Cost comparison of laparoscopic colectomy versus open colectomy in colon cancer

Effect of insurance status on perioperative outcomes after robotic pancreaticoduodenectomy: a propensity-score matched analysis

The influence of Medicaid or being uninsured is prevailingly thought to negatively impact a patient's socioeconomic and postoperative course, yet little has been published to support this claim specifically in reference to robotic pancreaticoduodenectomy. This study was undertaken to determine impact of health insurance type on perioperative outcomes in patients undergoing robotic pancreaticoduodenectomy. Following IRB approval, we prospectively followed 364 patients who underwent robotic pancreaticoduodenectomy. Patients were stratified by insurance status (i.e., Private, Medicare, and Medicaid/Uninsured); 100 patients were 2:2:1 propensity-score matched by age, BMI, ASA class, pathology, 8th edition AJCC staging, and tumor size. Perioperative variables were compared utilizing contingency testing and ANOVA. Statistical significance was accepted at a p-value ≤ 0.05 and data are presented as median (mean ± SD). The 100 patients undergoing propensity-score matching were 64 (65 ± 9.1) years old with a BMI of 27 (27 ± 4.9) kg/m2 and ASA class of 3 (3 ± 0.5). Operative duration was 421 (428 ± 105.9) minutes and estimated blood loss was 200 (385 ± 795.0) mL. There were 4 in-hospital deaths and 8 readmissions within 30 days of discharge. Total hospital cost was $32,064 (38,014 ± 22,205.94). After matching, no differences were found in pre-, intra-, and short-term postoperative variables among patients with different insurances, including hospital cost and time to initiate adjuvant treatment, which was 8 (9 ± 7.9) weeks for patients with malignant disease. In our hepatopancreaticobiliary program, health insurance status did not impact perioperative outcomes or hospital costs. These findings highlight that financial coverage does not influence quality of perioperative care, reinforcing the equity of robotic surgery.

Cost Drivers of Elective Colon and Rectal Surgery: A Retrospective Cohort Analysis

BACKGROUND

Colorectal surgery is expensive. Few studies have evaluated complications as an economic cost driver, and there is little evidence comparing multiple cost drivers of colorectal surgery to determine the most effective means of reducing total cost.

OBJECTIVE

This study aimed to determine the effects of surgical techniques, use of enhanced recovery protocols, and presence or absence of complications on the total cost of hospitalization for elective colorectal surgery.

DESIGN

A retrospective cohort analysis using data from 2011 to 2018 was performed. The primary end point was a mean cost per hospitalization. The cost was compared between patients who experienced minimally invasive versus open surgeries, enhanced recovery after surgery protocols versus not, and complications versus none.

SETTINGS

This study was conducted at a university-affiliated teaching hospital in the Northeastern United States.

PATIENTS

Adult patients who have undergone elective colorectal surgery were included.

MAIN OUTCOME MEASURES

The primary outcome for this study was the mean cost per hospitalization calculated using inpatient cost based on the total cost of the episode of care.

RESULTS

A total of 1039 patients met the criteria for inclusion. The average cost of all hospitalizations was $19,801. Multivariate analysis demonstrated that enhanced recovery protocols substantially lowered the cost of care by $6392 ( p = 0.001), whereas complications increased the cost of care by $16,780 per episode ( p < 0.001). When complications occurred, enhanced recovery protocols reduced the cost by $17,963 ( p = 0.010).

LIMITATIONS

This retrospective cohort study performed at a single institution has inherent limitations, including confounding and selection bias.

CONCLUSIONS

For elective colorectal surgery, complications are associated with significantly increased costs. Avoiding complications should be a priority to reduce costs. Enhanced recovery protocols are associated with significantly reduced costs. Surgeons should focus future research efforts on improving protocols and processes that decrease postoperative complications to improve patient outcomes and to reduce costs associated with elective colorectal hospitalizations. See Video Abstract at http://links.lww.com/DCR/B927 .

