Evaluating the Validity of the Clavien-Dindo Classification in Colectomy Studies: A 90-Day Cost of Care Analysis.

BACKGROUND: The Clavien-Dindo classification is widely used to report postoperative morbidity but may underestimate the severity of colectomy complications. OBJECTIVE: The purpose of this study was to assess how well the Clavien-Dindo classification represents the severity of all grades of complications after colectomy using cost of care modeling. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a comprehensive cancer center. PATIENTS: Consecutive patients (N = 1807) undergoing elective colon or rectal resections without a stoma performed at Memorial Sloan Kettering Cancer Center between 2009 and 2014 who were followed up for ≥90 days, were not transferred to other hospitals, and did not receive intraperitoneal chemotherapy were included in the study. MAIN OUTCOME MEASURES: Complication severity was measured by the highest-grade complication per patient and attributable outpatient and inpatient costs. Associations were evaluated between patient complication grade and cost during 3 time periods: the 90 days after surgery, index admission, and postdischarge (<90 d). RESULTS: Of the 1807 patients (median age = 62 y), 779 (43%) had a complication; 80% of these patients had only grade 1 or 2 complications. Increasing patient complication grade correlated with 90-day cost, driven by inpatient cost differences (p < 0.001). For grade 1 and 2 patients, most costs were incurred after discharge and were the same between these grade categories. Among patients with a single complication (52%), there was no difference in index hospitalization, postdischarge, or total 90-day costs between grade 1 and 2 categories. LIMITATIONS: The study was limited by its retrospective design and generalizability. CONCLUSIONS: The Clavien-Dindo classification correlates well with 90-day costs, driven largely by inpatient resource use. Clavien-Dindo does not discriminate well among patients with low-grade complications in terms of their substantial postdischarge costs. These patients represent 80% of patients with a complication after colectomy. Examining the long-term burden associated with complications can help refine the Clavien-Dindo classification for use in colectomy studies. See Video Abstract at http://links.lww.com/DCR/B521. EVALUACIN DE LA VALIDEZ DE LA CLASIFICACIN DE CLAVIENDINDO EN ESTUDIOS DE COLECTOMA ANLISIS DEL COSTO DE LA ATENCIN EN DAS: ANTECEDENTES:La clasificación de Clavien-Dindo es utilizada ampliamante para conocer la morbilidad posoperatoria, pero puede subestimar la gravedad de las complicaciones de la colectomía.OBJETIVO:Evaluar que tan bien representa la clasificación de Clavien-Dindo la gravedad de todos los grados de complicaciones después de la colectomía utilizando un modelo de costo de la atención.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Centro oncológico integral.PACIENTES:Pacientes consecutivos (n = 1807) sometidos a resecciones electivas de colon o recto sin estoma realizadas en el Memorial Sloan Kettering Cancer Center entre 2009 y 2014 que fueron seguidos durante ≥ 90 días, no fueron transferidos a otros hospitales y no recibieron quimioterapia intraperitoneal.PRINCIPALES MEDIDAS DE VALORACION:Gravedad de la complicación medida por la complicación de mayor grado por paciente y los costos atribuibles para pacientes ambulatorios y hospitalizados. Se evaluó la asociación entre el grado de complicación del paciente y el costo durante 3 períodos de tiempo: posterior a la cirugía (hasta 90 días), a su ingreso y posterior al egreso (hasta 90 días).RESULTADOS:De los 1807 pacientes (mediana de edad de 62 años), 779 (43%) tuvieron una complicación; El 80% de estos pacientes tuvieron solo complicaciones de grado 1 o 2. El aumento del grado de complicación del paciente se correlacionó con el costo a 90 días, impulsado por las diferencias en el costo de los pacientes hospitalizados (p <0,001). Para los pacientes de grado 1 y 2, la mayoría de los costos se incurrieron después del alta y fueron los mismos entre ambas categorías. Entre los pacientes con una sola complicación (52%), no hubo diferencia en el índice de hospitalización, posterior al alta o en el costo total de 90 días entre las categorías de grado 1 y 2.LIMITACIONES:Diseño retrospectivo, generalizabilidad.CONCLUSIONES:La clasificación de Clavien-Dindo se correlaciona bien con los costos a 90 días, impulsados en gran parte por la utilización de recursos de pacientes hospitalizados. Clavien-Dindo no discrimina entre los pacientes con complicaciones de bajo grado en términos de sus costos sustanciales posterior al alta. Estos pacientes representan el 80% de los pacientes aquellos con una complicación tras la colectomía. Examinar la carga a largo plazo asociada a las complicaciones puede ayudar a mejorar la clasificación de Clavien-Dindo para su uso en estudios de colectomía. Consulte Video Resumen en http://links.lww.com/DCR/B521.

