Financial burden of postoperative complications following colonic resection: A systematic review

Quantifying societal burden of radiation-induced small bowel toxicity in patients with rectal cancer

Introduction

Advancements in rectal cancer (RC) treatment not only led to an increase in lives saved but also improved quality of life (QoL). Notwithstanding these benefits, RC treatment comes at the price of gastrointestinal morbidity in many patients. Health economic modelling poses an opportunity to explore the societal burden of such side-effects. This study aims to quantify radiation-induced late small bowel (SB) toxicity in survivors of RC for Three-Dimensional Conformal Radiation Therapy (3D-CRT), Intensity Modulated Radiation Therapy (IMRT) and Intensity Modulated Radiation Therapy - Image Guided Radiation Therapy (IMRT/IGRT).

Materials and methods

Materials and A model-based health economic evaluation was performed. The theoretical cohort consists of a case-mix of survivors of RC aged 25-99 years according to Belgian age-specific incidence rates. A societal perspective was adopted. The base case analysis was complemented with one-way deterministic analyses, deterministic scenario analyses and probabilistic sensitivity analysis (1,000 iterations). Results were presented as mean lifetime incremental cost (€) and utility (QALYs) per patient.

Results

The analyses showed that the use of innovative radiotherapy (RT) improves lifetime QoL in survivors of RC by 0.11 QALYs and 0.05 QALYs by preferring IMRT/IGRT and IMRT over 3D-CRT, respectively. The use of IMRT/IGRT and IMRT results in an incremental cost-saving of €3,820 and €1,863 per patient, solely by radiation-induced SB toxicity, compared to 3D-CRT.

Discussion and conclusion

It is important to consider late toxicity effects in decisions regarding investments and reimbursement as our analysis highlighted the potential long-term cost-savings and improved QoL of novel RT techniques in patients with rectal cancer.

Procalcitonin and C-reactive protein as early markers of anastomotic leakage in intestinal resections for advanced ovarian cancer (EDMOCS)

INTRODUCTION

Serum levels of procalcitonin and C-reactive protein (CRP) have been used to predict anastomotic leakage after colorectal surgery, but information is scarce in advanced ovarian cancer (AOC) surgery with bowel resection. This study aimed to assess the predictive value of procalcitonin and CRP in detecting anastomotic leakage after AOC surgery with bowel resection. The study also aimed to determine the optimal postoperative reference values and the best day for evaluating these markers.

MATERIAL AND METHODS

This prospective, observational and multicentric trial included 92 patients with AOC undergoing debulking surgery with bowel resection between 2017 and 2020 in 10 reference hospitals in Spain. Procalcitonin and CRP levels were measured at baseline and on postoperative days 1-6. Receiver operating characteristic analysis was performed to evaluate the predictive value of procalcitonin and CRP at each postoperative day. Sensitivity, specificity, positive and negative predictive values were calculated.

RESULTS

Anastomotic leakage was detected in six patients (6.5%). Procalcitonin and CRP values were consistently higher in patients with anastomotic leakage at all postoperative days. The maximum area under the curve (AUC) for procalcitonin was observed at postoperative day 1 (AUC = 0.823) with a cutoff value of 3.8 ng/mL (83.3% sensitivity, 81.3% specificity). For CRP, the maximum AUC was found at postoperative day 3 (AUC = 0.833) with a cutoff level of 30.5 mg/dL (100% sensitivity, 80.4% specificity).

CONCLUSIONS

Procalcitonin and C-reactive protein are potential biomarkers for early detection of anastomotic leakage after ovarian cancer surgery with bowel resection. Further prospective studies with a larger sample size are needed to confirm these findings.

The hospital costs of complications following major abdominal surgery: a retrospective cohort study

OBJECTIVE

Postoperative complications following major abdominal surgeries is a pressing concern for hospital care and health economics. Given the paucity of available cost data for patients undergoing major abdominal surgery, we evaluated the number and the severity of postoperative complications following major abdominal surgeries and calculated the costs borne by a single centre university hospital within an Australian healthcare system.

RESULTS

The overall incidence of postoperative complications for 1790 adult patients undergoing major abdominal surgeries (i.e., colonic, liver, small bowel resections and Whipple procedures) between January 2013 and June 2018 was 75.2%. Of these complications, 56.9% were minor (Clavien-Dindo (CVD) Grades I or II) and 15.5% were major (CVD Grades III or IV). As the severity of complications increased, median adjusted total hospital costs rose significantly, with a median (interquartile range [IQR]) of AUD 29,519.70 (IQR 21,828.80-40,527.90) in CVD Grade II versus AUD 50,702.40 (IQR 35,866.00-69,296.80) in CVD Grade III (p <.001). Further, developing one, two or three complications resulted in significantly increased hospital costs by AUD 2618.30 (13.3% increase), AUD 3605.50 (16.2% increase) and AUD 3173.00 (12.3% increase) (p <.0001), respectively, with an exponential spike in costs incurred by patients who developed more than three complications (AUD 23,719.70; 81.7% increase; p < 0001).