FACTORES DE COSTO DE LA CIRUGA ELECTIVA DE COLON Y RECTO UN ANLISIS DE COHORTE RETROSPECTIVE

ANTECEDENTES:La cirugía colorrectal es costosa. Pocos estudios han examinado las complicaciones como un factor de costo económico, y hay poca evidencia que compare múltiples factores de costo de la cirugía colorrectal para determinar los medios más efectivos para reducir el costo total.OBJETIVO:Este estudio tiene como objetivo determinar los efectos de las técnicas quirúrgicas, el uso de protocolos de enhanced recovery y la presencia o ausencia de complicaciones en el costo total de hospitalización por cirugía colorrectal electiva.DISEÑO:Se realizó un análisis retrospectivo de cohortes utilizando data del 2011-2018. El punto principal fue el costo medio por hospitalización. Se comparó el costo entre los pacientes que experimentaron: cirugías mínimamente invasivas versus abiertas, protocolos de enhanced recovery después de la cirugía versus no, y complicaciones versus no.FUENTE DE DATOS:Se consultó la base de datos financiera y contable del hospital y el registro médico electrónico para la obtencion de datos.ENTORNO CLINICO:Este estudio se realizó en un hospital docente afiliado a una universidad en el noreste de los Estados Unidos.PACIENTES:Se incluyeron pacientes adultos sometidos a cirugía colorrectal electiva.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal de este estudio fue el costo medio por hospitalización calculado utilizando el costo de hospitalización basado en el costo total del episodio de atención.RESULTADOS:Un total de 1.039 pacientes cumplieron los criterios de inclusión. El costo promedio de todas las hospitalizaciones fue de $19801. El análisis multivariante demostró que los protocolos de enhanced recovery redujeron sustancialmente el costo de la atención en $6392 ( p = 0,001), mientras que las complicaciones aumentaron el costo en $16780 por episodio ( p < 0,001). Cuando ocurrieron complicaciones, los protocolos de enhanced recovery redujeron el costo en $17963 ( p = 0,010).LIMITACIONES:Este es un estudio de cohorte retrospectivo realizado en una sola institución y tiene limitaciones inherentes que incluyen confusión y sesgo de selección.CONCLUSIONES:Video Resumen en http://links.lww.com/DCR/B927 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Intracorporeal or extracorporeal ileocolic anastomosis after laparoscopic right colectomy: cost analysis of the Torino trial

BACKGROUND

Intracorporeal (IIA) and extracorporeal anastomosis (EIA) are two well-established techniques for restoration of bowel continuity after laparoscopic right colectomy (LRC). Since no economic analysis comparing the two different anastomotic techniques has been performed yet, it is still unclear if IIA can reduce perioperative costs. The aim of the study was to compare costs of LRC with IIA or EIA for right-sided colon neoplasm.

METHODS

This is a cost analysis of a single-institution double-blinded randomized controlled trial comparing the outcomes of LRC with IIA and LRC with EIA in patients with a right-sided colon neoplasm. All direct in-hospital costs related to patient's admission were recorded (intraoperative costs: operative room, surgical tools, blood units-postoperative costs: hospital stay, laboratory and microbiology analyses, diagnostic services, analgesic drugs and antibiotic therapy, blood units, reoperation-outpatient costs: post-discharge wound medications). This trial was registered with ClinicalTrials.gov, Number NCT03045107.

RESULTS

A total of 140 patients were randomized and analyzed. Mean overall costs in the IIA group exceeded 349 € the mean overall costs of the EIA group (7926.87 ± 4617.23 € vs. 7577.45 ± 6131.17 €; P = 0.704). A mean extra charge of 608 € regarding total intraoperative costs was recorded in the IIA group (3058.84 ± 897.42 € vs. 2450.15 ± 558.90 €; P < 0.001). The cost of surgical instruments resulted in 542 € additional charge per patient in the IIA group compared to EIA group (1782.74 ± 541.26 € vs. 1240.55 ± 384.09 €; P < 0.001). The mean cost of operative room occupancy was comparable in IIA and EIA group: 1276.09 ± 514.94 € vs. 1209.60 ± 422.80 € (P = 0.405). No significant differences were observed in postoperative costs and in outpatient costs.

