessment. The pathway was not associated with any increase in postoperative complications or patient dissatisfaction. Surgeons who operate frequently have lower average lengths of stay and hospital charges than those who operate infrequently.

Why use clinical pathways rather than practice guidelines?

BACKGROUND

Financial pressures from managed care organizations, the government, and other "stakeholders" have resulted in the production of practice guidelines and clinical pathways. Clinical pathways involve all segments of a health care system and may prove to be more beneficial and less hazardous to patients and health care providers.

METHODS

A historical narrative describing the development of clinical pathways by the Southwestern Surgical Congress (SWSC) and the Southeastern Surgical Congress (SESC) is made. The motivations, the benefits, and the hazards of both clinical pathways and practice guidelines are discussed.

RESULTS

Clinical pathways have proven to reduce length of stay (LOS), complications, and cost, and provide increased patient satisfaction whereas practice guidelines from some specialties show improved quality of care when compared with nonspecialists. However, many practice guidelines are developed by specialists on "best practice" standards, and few have documented studies proving their effectiveness.

CONCLUSIONS

Eleven clinical pathways were developed by the SWSC and the SESC and are in the process of revision and study for efficacy. They will be disseminated in the American Surgeon and on the SWSC web site for review and comment. In 1998, both congresses hope to publish the efficacy of selected pathways by describing their effect on LOS and charge for those diagnostic-related groups.

Implementation of a clinical pathway decreases length of stay and hospital charges for patients undergoing total colectomy and ileal pouch/anal anastomosis

BACKGROUND

Clinical pathways are increasingly being used by hospitals to improve efficiency in the care of certain patient populations; however, little prospective data are available to support their use. This study examined whether using a clinical pathway for patients undergoing ileal pouch/anal anastomosis, a complex procedure in which we had extensive practical experience, affected hospital charges or length of stay (LOS).

METHODS

A clinical pathway was developed to serve patients undergoing elective total colectomy and ileal pouch/anal anastomosis. All operations were performed by two attending physicians (J.E.F., M.S.N.). Before implementation, 10 pilot patients were prospectively monitored to ensure that hospital charges were accurately generated. In addition, charge audits were performed by an outside agency to verify the accuracy of the hospital bills. The pathway was then implemented, and 14 patients were prospectively analyzed.

RESULTS

In all patients the principal diagnosis was ulcerative colitis, with the exception of three patients with familial polyposis. Mean external audit charges were within 2% of the hospital bills; therefore the hospital bills were used in all calculations. The mean LOS decreased from 10.3 days to 7.5 days (p = 0.046) for patients on the pathway versus pilot patients. Mean hospital charges also decreased significantly, from $21,650 to $17,958 per patient (p = 0.005).

CONCLUSIONS

Implementation of a clinical pathway, even for an operation in which the surgeon has much experience, is an effective method for reducing LOS and charges for patients. This is likely the result of interdisciplinary cooperation, elimination of unnecessary interventions, and streamlined involvement of ancillary services. These results support the development of clinical pathways for procedures that involve routine preoperative and postoperative care. In addition, the benefits of clinical pathways should increase proportionally with increasing case volume for a particular procedure.