1
|
Ciftci Y, Radomski SN, Johnson BA, Johnston FM, Greer JB. Adoption of an Enhanced Recovery After Surgery Protocol Increases Cost of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy and Does not Improve Outcomes. Ann Surg Oncol 2024; 31:5390-5399. [PMID: 38777898 DOI: 10.1245/s10434-024-15320-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 04/04/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols have been shown to reduce length of stay (LOS) and complications. The impact of ERAS protocols on the cost of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has not been studied. PATIENTS AND METHODS We performed a retrospective cohort analysis of patients undergoing CRS-HIPEC from 2016-2022 at a single quaternary center. Propensity score matching was used to create pre-and post-ERAS cohorts. Cost, overall and serious complications, and intensive care unit (ICU) length of stay (LOS) between the two cohorts were compared using the Mann-Whitney U-test for continuous variables and χ2 test for categorical variables. RESULTS Our final matched cohort consisted of 100 patients, with 50 patients in both the pre- and post-ERAS groups. After adjusting for patient complexity and inflation, the median total cost [$75,932 ($67,166-102,645) versus $92,992 ($80,720-116,710), p = 0.02] and operating room cost [$26,817 ($23,378-33,121) versus $34,434 ($28,085-$41,379), p < 0.001] were significantly higher in the post-ERAS cohort. Overall morbidity (n = 22, 44% versus n = 17, 34%, p = 0.40) and ICU length of stay [2 days (IQR 1-3) versus 2 days (IQR 1-4), p = 0.70] were similar between the two cohorts. A total cost increase of $22,393 [SE $13,047, 95% CI (-$3178 to $47,965), p = 0.086] was estimated after implementation of ERAS, with operating room cost significantly contributing to this increase [$8419, SE $1628, 95% CI ($5228-11,609), p < 0.001]. CONCLUSIONS CRS-HIPEC ERAS protocols were associated with higher total costs due to increased operating room costs at a single institution. There was no significant difference in ICU LOS and complications after the implementation of the ERAS protocol.
Collapse
Affiliation(s)
- Yusuf Ciftci
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shannon N Radomski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Blake A Johnson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
2
|
Ciftci Y, Radomski SN, Johnston FM, Greer JB. Predictors of Financial Toxicity Risk Among Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC). Ann Surg Oncol 2024; 31:1980-1989. [PMID: 38044348 DOI: 10.1245/s10434-023-14577-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/27/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the preferred treatment for select patients with peritoneal malignancies. However, the procedure is resource intensive and costly. This study aimed to determine the risk of financial toxicity for patients undergoing CRS-HIPEC. PATIENTS AND METHODS We performed a retrospective cohort study of patients undergoing CRS-HIPEC at a single institution from 2016 to 2022. We utilized insurance status, out-of-pocket expenditures, and estimated post-subsistence income to determine risk of financial toxicity. A multivariable logistic regression was used to determine risk factors for financial toxicity. RESULTS Our final study cohort consisted of 163 patients. Average age was 58 [standard deviation 10] years, and 52.8% (n = 86) were male. A total of 52 patients (31.9%) were at risk of financial toxicity. A total of 36 patients (22.1%) were from the lower income quartiles (first or second) and 127 patients (77.9%) were from the higher income quartiles (third or fourth). A total of 47 patients (29%) were insured by Medicare, and 116 patients (71%) had private insurance. The median out-of-pocket expenditure across the study cohort was $3500, with a median of $5000 ($3341-$7350) for the at-risk group and $3341 ($2500-$4022) for the not at-risk group (p < 0.001). Risk factors for financial toxicity included high out-of-pocket expenditures and a lower income quartile. CONCLUSIONS An estimated one-third of patients undergoing CRS-HIPEC at our institution were at risk for financial toxicity. Several preoperative factors were associated with an increased risk and could be utilized to identify patients who might benefit from interventions.