CONCLUSION

This economic analysis showed that IIA and EIA after LRC had similar overall costs, even though there were intraoperative extra costs of IIA.

Postoperative Use of Biologics was Less Common among Patients with Crohn's Disease With Emergent/Urgent Versus Elective Intestinal Resection

BACKGROUND & AIMS

Given the risk of intestinal resection for Crohn's disease, postoperative treatment may be informed by several risk factors, including resection type. We compared postoperative treatment strategies for Crohn's disease between emergent/urgent versus elective resection.

METHODS

We identified patients with intestinal resection for Crohn's disease between 2002-2018 using the MarketScan databases. We classified emergent/urgent resections as those occurring after emergency department admission or after the second day of admission. We estimated adjusted risk differences for the association between resection type (emergent/urgent versus elective) and 6-month postoperative medication strategy (biologic monotherapy, biologic combination therapy with an immunomodulator, immunomodulator monotherapy, other non-biologic medication for Crohn's [5-aminosalicylates, antibiotics, corticosteroids], or no medications for Crohn's).

RESULTS

During 6 months after resection among 4,187 patients, 23% received biologic monotherapy, 6% received combination therapy, 16% received immunomodulator monotherapy, and 36% received other non-biologics. Compared to elective resection, emergent/urgent resection was associated with more common use of "other non-biologic" medications (risk difference 6.4%; 95% confidence interval [CI] 2.8%, 10.0%), but less common use of biologic monotherapy (risk difference -3.2%; 95% CI -6.2%, -0.1%) and no medications (risk difference -3.6%; 95% CI -6.6%, -0.6%).

CONCLUSIONS

Although patients with emergent/urgent resection may benefit from more aggressive postoperative therapy, there was evidence that emergent/urgent resection was more associated than elective resection with postoperative use of non-biologics for Crohn's disease. Future studies of treatment patterns and comparative effectiveness of postoperative treatment strategies for Crohn's patients should consider these differences between resection types, which may be important drivers of longer-term outcomes.

Developing an International Standard Set of Patient-Reported Outcome Measures for Psychotic Disorders

OBJECTIVE

The objective of this project was to develop a set of patient-reported outcome measures for adolescents and adults who meet criteria for a psychotic disorder.

METHODS

A research team and an international consensus working group, including service users, clinicians, and researchers, worked together in an iterative process by using a modified Delphi consensus technique that included videoconferencing calls, online surveys, and focus groups. The research team conducted systematic literature searches to identify outcomes, outcome measures, and risk adjustment factors. After identifying outcomes important to service users, the consensus working group selected outcome measures, risk adjustment factors, and the final set of outcome measures. International stakeholder groups consisting of >100 professionals and service users reviewed and commented on the final set.

RESULTS

The consensus working group identified four outcome domains: symptoms, recovery, functioning, and treatment. The domains encompassed 14 outcomes of importance to service users. The research team identified 131 measures from the literature. The consensus working group selected nine measures in an outcome set that takes approximately 35 minutes to complete.

CONCLUSIONS

A set of patient-reported outcome measures for use in routine clinical practice was identified. The set is free to service users, is available in at least two languages, and reflects outcomes important to users. Clinicians can use the set to improve clinical decision making, and administrators and researchers can use it to learn from comparing program outcomes.

Quality of Life and Severity of Symptom Differences Between Post Open Colectomy and Laparoscopic Colectomy in Colorectal Cancer Patients

BACKGROUND

Worldwide, colorectal cancer is the third most common cancer in men and the second in women. The main surgical methods for colorectal cancer patients include a conventional open colectomy and laparoscopic-assisted colectomy. Laparoscopic-assisted colectomy is associated with less blood loss, faster recovery of bowel function, and shorter hospital stays.

OBJECTIVE

The aim of this study was to compare the quality of life and symptom severity in patients with colorectal cancer 1 month after conventional open colectomy or laparoscopic-assisted colectomy.

METHODS

A comparative cross-sectional study design was conducted from September 2015 to May 2016. Participants were recruited through convenience sampling from the surgical outpatient department of a medical center in Northern Taiwan; 33 patients underwent each type of surgery.