National Landscape of Unplanned 30-Day Readmission Rates for Acute Non-hemorrhagic Diverticulitis: Insight from National Readmission Database.

BACKGROUND: Early readmissions are an important indicator of the quality of care. Limited data exist describing hospital readmissions in acute diverticulitis. The study aimed to describe unplanned, 30-day readmissions among adult acute diverticulitis patients and to assess readmission predictors. METHODS: We analyzed the 2013 and 2014 United States National Readmission Database and identified acute diverticulitis admissions using administrative codes in adult patients older than 18 years of age. Our primary outcome was a 30-day, unplanned readmission rate. We used Chi-square tests, t tests, and Wilcoxon rank-sum tests for descriptive analyses and survey logistic regression to calculate adjusted odds ratios (aORs) and 95% confidence intervals for associations with readmissions adjusting for confounders. RESULTS: In the cohort of 364,511 hospitalizations with acute diverticulitis, as the primary diagnosis on index admission, 31,420 (8.6%) had at least one unplanned 30-day readmission. Sixty percent of the readmissions occurred within the first 2 weeks of the index admission. The most common reasons for unplanned 30-day readmission were due to diverticulitis of the colon (41.5%), postoperative infection (4.2%), septicemia (3.6%), intestinal infection due to Clostridium difficile (3%), and other digestive system complications such bleeding or fistula (2.8%). Multivariable analysis showed advance age (> 75 years), discharge against medical advice, comorbidities (renal failure, coronary artery disease, atrial fibrillation, congestive heart failure, hypertension, diabetes, obesity, weight loss, chronic lung disease, malignancy), blood transfusion, Medicare and Medicaid insurance, and increased length of stay (> 3 days) were associated with significantly higher odds for readmission. Patients who have undergone abdominal surgery during index admission were 31% less likely to get readmitted. CONCLUSIONS: On a national level, 1 in 11 hospitalizations for acute diverticulitis was followed by unplanned readmission within 30 days with most admissions occurring in the first 2 weeks. Multiple modifiable and non-modifiable factors influencing readmission rates were noted. Further studies should examine if strategies that address these predictors can decrease readmissions.

Enhanced Recovery Pathway Benefits Patients Undergoing Nonelective Colorectal Surgery.

OBJECTIVE: The aim of our study was to determine if an enhanced recovery pathway (ERP) can successfully be applied in nonelective colorectal surgery. BACKGROUND: ERPs have been shown to reduce hospital length of stay (LOS), complications, and costs after elective colorectal surgery. Yet, little data exist regarding the benefits of ERPs in patients undergoing nonelective colorectal surgery. We hypothesized that ERP implementation in a nonelective colorectal surgery population is associated with decreased postoperative LOS. METHODS: A prospectively-maintained database was used to identify consecutive patients undergoing colorectal surgery after emergency room (ER) or hospital transfer admissions over a period from 2 years before until 1 year after implementation of a comprehensive ERP. The primary endpoint was LOS. Secondary endpoints included total LOS [TLOS = postoperative LOS + LOS of readmission(s)], readmission rates, complication rates, 30-day mortality, and hospital costs. Univariate and multivariate analyses were performed to assess the relationship between ERP implementation and LOS. RESULTS: We identified 269 pre-ERP and 135 ERP patients fulfilling the inclusion criteria. Admit source (ER 43.4% vs transfers 56.7%), Charlson comorbidity index, American Society of Anesthesiologists (ASA) status, diagnosis (inflammatory bowel disease 45.8%, malignancy 19.6%, benign intestinal obstructions 10.4%, diverticulitis 9.4%, others 10.4%), and blood loss were comparable (P > 0.05) between the cohorts. Pre-ERP patients had a higher number of previous abdominal surgeries, whereas post-ERP patients had more laparoscopy and more compliance with ERP elements. ERP patients had a shorter postoperative LOS [6 (4, 10) vs 7 (5, 12) days; P = 0.0007]. Hospital costs were 13.4% lower (P = 0.004). Postoperative 30-day morbidity, mortality, and readmissions were comparable, although reoperation rate was higher in the ERP group. On multivariate analysis, ERP implementation and laparoscopy were the only modifiable variables independently associated with shorter LOS, whereas longer operative times and higher ASA classification were associated with longer LOS. CONCLUSIONS: Patients undergoing nonelective colorectal surgery after ER or hospital transfer admission benefit from the use of an ERP, demonstrating decreased LOS and costs without an increase in complications.