Collapse
Affiliation(s)
- Yusuf Ciftci
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shannon N Radomski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
3
|
Chatani PD, Manzella A, Gribkova YY, Ecker BL, Beninato T, Kennedy T, Pitt HA, Alexander HR. Does Hospital Operative Volume Influence the Outcomes of Patients After Heated Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis? Ann Surg Oncol 2024; 31:1049-1057. [PMID: 37906385 DOI: 10.1245/s10434-023-14450-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/02/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND For some cancer operations, center volume is associated with improved patient outcomes. Whether this association is true for cytoreductive surgery/heated intraperitoneal chemotherapy (CRS/HIPEC) is unclear. Given the rapidly expanding use of CRS/HIPEC, the aim of this analysis was to determine whether a volume-outcome relationship exists for this strategy. METHODS The Vizient Clinical Database® was queried for CRS/HIPEC cases from January 2020 through December 2022. Low-, medium-, and high-volume designations were made by sorting hospitals by case volume and creating equal tertiles based on total number of cases. Analysis was performed via one-way ANOVA with post-hoc Tukey test, as indicated. RESULTS In the 36-month study period, 5165 cases were identified across 149 hospitals. Low- (n = 113), medium- (n = 25), and high-volume (n = 11) centers performed a median of 4, 21, and 47 cases per annum, respectively. Most cases were performed for appendiceal (39.3%) followed by gynecologic neoplasms (20.4%). Groups were similar with respect to age, gender, race, comorbidities, and histology. Low-volume centers were more likely to utilize the ICU post-operatively (59.6% vs. 40.5% vs. 36.3%; p = 0.02). No differences were observed in morbidity (9.4% vs. 7.1% vs. 9.0%, p = 0.71), mortality (0.9% vs. 0.6% vs. 0.7%, p = 0.93), length of stay (9.3 vs. 9.4 vs. 10 days, p = 0.83), 30-day readmissions (5.6% vs. 5.6% vs. 5.6%, p = 1.0), or total cost among groups. CONCLUSIONS No association was found between CRS/HIPEC hospital volume and post-operative outcomes. These data suggest that in academic medical centers with HIPEC programs, outcomes for commonly treated cancers are not associated with hospital volume.
Collapse
Affiliation(s)
- Praveen D Chatani
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Alexander Manzella
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Yelizaveta Y Gribkova
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Brett L Ecker
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Toni Beninato
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Timothy Kennedy
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Henry A Pitt
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
| | - Henry Richard Alexander
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
| |
Collapse
|
4
|
Abreu AA, Farah E, Nix R, Kethley D, Coble C, Wan Z, Alterio RE, Ngo F, Wadhwa A, Karagkounis G, Salgado Pogacnik J, Wang SC, Augustine M, Yopp AC, Zeh HJ, Polanco PM. Cost Analysis and Financial Implications of a Peritoneal Surface Malignancy Program in the USA. Ann Surg Oncol 2024; 31:630-644. [PMID: 37903950 DOI: 10.1245/s10434-023-14442-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/27/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND We aimed to describe the financial implications of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) in the USA. MATERIALS AND METHODS We conducted a retrospective cost analysis of 100 CRS/HIPEC procedures to examine the impact of patient and procedural factors on hospital costs and reimbursement. A comparison of surgeons' work relative value units (wRVUs) between CRS/HIPEC and a representative sample of complex surgical oncology procedures was made to assess the physicians' compensation rate. Univariable and multivariable backward logistic regression was used to analyze the association between perioperative variables and high direct cost (HDCs). RESULTS The median direct cost per CRS/HIPEC procedure was US $44,770. The median hospital reimbursement was US $43,066, while professional reimbursement was US $8608, resulting in a positive contribution margin of US $7493/procedure. However, the contribution margin significantly varied with the payer mix. Privately insured patients had a positive median contribution margin of US $23,033, whereas Medicare-insured patients had a negative contribution margin of US $13,034. Length of stay (LOS) had the most significant association with HDC, and major complications had the most significant association with LOS. Finally, CRS/HIPEC procedures generated a median of 13 wRVU/h, which is significantly lower than the wRVU/h generated by open pancreatoduodenectomies, open gastrectomies, and hepatectomies. However, higher operation complexity and multiple visceral resections help compensate for the relatively low wRVU/h. CONCLUSIONS CRS/HIPEC is an expensive operation, and prolonged LOS has the most significant impact on the total cost of the procedure. High-quality care is essential to improve patient outcomes and maintain the economic sustainability of the procedure.