Wearable Sensors as a Preoperative Assessment Tool: A Review

Surgery is a common first-line treatment for many types of disease, including cancer. Mortality rates after general elective surgery have seen significant decreases whilst postoperative complications remain a frequent occurrence. Preoperative assessment tools are used to support patient risk stratification but do not always provide a precise and accessible assessment. Wearable sensors (WS) provide an accessible alternative that offers continuous monitoring in a non-clinical setting. They have shown consistent uptake across the perioperative period but there has been no review of WS as a preoperative assessment tool. This paper reviews the developments in WS research that have application to the preoperative period. Accelerometers were consistently employed as sensors in research and were frequently combined with photoplethysmography or electrocardiography sensors. Pre-processing methods were discussed and missing data was a common theme; this was dealt with in several ways, commonly by employing an extraction threshold or using imputation techniques. Research rarely processed raw data; commercial devices that employ internal proprietary algorithms with pre-calculated heart rate and step count were most commonly employed limiting further feature extraction. A range of machine learning models were used to predict outcomes including support vector machines, random forests and regression models. No individual model clearly outperformed others. Deep learning proved successful for predicting exercise testing outcomes but only within large sample-size studies. This review outlines the challenges of WS and provides recommendations for future research to develop WS as a viable preoperative assessment tool.

Impact of surgical complications on hospital costs and revenues: retrospective database study of Medicare claims

Aim: To compare the length of stay, hospital costs and hospital revenues for Medicare patients with and without a subset of potentially preventable postoperative complications after major noncardiac surgery. Materials & methods: Retrospective data analysis using the Medicare Standard Analytical Files, Limited Data Set, 5% inpatient claims files for years 2016-2020. Results: In 74,103 claims selected for analysis, 71,467 claims had no complications and 2636 had one or more complications of interest. Claims with complications had significantly longer length of hospital stay (12.41 vs 3.95 days, p < 0.01), increased payments to the provider ($34,664 vs $16,641, p < 0.01) and substantially higher estimates of provider cost ($39,357 vs $16,158, p < 0.01) compared with claims without complications. This results on average in a negative difference between payments and costs for patients with complications compared with a positive difference for claims without complications (-$4693 vs $483, p < 0.01). Results were consistent across three different cost estimation methods used in the study. Conclusion: Compared with patients without postoperative complications, patients developing complications stay longer in the hospital and incur increased costs that outpace the increase in received payments. Complications are therefore costly to providers and payers, may negatively impact hospital profitability, and decrease the quality of life of patients. Quality initiatives aimed at reducing complications can be immensely valuable for both improving patient outcomes and hospital finances.

All-cause 30- and 90-day inpatient readmission costs associated with four minimally invasive colon surgery approaches: A propensity-matched analysis using Medicare and commercial claims data

Background

The purpose of this study is to assess which minimally invasive colon surgery approach may be associated with the least 30- and 90-day inpatient readmission costs from a payer perspective.

Methods

This retrospective claims analysis included adult Medicare and commercially insured beneficiaries who underwent minimally invasive sigmoid, left, or right colon surgery between January 2016 and December 2019. Two cohorts were created based on the use of near-infrared fluorescence (NIF) and were propensity-score matched 1 NIF:5 NoNIF. Four subgroups were then created based on the presence of robotics (R): NIF-NoR, NIF-R, NoNIF-R, and NoNIF-NoR.

Results

A total of 50,148 patients were identified, of which 165 (0.3%) indicated the use of NIF and 49,983 (99.7%) did not. After propensity score matching, 990 patients were included (NIF cohort: 165; NoNIF cohort: 825). Of the 165 NIF patients, 87 were robotic-assisted and 78 were conventional laparoscopy. Of the 825 NoNIF patients, 136 were robotic-assisted and 689 were conventional laparoscopy. Postindex inpatient readmission costs were significantly different between the NIF and NoNIF cohorts with the NIF cohort having the lowest 30- and 90-day postindex readmission costs. Postindex readmission costs were also significantly different across the 4 subgroups at 30 and 90 days, with the NIF-NoR group having the lowest postindex readmission costs (all P < .05).

Conclusion

Using NIF without the robot during minimally invasive colon surgery is associated with the least 30- and 90-day inpatient readmission costs compared to the other 3 approaches. Hospitals may want to consider these potential cost savings when evaluating technologies for laparoscopic colon surgery.

Key Message

Near-infrared fluorescence (NIF) imaging without the robot during minimally invasive colon surgery may significantly save hospitals 30- and 90-day inpatient readmission costs compared to NIF with the robot, NoNIF with the robot, and NoNIF without the robot. This is important as hospitals may want to consider these cost findings in addition to capital equipment and disposable costs when evaluating technologies for laparoscopic colon surgery.