Associations of a Preoperative Anemia and Suboptimal Iron Stores Screening and Management Clinic in Colorectal Surgery With Hospital Cost, Reimbursement, and Length of Stay: A Net Cost Analysis.

BACKGROUND: In 2016, a preoperative clinic was implemented to screen, evaluate, and manage anemia and suboptimal iron stores at a major tertiary care medical center in Western Australia. Few studies compare the costs and reimbursements associated with preoperative anemia and suboptimal iron stores management. The objective of our study was to conduct a net cost analysis associated with the implementation of this clinic. METHODS: We designed a retrospective cohort study involving elective colorectal surgical admissions over a 3-year period. The baseline year selected was the 2015-2016 financial year, with outcomes in the 2016-2017 and 2017-2018 year compared to baseline. The study perspective was the Western Australian Health System. Hospital costs were extracted from the health service clinical costing system, which captures costs at the admission level. The primary outcome was net cost, defined as gross cost minus reimbursement (or funding) received. RESULTS: Our 3-year study included 544 admissions for elective colorectal surgery. After the implementation of the preoperative clinic, 73.4% (n = 257) of admissions were screened for anemia and suboptimal iron stores, and 31.4% (n = 110) received intravenous iron. In our adjusted analysis, when comparing the final year (2017-2018) with baseline (2015-2016), the units of red blood cells transfused per admission decreased 53% (142 vs 303 units per 1000 discharges; P = .006), and mean hospital length of stay decreased 15% (7.7 vs 9.1 days; P = .008). When comparing the final year with baseline, rectal resection admissions were associated with a mean decrease in the net cost of Australian dollar (A$) 7619 (95% confidence interval, 4230-11,008; P < .001) between 2015-2016 and 2017-2018. For small and large bowel procedures, there was a mean decrease of A$6744 (95% confidence interval, 2430-11,057; P = .002). CONCLUSIONS: The implementation of a preoperative anemia and suboptimal iron stores screening and management clinic in elective colorectal surgery was associated with reductions in red cell transfusions, length of stay, and net costs.

Treating pediatric colorectal patients in low and middle income settings: Creative adaptation to the resources available.

Colorectal disease profiles for children in low- and middle-income settings (LMIC) are characterized by late presentation, increased complications and limited follow-up in many cases. There is a high prevalence of infectious conditions causing secondary colorectal disease such as Mycobacterium Tuberculosis(TB), Human Immunodeficiency Virus(HIV) and Human Papilloma Virus(HPV), which also impact the management of other primary colorectal conditions, such as wound-healing and intestinal anastomosis. Perineal trauma from sexual assault, motor vehicle or pedestrian accidents, burns, and traditional enemas are commonly encountered and may require adaptation of principles used in treatment of congenital anomalies such as Hirschsprung's disease and Anorectal Malformations for reconstruction. Endemic conditions in certain LMIC require further research to delineate underlying causes and optimize management, such as "African" degenerative visceral leiomyopathy, congenital pouch colon in the Indian subcontinent, and congenital H-type rectal fistulae prevalent in Asia. These unique disease profiles require creative adaptations of resources within poor healthcare infrastructure settings. These special challenges and pitfalls in colorectal care and complications of adverse socioeconomic conditions, are discussed.

Preoperative oral antibiotic bowel preparation in elective resectional colorectal surgery reduces rates of surgical site infections: a single-centre experience with a cost-effectiveness analysis.

INTRODUCTION: Surgical site infections cause considerable postoperative morbidity and mortality. The aim of this study was to determine the effect on surgical site infection rates following introduction of a departmental oral antibiotic bowel preparation protocol. METHODS: A prospective single-centre study was performed for elective colorectal resections between May 2016-April 2018; with a control group with mechanical bowel preparation and treatment group with oral antibiotic bowel preparation (neomycin and metronidazole) and mechanical bowel preparation. The primary outcome of surgical site infection and secondary outcomes of anastomotic leak, length of stay and mortality rate were analysed using Fisher's exact test and independent samples t-tests. A cost-effectiveness analysis was also performed. RESULTS: A total of 311 patients were included; 156 in the mechanical bowel preparation group and 155 in the mechanical bowel preparation plus oral antibiotic bowel preparation group. The study included 180 (57.9%) men and 131 (42.1%) women with a mean age of 68 years. There was a significant reduction in surgical site infection rates (mechanical bowel preparation 16.0% vs mechanical bowel preparation plus oral antibiotic bowel preparation 4.5%; P = 0.001) and mean length of stay (mechanical bowel preparation 10.2 days vs mechanical bowel preparation plus oral antibiotic bowel preparation 8.2 days; P = 0.012). There was also a reduction in anastomotic leak and mortality rates. Subgroup analyses demonstrated significantly reduced surgical site infection rates in laparoscopic resections (P = 0.008). There was an estimated cost saving of £239.13 per patient and £37,065 for our institution over a one-year period. CONCLUSION: Oral antibiotic bowel preparation is a feasible and cost-effective intervention shown to significantly reduce the rates of surgical site infection and length of stay in elective colorectal surgery.