RESULTS

The laparoscopic-assisted colectomy group scored 9.39 points higher in quality of life and lower in symptom severity by 14.88 points than the conventional open colectomy group (P = .03 and P = .05, respectively). Both groups reported low symptom severity; "changes in bowel habits" was the symptom with the highest severity. The conventional open colectomy group had higher insomnia and worried about their future more than did the laparoscopic-assisted colectomy group.

CONCLUSIONS

Patients who received the laparoscopic-assisted colectomy procedure reported a better quality of life and lower symptom severity than those who received the conventional open colectomy surgical method.

IMPLICATIONS FOR PRACTICE

Patients who will have a conventional open colectomy will likely need enhanced management of symptoms and attention to their quality of life.

The Trends in Adoption, Outcomes, and Costs of Laparoscopic Surgery for Colorectal Cancer in the Elderly Population

BACKGROUND

The elderly constitute the majority of both colorectal cancer and surgical volume. Despite established safety and feasibility, laparoscopy may remain underutilized for colorectal cancer resections in the elderly. With proven benefits, increasing laparoscopy in elderly colorectal cancer patients could substantially improve outcomes. Our goal was to evaluate utilization and outcomes for laparoscopic colorectal cancer surgery in the elderly.

METHODS

A national inpatient database was reviewed for elective inpatient resections for colorectal cancer from 2010 to 2015. Patients were stratified into elderly (≥ 65 years) and non-elderly cohorts (< 65 years), then grouped into open or laparoscopic procedures. The main outcomes were trends in utilization by approach and total costs, length of stay (LOS), readmission, and complications by approach in the elderly. Multivariable regression models were used to control for differences across platforms, adjusting for patient demographics, comorbidities, and hospital characteristics.

RESULTS

Laparoscopic adoption for colorectal cancer in the elderly increased gradually until 2013, then declined, with simultaneously increasing rates of open surgery. Laparoscopy significantly improved all primary outcomes compared to open surgery (all p < 0.01). From the adjusted analysis, laparoscopy reduced complications by 30%, length of stay by 1.99 days, and total costs by $3276/admission. Laparoscopic patients were 34% less likely to be readmitted; when readmitted, the episodes were less expensive when index procedure was laparoscopic.

CONCLUSION

The adoption of laparoscopy for colorectal cancer surgery in the elderly is slow and even declining recently. In addition to the clinical benefits, there are reduced overall costs, creating a tremendous value proposition if use can be expanded.

PRECIS

This national contemporary study shows the slow uptake and recent decline in adaption of laparoscopic surgery for colorectal cancer in the elderly, despite the benefits in clinical outcomes and costs found. This data can be used to target education, regionalization, and quality improvement efforts in this expanding population.

Effects of laparoscopic vs open abdominal surgery on costs and hospital readmission rate and its effect modification by surgeons' case volume

BACKGROUND

Laparoscopy provides a minimally invasive alternative to open abdominal surgery. Current data describing its association with hospital readmission and costs in relation to surgeon laparoscopic case volume is limited to smaller databases and subsets of operations.

METHODS

This retrospective cohort study of 23,285 adult abdominal operations from 2007 to 2015 compares 30-day readmission rate and costs between laparoscopic and open abdominal operations and examines effect modification by surgeon laparoscopic case volume. Outcomes were all-cause hospital readmission within 30 days after discharge and index hospital admission cost.

RESULTS

All-cause hospital readmission rates were significantly lower after laparoscopic abdominal operations compared with open operations (adjusted odds ratio [aOR] 0.56, 95% CI 0.46-0.69, p < 0.001) with a difference in readmission risk attributable to laparoscopic approach of - 4.0% (95% CI - 5.4 to - 2.6%) in complete-case analysis. Among surgeons with a high laparoscopic case volume, the estimated difference in readmission risk through laparoscopy was magnified (- 5.8%, 95% CI - 7.5 to - 4.1%) compared to low surgeon laparoscopic case volume (- 2.9%, 95% CI - 4.8 to -1.1%, p for interaction = 0.005). The estimated difference in costs of the index hospital admission attributable to laparoscopic approach was - $3869 (95% CI - $4200 to - $3538; adjusted incidence rate ratio 0.77, 95% CI 0.75-0.79, p < 0.001). Laparoscopy was followed by significantly lower rates of readmissions related to gastrointestinal (aOR 0.68, 95% CI 0.55-0.85, p = 0.001), wound complications (infection: aOR 0.33, 95% CI 0.23-0.47, p < 0.001; non-infectious: aOR 0.47, 95% CI 0.30-0.74, p = 0.001), and malignancy (aOR 0.68, 95% CI 0.55-0.85, p < 0.001). The findings remain robust after multiple imputation and sensitivity analyses.

