Comparison of expenditure between an inpatient palliative care unit and tertiary adult medical and surgical wards for patients at end of life: a retrospective chart analysis.

BACKGROUND: The highest healthcare expenditures occur towards the end of life. Costs relate to hospital admissions and investigations to diagnose, prognosticate and direct treatment. AIMS: AnAustralian study to compare the cost of investigations in the last 72 h of life between an inpatient palliative care unit (PCU) and a tertiary hospital. METHOD: We retrospectively reviewed 50 adult medical and surgical patients (admitted for >72 h and who died in hospital) from the PCU and referring tertiary centre between March and July 2016. Patients in the emergency department, intensive care, medical assessment and paediatric and obstetric units were excluded. All patients had an acute resuscitation plan and were on the 'Care of the Dying' pathway. RESULTS: Expenditure was less if palliative care were the primary caregivers, with statistically significant differences in the amount of imaging (P < 0.001) and pathology (P < 0.001) ordered. There was no difference in microbiology (P = 0.172) and histology (P ~ 1) ordered. Total cost of investigations for PCU patients was $1340.60 (4 of 50 patients) compared with $9467.78 (29 of 50 patients) in the tertiary hospital. PCU patients had longer lengths of stay (15.54 days vs 11.06 days) but cost less per bed day ($868.32 vs $878.79 respectively). CONCLUSION: Inpatient PCU are less likely to order investigations and are more cost-effective. A prospective study comparing an inpatient PCU and patients at a tertiary centre, with and without consult liaison palliative care input, would be worthwhile to see if outcomes remain the same and if consult liaison palliative care affects the investigative burden.

Inter-surgeon Variability in Cystic Artery Lymph Node Excision during Laparoscopic Cholecystectomy.

Introduction Expert opinion recommends that surgeons perform a laparoscopic cholecystectomy (LC) in a standardized manner by dissecting the hepatobiliary triangle lateral to the cystic artery lymph node (LN) to minimize the rate of a major bile duct injury. Methods To determine whether surgeons performed a laparoscopic cholecystectomy in a standardized manner, the study assessed the variability in the frequency of an LN excision. All LCs that were performed at a single hospital were identified from a prospective dataset. The presence of an LN was retrospectively determined from the histology report. Results Twenty-seven surgeons were recorded to have performed 2332 laparoscopic cholecystectomies. Out of the total number of patients, 76.8% were female. The median patient age was 42.4 years. About 60.8% of the LCs were elective, while 39.2% of them were acute. Nineteen pathologists reported that in 99% of the specimens - the LN status of 1831 (78.5%) gallbladders was reported and analyzed. Overall, the LN yield per surgeon varied from 0% to 50% (mean 18.7%). Conclusion  The high inter-surgeon variability in the rate of LN excision during laparoscopic cholecystectomy shows that surgeons dissect the hepatobiliary triangle differently. The LN yield may also represent a surrogate marker of surgical technique (which is easy to measure).