Increased Healthcare Utilization for Medical Comorbidities Prior to Surgery Improves Postoperative Outcomes.

OBJECTIVE: The purpose of this study was to evaluate the impact of optimization of preoperative comorbidities by nonsurgical clinicians on short-term postoperative outcomes. SUMMARY BACKGROUND DATA: Preoperative comorbidities can have substantial effects on operative risk and outcomes. The modifiability of these comorbidity-associated surgical risks remains poorly understood. METHODS: We identified patients with a major comorbidity (eg, diabetes, heart failure) undergoing an elective colectomy in a multipayer national administrative database (2010-2014). Patients were included if they could be matched to a preoperative surgical clinic visit within 90 days of an operative intervention by the same surgeon. The explanatory variable of interest ("preoperative optimization") was defined by whether the patient was seen by an appropriate nonsurgical clinician between surgical consultation and subsequent surgery. We assessed the impact of an optimization visit on postoperative complications with use of propensity score matching and multilevel, multivariable logistic regression. RESULTS: We identified 4531 colectomy patients with a major potentially modifiable comorbidity (propensity weighted and matched effective sample size: 6037). After matching, the group without an optimization visit had a higher rate of complications (34.6% versus 29.7%, P = 0.001). An optimization visit conferred a 31% reduction in the odds of a complication (P < 0.001) in an adjusted analysis. Median preoperative costs increased by $684 (P < 0.001) in the optimized group, and a complication increased total costs of care by $14,724 (P < 0.001). CONCLUSIONS AND RELEVANCE: We demonstrated an association between use of nonsurgical clinician visits by comorbid patients prior to surgery and a significantly lower rate of complications. These findings support the prospective study of preoperative optimization as a potential mechanism for improving postoperative outcomes.

Splenic flexure mobilization for sigmoid and low anterior resections in the minimally invasive era: How often and at what cost?

BACKGROUND: Splenic flexure mobilization (SFM) increases left colonic reach for a better vascularized and tension-free anastomosis. Open SFM is challenging due to anatomic position. Minimally invasive SFM improves visualization and minimizes splenic traction. METHODS: We retrospectively reviewed all sigmoid and low anterior resections (LAR) by a colorectal surgical group over 10-year period. We analyzed indications, surgical methods and perioperative outcomes of open and MIS SFM cohorts. RESULTS: 793 patients were included; 122 (15.5%) open, 671 (84.5%) MIS (60% laparoscopic-assisted (LA), 40% hand-assisted (HA)). Overall, indications were cancer (56%), diverticulitis (31%), and other benign diseases (13%). Compared to MIS, open cases had more complex disease (45% vs. 18%, p < 0.01), with fewer SFM performed (40% vs. 86%, p < 0.01), required more frequent diversion (30% vs. 21%, p = 0.02) and were complicated by higher leak/abscess (7% vs. 3%, p = 0.06) and reoperation rates (10% vs. 6%, p = 0.11). 1% of SFM required conversion (LA to HA 0.5%, MIS to open 0.5%). There were no open SFM complications. There were 26 (5%) MIS SFM complications; bleeding (18; 12 splenic capsular tears (0 splenectomy/splenorraphy), 6 mesenteric) and organ injury (bowel (3), pancreatic (4), renal (1)). CONCLUSIONS: Our SFM rate was high in the MIS group, with a low overall complication rate. Of note, the anastomotic leak/abscess rate was 3%, and may be related to the high SFM rate. It is the authors' opinion that a major advantage of MIS is to facilitate SFM, hence SFM is more likely to be performed with these methods compared to open procedures.

Hand-assisted Laparoscopy: Expensive but Considerable Step Between Laparoscopic and Open Colectomy.