Collapse
Affiliation(s)
- Andres A Abreu
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Emile Farah
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert Nix
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dustin Kethley
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Collin Coble
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Zhihan Wan
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rodrigo E Alterio
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Fallon Ngo
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anupama Wadhwa
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Georgios Karagkounis
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Javier Salgado Pogacnik
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sam C Wang
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mathew Augustine
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Adam C Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Herbert J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Patricio M Polanco
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| |
Collapse
|
5
|
Bogach J, Maciver A, Francescutti VA. Value-Based Health Care: The Fine Balance of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS ± HIPEC). Ann Surg Oncol 2023; 30:7926-7928. [PMID: 37782410 DOI: 10.1245/s10434-023-14303-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 09/01/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Jessica Bogach
- Division of General Surgery, Department of Surgery, Juravinski Hospital and Cancer Center and McMaster University, Hamilton, ON, Canada
| | - Allison Maciver
- Divisions of General Surgery and Surgical Oncology, Western University, London Health Sciences Centre, London, ON, Canada
| | - Valerie A Francescutti
- Division of General Surgery, Department of Surgery, Juravinski Hospital and Cancer Center and McMaster University, Hamilton, ON, Canada.
| |
Collapse
|
6
|
Winicki NM, Radomski SN, Florissi IS, Cloyd JM, Gutta G, Grotz TE, Scally CP, Fournier KF, Dineen SP, Powers BD, Veerapong J, Baumgartner JM, Clarke CN, Kothari AN, Maduekwe UN, Patel SH, Wilson GC, Schwartz P, Varley PR, Raoof M, Lee B, Malik I, Johnston FM, Greer JB. Neighborhood-Level Socioeconomic Disadvantage Predicts Outcomes in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Malignancy. Ann Surg Oncol 2023; 30:7840-7847. [PMID: 37620532 PMCID: PMC10592201 DOI: 10.1245/s10434-023-14074-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) improves survival in select patients with peritoneal metastases (PM), but the impact of social determinants of health on CRS/HIPEC outcomes remains unclear. PATIENTS AND METHODS A retrospective review was conducted of a multi-institutional database of patients with PM who underwent CRS/HIPEC in the USA between 2000 and 2017. The area deprivation index (ADI) was linked to the patient's residential address. Patients were categorized as living in low (1-49) or high (50-100) ADI residences, with increasing scores indicating higher socioeconomic disadvantage. The primary outcome was overall survival (OS). Secondary outcomes included perioperative complications, hospital/intensive care unit (ICU) length of stay (LOS), and disease-free survival (DFS). RESULTS Among 1675 patients 1061 (63.3%) resided in low ADI areas and 614 (36.7%) high ADI areas. Appendiceal tumors (n = 1102, 65.8%) and colon cancer (n = 322, 19.2%) were the most common histologies. On multivariate analysis, high ADI was not associated with increased perioperative complications, hospital/ICU LOS, or DFS. High ADI was associated with worse OS (median not reached versus 49 months; 5 year OS 61.0% versus 28.2%, P < 0.0001). On multivariate Cox-regression analysis, high ADI (HR, 2.26; 95% CI 1.13-4.50; P < 0.001), cancer recurrence (HR, 2.26; 95% CI 1.61-3.20; P < 0.0001), increases in peritoneal carcinomatosis index (HR, 1.03; 95% CI 1.01-1.05; P < 0.001), and incomplete cytoreduction (HR, 4.48; 95% CI 3.01-6.53; P < 0.0001) were associated with worse OS. CONCLUSIONS Even after controlling for cancer-specific variables, adverse outcomes persisted in association with neighborhood-level socioeconomic disadvantage. The individual and structural-level factors leading to these cancer disparities warrant further investigation to improve outcomes for all patients with peritoneal malignancies.