CONCLUSIONS

Laparoscopy versus open abdominal surgery is associated with reduced hospital readmissions related to malignancy, gastrointestinal, and wound complications. Effect modification by higher laparoscopy case volume argues for continued proliferation of laparoscopy in abdominal surgeries.

A Paradigm Shift in Physician Reimbursement: A Model to Align Reimbursement to Value in Laparoscopic Colorectal Surgery in the United States

BACKGROUND

Despite common beliefs, underuse of laparoscopic colorectal surgery remains an issue. A paradigm shift to increase laparoscopy and align payment with effort is needed, with pressures to improve value.

OBJECTIVE

The purpose of this study was to compare reimbursement across surgical approach and payer for common colorectal procedures and to propose a novel way to increase use in the United States.

DATA SOURCES

Centers for Medicare & Medicaid Services (Medicare) reimbursement and commercial claims data from 2012 to 2015 were used.

STUDY SELECTION

Reimbursement across payers was mapped for the 10 most common colorectal procedures using the open and laparoscopic approaches.

MAIN OUTCOME MEASURES

The reimbursement difference across approaches by payer and potential value proposition from a cost-shifting model increasing reimbursement with corresponding increases in laparoscopic use was measured.

RESULTS

For Medicare, reimbursement was lower laparoscopically than open for the majority. With commercial, laparoscopy was reimbursed less for 3 procedures. When laparoscopic reimbursement was higher, the amount was not substantial. Medicare payments were consistently lower than commercial, with corresponding lower reimbursement for laparoscopy. Increasing reimbursement by 10%, 20%, and 30% resulted in significant cost savings with laparoscopy. Savings were amplified with increasing use, with additional savings over baseline at all levels, except 30% reimbursement/10% increased use.

LIMITATIONS

The study was limited by the use of claims data, which could have coding errors and confounding in the case mix across approaches.

CONCLUSIONS

Reimbursement for laparoscopic colorectal surgery is comparatively lower than open. Reimbursement can be increased with significant overall cost savings, as the reimbursement/case is still less than total cost savings with laparoscopy compared with open cases. Incentivizing surgeons toward laparoscopy could drive use and improve outcomes, cost, and quality as we shift to value-based payment. See Video Abstract at http://links.lww.com/DCR/B290. CAMBIOS EN LOS PARADIGMAS DE REEMBOLSOS MÉDICOS: UN MODELO PARA ALINEAR EL REEMBOLSO AL VALOR REAL DE LA CIRUGÍA COLORRECTAL LAPAROSCÓPICA EN LOS ESTADOS UNIDOS: A pesar de las creencias comunes, la subutilización de la cirugía colorrectal laparoscópica sigue siendo un problema. Se necesita un cambio en los paradigmas para aumentar y alinear el rembolso de la laparoscopia aplicando mucho esfuerzo para obtener una mejoría en su valor real.Comparar los reembolsos del abordaje quirúrgico y los de la administración para procedimientos colorrectales comunes y proponer una nueva forma de aumentar su uso en los Estados Unidos.Reembolsos en los Centros de Servicios de Medicare y Medicaid (Medicare) y los datos de reclamos comerciales encontrados de 2012-2015.El reembolso administrativo se mapeó para los diez procedimientos colorrectales más comunes utilizando los enfoques abiertos y laparoscópicos.Diferencias de reembolso entre los enfoques por parte de la administración y la propuesta de valor real de un modelo de cambio de costos que aumentan el reembolso con los aumentos correspondientes si se utiliza la laparoscopía.Para Medicare, el reembolso fue menor para una mayoría por vía laparoscópica que abierta. Comercialmente, la laparoscopia se reembolsó menos por 3 procedimientos. Cuando el reembolso laparoscópico fue mayor, la cantidad no fue sustancial. Los pagos de Medicare fueron consistentemente más bajos que los pagos comerciales, con el correspondiente reembolso más bajo por laparoscopia. El aumento del reembolso en un 10%, 20% y 30% resultó en ahorros de costos significativos con la laparoscopía. Los ahorros se amplificaron con el aumento de la utilización, con ahorros adicionales sobre la línea de base en todos los niveles, excepto el 30% de reembolso / 10% de mayor uso.Uso de datos de reclamos, que podrían tener errores de codificación y confusión en la combinación de casos entre enfoques.El reembolso por la cirugía colorrectal laparoscópica es comparativamente más bajo que el abordaje abierto. El reembolso se puede aumentar con ahorros significativos en los costos generales, ya que el reembolso / caso es aún menor que el ahorro total en los costos de la laparoscopia en comparación con los casos abiertos. Incentivar a los cirujanos hacia la laparoscopía podría impulsar la utilización y mejorar los resultados, el costo y la calidad a medida que se pasa al pago basado en el valor real. Consulte Video Resumen en http://links.lww.com/DCR/B290. (Traducción-Dr Xavier Delgadillo).