PURPOSE: Hand-assisted laparoscopic colectomy (HALC) and laparoscopic-assisted colectomy (LAC) have been shown to have comparable short-term outcomes while there are limited data regarding costs. The aim of our study was to compare the short-term outcomes and costs of HALC and LAC. MATERIALS AND METHODS: In total, 46 patients who underwent HALC or LAC for benign or malignant disease between January 2011 and December 2014 at our institution were included in the study. Patients were randomized into HALC or LAC group. Patients' demographics and characteristics, operative details, short-term outcomes, and costs were evaluated. RESULTS: There were 25 patients in LAC group and 21 patients in HALC group. Patient's demographics and characteristics and short-term outcomes were comparable between the LAC and HALC groups. Conversion rate was significantly lower in the HALC group (4.7% vs. 28%, P=0.03) while surgical costs ($1706.83±203.70 vs. $1304.93±305.67, P=0.038) and total costs ($2427.18±254.27 vs. $2044.03±215.22, P=0.021) were significantly higher in HALC group. CONCLUSIONS: HALC is associated with increased surgical and total hospital costs, and decreased rate of conversion. Although it is more expensive, HALC may be helpful by providing a step between LAC and open surgery before considering conversion.

Failure of efforts to contain costs of care after colorectal procedures: Nationwide trends in length of stay, costs and post-acute care utilization.

BACKGROUND: This study aims to report trends in healthcare resource utilization and costs after colorectal surgery in the US. METHODS: From all-payer inpatient data, patients who were discharged after elective colorectal procedures (2002-2011) were identified. Trends in postoperative hospital stay, costs and post-acute care were evaluated. RESULTS: Of 251,583 included patients, median length of stay was 6 days. Trends over time suggested a progressive reduction in hospital stay after surgery until 2008 after which there was an increase (6.6 days in 2002, 5.9 days in 2008 and 6.1 days in 2010). Costs (peak:2011, $51,731) and post-acute care (peak:2011, 19.4%) continued to increase throughout. CONCLUSIONS: While length of stay over the last decade reduced, a further reduction may not be feasible. Meanwhile, inpatient costs as well as the use of post-acute care programs have continued to rise. Healthcare planning needs to focus on patients who cannot be discharged early, and more comprehensively evaluate the interplay between length of stay, readmissions, inpatient and post-acute care utilization if we are to contain overall healthcare costs.

Massachusetts Healthcare Reform and Trends in Emergent Colon Resection.

BACKGROUND: Insurance impacts access to therapeutic options, yet little is known about how healthcare reform might change the pattern of surgical admissions. OBJECTIVE: We compared rates of emergent admissions and outcomes after colectomy before and after reform in Massachusetts with a nationwide control group. DESIGN: This study is a retrospective cohort analysis in a natural experiment. Prereform was defined as hospital discharge from 2002 through the second quarter of 2006 and postreform from the third quarter of 2006 through 2012. Categorical variables were compared by χ. Piecewise functions were used to test the effect of healthcare reform on the rate of emergent surgeries. SETTINGS: The study included acute care hospitals in the Massachusetts Healthcare Cost and Utilization Project State Inpatient Database (2002-2012) and the Nationwide Inpatient Sample (2002-2011). PATIENTS: Patients aged 18 to 64 years with public or no insurance who underwent inpatient colectomy (via International Classification of Diseases, Ninth Revision, Clinical Modification procedural code) were included and patients with Medicare were excluded. INTERVENTION: Massachusetts health care reform was the study intervention. MAIN OUTCOME MEASURES: We measured the rate of emergent colectomy, complications, and mortality. RESULTS: The unadjusted rate of emergent colectomies was lower in Massachusetts after reform but did not change nationally over the same time period. For emergent surgeries in Massachusetts, a piecewise model with an inflection point (peak) in the third quarter of 2006, coinciding with implementation of healthcare reform in Massachusetts, had a lower mean squared error than a linear model. In comparison, the national rate of emergent surgeries demonstrated no change in pattern. Postreform, length of stay decreased by 1 day in Massachusetts; however, there were no significant improvements in other outcomes. LIMITATIONS: The study was limited by its retrospective design and unadjusted analysis. CONCLUSIONS: There was a unique and sustained decline in the rate of emergent colon resection among publically insured and uninsured patients after 2006 in Massachusetts, in contradistinction to the national pattern, suggesting improved access to care associated with health insurance expansion. The reasons for lack of improvement in outcomes are multifactorial.

Surgeon Volume Correlates with Reduced Mortality and Improved Quality in the Surgical Management of Diverticulitis.