Collapse
Affiliation(s)
- Nolan M Winicki
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shannon N Radomski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Isabella S Florissi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jordan M Cloyd
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Goutam Gutta
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | | | - Christopher P Scally
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keith F Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean P Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Benjamin D Powers
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jula Veerapong
- Department of Surgery, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Joel M Baumgartner
- Department of Surgery, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Callisia N Clarke
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anai N Kothari
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ugwuji N Maduekwe
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Patrick Schwartz
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Patrick R Varley
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Mustafa Raoof
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Byrne Lee
- Department of Surgery, Stanford University, Palo Alto, CA, USA
| | - Ibrahim Malik
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Division of Gastrointestinal Surgical Oncology, Peritoneal Surface Malignancy Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
7
|
Gelissen JH, Adjei NN, McNamara B, Mutlu L, Harold JA, Clark M, Altwerger G, Dottino PR, Huang GS, Santin AD, Azodi M, Ratner E, Schwartz PE, Andikyan V. Hyperthermic Intraperitoneal Chemotherapy in Ovarian Cancer. Ann Surg Oncol 2023; 30:5597-5609. [PMID: 37358686 DOI: 10.1245/s10434-023-13757-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/04/2023] [Indexed: 06/27/2023]
Abstract
Hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment modality that aims to target the main site of tumor dissemination in ovarian cancer, the peritoneum, by combining the benefits of intraperitoneal chemotherapy with the synergistic effects of hyperthermia all during a single administration at the time of cytoreductive surgery. High-quality evidence currently only supports the use of HIPEC with cisplatin at the time of interval cytoreduction after neoadjuvant chemotherapy for stage III epithelial ovarian cancer. Many questions remain, including HIPEC's role at other timepoints in ovarian cancer treatment, who are optimal candidates, and specifics of HIPEC protocols. This article reviews the history of normothermic and hyperthermic intraperitoneal chemotherapy in ovarian cancer and evidence regarding HIPEC implementation and patient outcomes. Additionally, this review explores details of HIPEC technique and perioperative care, cost considerations, complication and quality of life data, disparities in HIPEC use, and unresolved issues.
Collapse
Affiliation(s)
- Julia H Gelissen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA.
| | - Naomi N Adjei
- Gynecologic Oncology and Reproductive Medicine Department, MD Anderson Cancer Center, Houston, TX, USA
| | - Blair McNamara
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Levent Mutlu
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Justin A Harold
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Mitchell Clark
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Gary Altwerger
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Peter R Dottino
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Gloria S Huang
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Alessandro D Santin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Masoud Azodi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Elena Ratner
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Peter E Schwartz
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Vaagn Andikyan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
8
|
van der Zant FA, Kooijman BJL, Hentzen JEKR, Helfrich W, Ploeg EM, van Ginkel RJ, van Leeuwen BL, Been LB, Klaase JM, Hemmer PHJ, van der Hilst CS, Kruijff S. Impact of cumulative complications on 1-year treatment-related healthcare costs in patients with colorectal peritoneal metastases undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. BJS Open 2022; 6:6758035. [PMID: 36218348 PMCID: PMC9552551 DOI: 10.1093/bjsopen/zrac109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/27/2022] [Accepted: 08/01/2022] [Indexed: 11/12/2022] Open
Abstract