Laparoscopy improves failure to rescue compared to open surgery for emergent colectomy

Emergent colectomy is performed in thousands of Americans each year and carries significant morbidity and mortality. Although laparoscopy has gained favor in the elective setting, its impact on failure to rescue has not been studied on a population level for emergent colectomy. The purpose of this study was to compare failure to rescue following laparoscopic versus open colectomy in the emergency setting. This was a retrospective cohort study of The American College of Surgeons National Surgical Quality Improvement Program. Adult patients undergoing emergent colectomy between 2005 and 2018 were selected and stratified into laparoscopic or open surgery groups using the Current Procedural Terminology codes. Propensity matching was performed based on the demographic and comorbidity data. Main outcomes were failure to rescue, mortality, overall morbidity, individual complications, and length of hospital stay. After matching, 11,484 cases were included for analysis, of which 3829 were laparoscopic. Overall, open colectomy conferred higher odds of failure to rescue (OR 1.71, 95% CI 1.42-2.08), mortality (OR 1.72, 95% CI 1.44-2.07), and morbidity (OR 1.73, 95% CI 1.60-1.88) vs laparoscopic cases. Open surgery significantly increased the risk of nearly all measured postoperative complications including return to operating room (OR 1.25, 95% CI 1.08-1.45), ventilator use > 48 h (OR 2.43, 95% CI 2.03-2.93), and septic shock (OR 2.34, 95% CI 1.97-2.80). Hospital length of stay was shorter for patients undergoing laparoscopic (10.4 days) vs open (12.3 days) colectomy (p < 0.0001). This study demonstrates the safety and efficacy of the laparoscopic approach for emergent colectomy vs open surgery. Laparoscopy was associated with improved complications rates, mortality, and failure to rescue, indicating that it is a promising option to improve patient outcomes during emergent colectomy.

Social determinants of health and their impact on postcolectomy surgery readmissions: a multistate analysis, 2009–2014

Aim: To examine the effect of race/ethnicity, insurance status and median household income on postoperative readmissions following colectomy. Patients & methods: Multivariate analysis of hospital discharge data from California, Florida, Maryland and New York from 2009 to 2014. Primary outcomes included adjusted odds of 30- and 90-day readmissions following colectomy by race, insurance status and median income quartile. Results: Total 330,840 discharges included. All 30-day readmissions were higher for black patients (adjusted odds ratio [aOR]: 1.07). Both 30- and 90-day readmissions were higher for Medicaid (aOR: 1.30 and 1.26) and Medicare (aOR: 1.30 and 1.29). The 30- and 90-day readmissions were lower in the highest income quartiles. Conclusion: Race, insurance status and median household income are all independent predictors of disparity in readmissions following colectomy.