BACKGROUND: Volume has been shown to be an important determinant of quality and cost outcomes. METHODS: We performed a retrospective study of patients who underwent surgery for diverticulitis using the University HealthSystem Consortium database from 2008­2012. Outcomes evaluated included minimally invasive approach, stoma creation, intensive-care admission, post-operative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized into four categories by mean annual volumes: very-high (VHVS) (>31), high (HVS) (13­31), medium (MVS) (6­12), and low (LVS) (≤5). RESULTS: A total of 19,212 patients with a mean age of 59 years, 54 % female makeup, and 55 % rate of private insurance were included. Similar to the unadjusted analysis, multivariable analysis revealed decreasing odds of stoma creation, complications, ICU admission, reoperation, readmission, and inpatient mortality with increasing surgeon volume. Additionally, compared with LVS, a higher surgeon volume was associated with higher rates of the minimally invasive approach. Median length of stay and costs were also notably lower with increasing surgeon volume. CONCLUSION: Quality and the use of minimally invasive technique are tightly associated with surgeon volume. Further studies are necessary to validate the direct association of volume with outcomes in surgery for diverticulitis.

Healthcare Spending and Performance of Specialty Hospitals: Nationwide Evidence from Colorectal-Anal Specialty Hospitals in South Korea.

PURPOSE: Aim of this study is to investigate the characteristics and performance of colorectal-anal specialty vs. general hospitals for South Korean inpatients with colorectal-anal diseases, and assesses the short-term designation effect of the government's specialty hospital. MATERIALS AND METHODS: Nationwide all colorectal-anal disease inpatient claims (n=292158) for 2010-2012 were used to investigate length of stay and inpatient charges for surgical and medical procedures in specialty vs. general hospitals. The patients' claim data were matched to hospital data, and multi-level linear mixed models to account for clustering of patients within hospitals were performed. RESULTS: Inpatient charges at colorectal-anal specialty hospitals were 27% greater per case and 92% greater per day than those at small general hospitals, but the average length of stay was 49% shorter. Colorectal-anal specialty hospitals had shorter length of stay and a higher inpatient charges per day for both surgical and medical procedures, but per case charges were not significantly different. A "specialty" designation effect also found that the colorectal-anal specialty hospitals may have consciously attempted to reduce their length of stay and inpatient charges. Both hospital and patient level factors had significant roles in determining length of stay and inpatient charges. CONCLUSION: Colorectal-anal specialty hospitals have shorter length of stay and higher inpatient charges per day than small general hospitals. A "specialty" designation by government influence performance and healthcare spending of hospitals as well. In order to maintain prosperous specialty hospital system, investigation into additional factors that affect performance, such as quality of care and patient satisfaction should be carried out.

Comparison of laparoscopic and open colonic resection within fast-track and traditional perioperative care pathways: Clinical outcomes and in-hospital costs.

BACKGROUND: This study examined short-term clinical outcomes and in-hospital costs of laparoscopic and open colonic resection within fast-track and traditional care pathways. MATERIAL AND METHODS: A case-control study was performed. From 2007 to 2009, 116 patients underwent laparoscopic or open colonic resection for benign or malignant disease within fast-track care pathway. The control group consisted of 116 age-, sex-, comorbidity-, type of surgery-, and diagnosis-matched patients who received a traditional perioperative care from 2000 to 2007. The main measures of outcome were postoperative hospital stay and in-hospital costs, with 30-day mortality, morbidity, reoperation, and readmission rates as secondary outcomes. RESULTS: The study groups were well balanced for baseline characteristics. Postoperative hospital stay was shorter in the fast-track than in the control group: laparoscopic resection median 3 versus 5 days (p < 0.001) and open resection 4 versus 7 days (p < 0.001). In multivariate analysis fast-track care, laparoscopic surgery and complications were independent determinants affecting the length of hospital stay. Overall, there was a trend toward lower in-hospital costs in the fast-track group compared with the traditional care group, but the difference was not statistically significant. Open surgery within fast-track care was the least costly option compared to laparoscopic or open surgery within traditional care but not significantly so when compared with laparoscopy within fast-track care. Intake of solid food and bowel function recovered 1 day earlier in the fast-track group than in the control group (p < 0.001). Complications were more frequent after open surgery than after laparoscopic surgery (23.3% vs 11.0%, p = 0.012). Reoperation and readmission rates were similar between the study groups. CONCLUSION: Laparoscopy improves the efficiency of fast-track perioperative care without significantly increasing in-hospital costs.

