Financial Impact of Postoperative Complication Following Hepato-Pancreatico-Biliary Surgery for Cancer.

BACKGROUND: Despite increasing efforts for cost containment, little is known regarding the financial implications of postoperative complication under current volume-driven payment paradigms. This study sought the test the associations between hospital finances and postoperative complications among hepato-pancreatico-bilary cancer patients. METHODS: Patients undergoing surgery for the management of a hepatobiliary or pancreatic cancer between January 1, 2009 and December 31, 2013 were identified using institutional claims and cost-accounting data. Multivariable linear regression analyses were used to calculate risk-adjusted fixed and variable costs, payments, and net margins. RESULTS: A total of 1483 met inclusion criteria. Fixed ($9290 [interquartile range (IQR) $7129-$11,598] vs. $14,784 [IQR $10,523-$22,799], p < 0.001) and variable costs ($12,342 [IQR $9886-$14,762] vs. $19,330 [IQR $13,967-$29,435], p < 0.001) were higher among patients who developed a postoperative complication following a hepatectomy. A higher contribution margin ($12,421 [IQR $8440-$16,445] vs. $20,016 [IQR $14,212-$39,179], p < 0.001), as well as a twofold higher net profit was noted among patients who developed postoperative complication ($2788 [IQR $660-$5815] vs. $5515 [IQR $1068-$10,315], p < 0.001). Total hospital costs ($26,840 [IQR $21,318-$35,358] vs. $46,628 [IQR $31,974-$69,326], p < 0.001) as well as payments ($32,761 [IQR $26,394-$41,883] vs. $53,612 [IQR $38,548-$78,116], p < 0.001) were more than 1.5 times higher among patients who developed a postoperative complication following pancreatic resection. Contribution margins ($18,356 [IQR $14,024-$24,390] vs. $29,153 [IQR $20,256-$41,785], p < 0.001), as well as net profits ($5907 [IQR $2179-$9412] vs. $8114 [IQR $2518-$14,249], p < 0.001) were higher among patients who developed postoperative complication following pancreatic surgery. CONCLUSIONS: A positive association was observed between net profits and postoperative complications. Future policies should target complications as a means to achieving a higher value for care.

Sociodemographic trends in the incidence of pancreatic and biliary tract cancer in UK primary care.

BACKGROUND: The UK incidence of pancreatic ductal adenocarcinoma (PDAC) is approximately 9/100,000 population compared with 1-2/100,000 for biliary tract cancer (BTC). This study explores the incidence of these cancers over time and the influence of socio-demographic and geographic factors in a UK primary care cohort. METHODS: This study uses data from a large UK primary care database, The Health Improvement Network (THIN). All adult patients contributing data to THIN between January 2000 and December 2010 were included. Annual incidence rates were calculated, adjusted for age, gender, time period, deprivation score (Townsend quintile) and strategic health authority. RESULTS: From 2000-2010, the annual incidence of PDAC increased by an average of 3% per year (95% CI 1.00-4.00%) and BTC by 4% (95% CI 2.00-6.00%). Incidence of both cancers increased steeply with age and was higher in men. BTC was associated with increasing deprivation (most deprived versus least deprived quintile (OR: 1.45 [95% CI: 1.17, 1.79.]). CONCLUSIONS: The overall incidence of both cancers is low but increasing. Variations in incidence may reflect changes in coding practice or increased exposure to associated risk factors.

Cost-effectiveness of gemcitabine + cisplatin vs. gemcitabine monotherapy in advanced biliary tract cancer.

OBJECTIVES: The ABC-02 trial demonstrated a statistically significant survival benefit associated with the addition of cisplatin to gemcitabine in the palliative treatment of advanced biliary tract cancer (BTC). Based on the ABC-02 findings, this analysis seeks to evaluate the cost-utility of adding cisplatin to standard gemcitabine therapy from a U.S. societal perspective. METHODS: A decision-analytic model was developed to estimate direct medical costs, patient time costs, and quality-adjusted life-years (QALYs) for two treatment strategies: (1) gemcitabine + cisplatin, (2) gemcitabine monotherapy. Model parameters were derived from the pivotal trial of gemcitabine + cisplatin in advanced BTC, published literature, and government sources. The model included trial-based adverse events and costs related to drug treatment, routine follow-up, adverse events, and post-progression care. The model results were examined using one-way and probabilistic sensitivity analyses (PSA). RESULTS: Total QALYs for the gemcitabine + cisplatin and gemcitabine monotherapy strategies were 0.751 and 0.561, respectively. Total costs were $44,885 and $33,653 respectively. Relative to gemcitabine monotherapy, gemcitabine + cisplatin had an incremental cost-effectiveness ratio (ICER) of $59,480 per QALY gained. One-way sensitivity analyses found results to be sensitive to progression-free survival, overall survival, pre and post-progression health state utility values, and the cost of post-progression care. In the PSA, gemcitabine monotherapy had the highest probability of being cost-effective until a willingness-to-pay of $60,000, after which the gemcitabine + cisplatin strategy had the highest probability. CONCLUSION: The results of this analysis suggest that in advanced BTC, the cisplatin + gemcitabine regimen is a cost-effective treatment alternative to gemcitabine monotherapy by currently accepted standards of willingness to pay.

Surgical aspects in management of hepato-pancreatico-biliary tumours in the elderly.

Hepato-pancreatico-biliary (HPB) surgery encompasses major hepatic resection and pancreatic surgery, both procedures of high complexity with a potentially high complication rate. The establishment of centres of excellence with a high patient volume has lowered the complication and increased the resection rate. Besides this, increased life expectancy and improved general health status have increased the number of elderly patients eligible for major surgery. Because elderly patients have more co-morbidities and decreased life expectancy, the benefit of these procedures must be critically evaluated in such patients. Analysis of the literature on this subject demonstrated that pancreatico-duodenectomy can be performed safely in selected elderly patients (80 years of age or older), with morbidity and mortality rates approaching those observed in younger patients. This aspect was also confirmed by cost analysis studies that reported similar data in both groups. Similar findings are also reported for major hepatic resection in elderly patients with either hepatocellular carcinoma (HCC), Klatskin tumour or gallbladder carcinoma. Nevertheless, those elderly patients who will benefit from surgery must be critically selected.