Background The aim of this study was to evaluate the impact of all minor and major complications on treatment-related healthcare costs in patients who undergo cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of colorectal peritoneal metastases (PMs). Method Patients with histologically proven colorectal PMs who underwent CRS + HIPEC from March 2006 to October 2019 in a tertiary referral centre were retrospectively identified from a prospectively maintained database. Patients were divided into six subgroups according to the severity of the complications, which were scored using the comprehensive complication index (CCI) (CCI 0–9.9, CCI 10–19.9, CCI 20–29.9, CCI 30–39.9, CCI 40–49.9, and CCI 50 or higher). Treatment-related healthcare costs up to 1 year after CRS + HIPEC were obtained from the financial department. Differences in costs and survival outcomes were compared using the chi-squared test and Kruskal–Wallis H test. Results A total of 142 patients were included (CCI 0–9.9, 53 patients; CCI 10–19.9, 0 patients; CCI 20–29.9, 45 patients; CCI 30–39.9, 14 patients; CCI 40–49, 9 patients; and CCI 50 or higher, 21 patients). Median (interquartile range) treatment-related healthcare costs increased significantly and exponentially for the CCI 30–39, CCI 40–49, and CCI 50 or higher groups (€48 993 (€44 262–€84 805); €57 167 (€43 047–€67 591); and €82 219 (€55 487–€145 314) respectively) compared with those for the CCI 0–9.9 and CCI 20–29.9 groups (€33 856 (€24 433–€40 779) and €40 621 (€31 501–€58 761) respectively, P < 0.010). Conclusion Treatment-related healthcare costs increase exponentially as more complications develop among patients who undergo CRS + HIPEC for the treatment of colorectal PMs. Anastomotic leakages after CRS + HIPEC lead to an increase of 295 per cent of treatment-related healthcare costs.
Collapse
Affiliation(s)
- Femke A van der Zant
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bob J L Kooijman
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Wijnand Helfrich
- Department of Surgery, Laboratory for Translational Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Emily M Ploeg
- Department of Surgery, Laboratory for Translational Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert J van Ginkel
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Barbara L van Leeuwen
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lukas B Been
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joost M Klaase
- Department of Surgery, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Patrick H J Hemmer
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Christian S van der Hilst
- Department of Surgery, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Schelto Kruijff
- Correspondence to: Schelto Kruijff, Department of Surgical Oncology, University Medical Center Groningen, Hanzeplein 1, Groningen, The Netherlands (e-mail: )
| |
Collapse
|
9
|
Radomski SN, Florissi I, Khan H, Siddiqi A, Paneitz DC, Johnston FM, Greer JB. Feasibility of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for advanced peritoneal surface tumors during the COVID-19 pandemic: A single-institution experience. J Surg Oncol 2022; 126:1375-1382. [PMID: 36081374 PMCID: PMC9538532 DOI: 10.1002/jso.27083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/19/2022] [Indexed: 12/03/2022]
Abstract
Background and objectives Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a complex treatment used in selected patients with peritoneal surface malignancies. HIPEC procedures are time and resource intensive. The primary aim of this analysis was to compare the experience of treating advanced abdominal tumors with CRS‐HIPEC before and during the coronavirus disease 2019 (COVID‐19) pandemic. Methods Patients included in this analysis received CRS‐HIPEC at a single center during either a prepandemic (March 18, 2019–March 17, 2020) or pandemic (March 18, 2020–February 5, 2021) interval. A retrospective chart review was performed. Results Our analysis included 67 patients: 30 (45%) treated prepandemic and 37 (55%) treated during the pandemic. Median age at the time of operation was 58 years (interquartile range: [49–65]); 53% of patients were women. Patients treated during the pandemic presented with higher peritoneal cancer index (PCI) scores with 32% (n = 12) having a PCI > 20 at the time of surgery (p = 0.01). Five patients had delays in surgery due to the pandemic. Rates of overall postoperative morbidity, reoperation, and readmission were not different between the cohorts. Conclusions Despite presenting with more extensive disease, patients treated with CRS‐HIPEC during the height of the COVID‐19 pandemic had comparable perioperative outcomes to patients treated prepandemic.