Healthcare Spending and Performance of Specialty Hospitals: Nationwide Evidence from Colorectal-Anal Specialty Hospitals in South Korea

PURPOSE: Aim of this study is to investigate the characteristics and performance of colorectal-anal specialty vs. general hospitals for South Korean inpatients with colorectal-anal diseases, and assesses the short-term designation effect of the government's specialty hospital. MATERIALS AND METHODS: Nationwide all colorectal-anal disease inpatient claims (n=292158) for 2010-2012 were used to investigate length of stay and inpatient charges for surgical and medical procedures in specialty vs. general hospitals. The patients' claim data were matched to hospital data, and multi-level linear mixed models to account for clustering of patients within hospitals were performed. RESULTS: Inpatient charges at colorectal-anal specialty hospitals were 27% greater per case and 92% greater per day than those at small general hospitals, but the average length of stay was 49% shorter. Colorectal-anal specialty hospitals had shorter length of stay and a higher inpatient charges per day for both surgical and medical procedures, but per case charges were not significantly different. A "specialty" designation effect also found that the colorectal-anal specialty hospitals may have consciously attempted to reduce their length of stay and inpatient charges. Both hospital and patient level factors had significant roles in determining length of stay and inpatient charges. CONCLUSION: Colorectal-anal specialty hospitals have shorter length of stay and higher inpatient charges per day than small general hospitals. A "specialty" designation by government influence performance and healthcare spending of hospitals as well. In order to maintain prosperous specialty hospital system, investigation into additional factors that affect performance, such as quality of care and patient satisfaction should be carried out.

A cost comparison of laparoscopic and open colon surgery in a publicly funded academic institution.

BACKGROUND: The objective of this study was to compare the total hospital cost of laparoscopic (lap) and open colon surgery at a publicly funded academic institution. METHODS: Patients undergoing elective laparoscopic or open colon surgery for all indications at the University Health Network, Toronto, Canada, from April 2004 to March 2009 were included. Patient demographic, operative, and outcome data were reviewed retrospectively. Hospital costs were determined from the Ontario Case Costing Initiative, adjusted for inflation, and compared using the Mann-Whitney U test. Linear regression was used to analyze the relationship between length of stay and total hospital cost. RESULTS: There were 391 elective colon resections (223 lap/168 open, 15.4 % conversion). There was no difference in median age, gender, or Charlson score. Body mass index was slightly higher for laparoscopic surgery (27.5/25.9 lap/open; p = 0.008), while the American Society of Anesthesiologists score was slightly higher for open surgery. Median operative time was greater for laparoscopic surgery (224/196 min, lap/open; p = 0.001). There was no difference in complication rates (21.6/22.5 % lap/open; p = 0.900), reoperations (5.8/6.5 % lap/open; p = 0.833) or 30-day readmissions (7.6/12.5 % lap/open; p = 0.122). Number of emergency room visits was greater with open surgery (12.6/20.8 % lap/open; p = 0.037). Operative cost was higher for laparoscopic surgery ($4,171.37/3,489.29 lap/open; p = 0.001), while total hospital cost was significantly reduced ($9,600.22/12,721.41 lap/open; p = 0.001). Median length of stay was shorter for laparoscopic surgery (5/7 days lap/open; p = 0.000), and this correlated directly with hospital cost. CONCLUSIONS: Laparoscopic colon surgery is associated with increased operative costs but significantly lower total hospital costs. The cost savings is related, in part, to reduced length of stay with laparoscopic surgery.

Plastic freezer bags: a cost-effective method to protect extraction sites in laparoscopic colorectal procedures?

PURPOSE: To review surgical-site infection (SSI) and retrieval-site tumor recurrence rates in laparoscopic colorectal procedures when using a plastic freezer bag as a wound protector. METHODS: Laparoscopic colorectal procedures where a plastic freezer bag used as a wound protector at the extraction site were reviewed between 1991 and 2008 from a prospectively collected database. χ test was used to compare SSI and tumor recurrence rates between groups. Costing data were obtained from the operating room supplies department. RESULTS: A total of 936 cases with 51 (5.45%) surgical-site infections were identified. SSI rates did not differ when comparing groups based on demographic factors, diagnosis, or location of procedure. Retrieval-site tumor recurrence rate was 0.21% (1/474). Cost of plastic freezer bags including sterilization ranged from $0.25 to $3. CONCLUSIONS: Plastic freezer bags as wound protectors in laparoscopic colorectal procedures are cost effective and have SSI and retrieval-site tumor recurrence rates that compare favorably to published data.

Optimizing cost and short-term outcomes for elderly patients in laparoscopic colonic surgery.

BACKGROUND: Elderly patients often are regarded as high-risk for major abdominal surgery because of a lack of functional reserve and associated medical comorbidities. The goal of this study was to compare the cost of care and short-term outcomes of elderly and nonelderly patients undergoing laparoscopic colectomy. Our hypothesis was that elderly patients managed with laparoscopic colorectal surgery and an enhanced recovery protocol (ERP) can realize the same benefits of lower hospital length of stay (LOS) without increasing hospital costs or readmission rates. METHODS: Review of a prospective database identified all patients that underwent an elective laparoscopic colectomy from 2009 to 2012. Patients were stratified into elderly (≥70 years old) and nonelderly (<70 years old) cohorts. The main outcome measures were discharge disposition, hospital costs, hospital LOS, and 30-day readmission rates between the laparoscopic and open groups. RESULTS: A total of 302 nonelderly (66%) and 153 elderly (34%) patients were included in the analysis. The elderly cohort had significantly higher comorbidities than the nonelderly group. There were no mortalities. Operative variables (procedure time, blood loss, and intraoperative complications) were similar. At discharge, significantly more elderly patients required temporary nursing or home care. There were no significant differences in short-term outcomes of LOS, 30-day readmission rates, or costs for the episode of care between the two groups. CONCLUSIONS: Combining laparoscopic colectomy with an ERP is cost-effective and results in similar short-term outcomes for the elderly and nonelderly patients. Despite higher comorbidities, elderly patients realized the same benefits of shorter LOS with similar hospital costs and readmission rates.

[Outpatient treatment of uncomplicated acute diverticulitis: Impact on healthcare costs]. / Tratamiento ambulatorio de la diverticulitis aguda no complicada: impacto sobre los costes sanitarios.

BACKGROUND: Outpatient treatment of uncomplicated acute diverticulitis is safe and effective. The aim of this study was to determine the impact of outpatient treatment on the reduction of healthcare costs. PATIENTS AND METHODS: A retrospective cohort study comparing 2 groups was performed. In the outpatient treatment group, patients diagnosed with uncomplicated acute diverticulitis were treated with oral antibiotics at home. In the hospital treatment group, patients met the criteria for outpatient treatment but were admitted to hospital and received intravenous antibiotic therapy. Cost estimates have been made using the hospital cost accounting system based on total costs, the sum of all variable costs (direct costs) plus overhead expenses divided by activity (indirect costs). RESULTS: A total of 136 patients were included, 90 in the outpatient treatment group and 46 in the hospital group. There were no differences in the characteristics of the patients in both groups. There were also no differences in the treatment failure rate in both groups (5.5% vs. 4.3%; P=.7). The total cost per episode was significantly lower in the outpatient treatment group (882 ± 462 vs. 2.376 ± 830 euros; P=.0001). CONCLUSIONS: Outpatient treatment of acute diverticulitis is not only safe and effective but also reduces healthcare costs by more than 60%.

[Multimodal rehabilitation program in elective colorectal surgery: Impact on hospital costs]. / Impacto de un programa de rehabilitación multimodal en cirugía electiva colorrectal sobre los costes hospitalarios.

INTRODUCTION: Multimodal rehabilitation (MMRH) programs in surgery have proven to be beneficial in functional recovery of patients. The aim of this study is to evaluate the impact of a MMRH program on hospital costs. METHOD: A comparative study of 2 consecutive cohorts of patients undergoing elective colorectal surgery has been designed. In the first cohort, we analyzed 134 patients that received conventional perioperative care (control group). The second cohort included 231 patients treated with a multimodal rehabilitation protocol (fast-track group). Compliance with the protocol and functional recovery after fast-track surgery were analyzed. We compared postoperative complications, length of stay and readmission rates in both groups. The cost analysis was performed according to the system «full-costing¼. RESULTS: There were no differences in clinical features, type of surgical excision and surgical approach. No differences in overall morbidity and mortality rates were found. The mean length of hospital stay was 3 days shorter in the fast-track group. There were no differences in the 30-day readmission rates. The total cost per patient was significantly lower in the fast-track group (fast-track: 8.107 ± 4.117 euros vs. control: 9.019 ± 4.667 Euros; P=.02). The main factor contributing to the cost reduction was a decrease in hospitalization unit costs. CONCLUSION: The application of a multimodal rehabilitation protocol after elective colorectal surgery decreases not only the length of hospital stay but also the hospitalization costs without increasing postoperative morbidity or the percentage of readmissions.