Collapse
Affiliation(s)
- Shannon N Radomski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Isabella Florissi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hamza Khan
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amn Siddiqi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dane C Paneitz
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
10
|
Schwartz PB, Abbott DE. ASO Author Reflections: An Opportunity to Provide Cost-Conscious Care for Patients Undergoing CRS-HIPEC. Ann Surg Oncol 2022; 29:6615-6616. [PMID: 35699815 DOI: 10.1245/s10434-022-12015-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022]
Abstract
The substantial cost of care for patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy can be augmented by changes in practice patterns. This report discusses the recent publication of the authors' group and their thoughts on cost-conscious cancer care.
Collapse
Affiliation(s)
- Patrick B Schwartz
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| |
Collapse
|
11
|
Schwartz PB, Stahl CC, Vidri RJ, Leverson GE, Puckett Y, Zafar SN, Varley P, Ronnekleiv-Kelly SM, Al-Niaimi A, Weber SM, Abbott DE. Rethinking Routine Intensive Care After Cytoreductive Surgery With Heated Intraperitoneal Chemotherapy: The Fiscal Argument. Ann Surg Oncol 2022; 29:6606-6614. [PMID: 35672624 DOI: 10.1245/s10434-022-11967-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/20/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients undergoing cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) are frequently admitted to the intensive care unit (ICU) for mitigation of potential complications, although ICU length of stay (LOS) is a significant driver of cost. This study asked whether a fiscal argument could be made for the selective avoidance of ICU admission after CRS/HIPEC. METHODS Prospective data for select low-risk patients (e.g., lower peritoneal cancer index [PCI]) admitted to the intermediate care unit (IMC) instead of the ICU after CRS/HIPEC were matched with a historic cohort routinely admitted to the ICU. Cohort comparisons and the impact of the intervention on cost were assessed. RESULTS The study matched 81 CRS/HIPEC procedures to form a cohort of 49 pre- and 15 post-intervention procedures for patients with similar disease burdens (mean PCI, 8 ± 6.7 vs. 7 ± 5.1). The pre-intervention patients stayed a median of 1 day longer in the ICU (1 day [IQR, 1-1 day] vs. 0 days [IQR, 0-0 days]) and had a longer LOS (8 days [IQR, 7-11 days] vs. 6 days [IQR, 5.5-9 days]). Complications and complication severity did not differ statistically. The median total hospital cost was lower after intervention ($30,845 [IQR, $30,181-$37,725] vs. $41,477 [IQR, $33,303-$51,838]), driven by decreased indirect fixed cost ($8984 [IQR, $8643-$11,286] vs. $14,314 [IQR, $12,206-$18,266]). In a weighted multiple variable linear regression analysis, the intervention was associated with a savings of $2208.68 per patient. CONCLUSIONS Selective admission to the IMC after CRS/HIPEC was associated with $2208.68 in savings per patient without added risk. In this era of cost-conscious practice of medicine, these data highlight an opportunity to decrease cost by more than 5% for patients undergoing CRS/HIPEC.
Collapse
Affiliation(s)
- Patrick B Schwartz
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
| | - Christopher C Stahl
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Roberto J Vidri
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Glen E Leverson
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Yana Puckett
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Syed N Zafar
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Patrick Varley
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sean M Ronnekleiv-Kelly
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Ahmed Al-Niaimi
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sharon M Weber
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| |
Collapse
|
12
|
Dellinger TH, Han ES. State of the Science: The role of HIPEC in the treatment of ovarian cancer. Gynecol Oncol 2021; 160:364-368. [PMID: 33419611 DOI: 10.1016/j.ygyno.2020.12.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Thanh H Dellinger
- Department of Surgery, Division of Gynecologic Oncology, City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA 91010, United States of America
| | - Ernest S Han
- Department of Surgery, Division of Gynecologic Oncology, City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA 91010, United States of America.
| |
Collapse
|