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Buchholz V, Lee DK, Liu DS, Aly A, Barnett SA, Hazard R, Le P, Kioussis B, Muralidharan V, Weinberg L. Cost burden following esophagectomy: A single centre observational study. World J Gastrointest Surg 2024; 16:2255-2269. [PMID: 39087114 PMCID: PMC11287706 DOI: 10.4240/wjgs.v16.i7.2255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/16/2024] [Accepted: 07/01/2024] [Indexed: 07/22/2024] Open
Abstract
BACKGROUND Cost analyses of patients undergoing esophagectomy is valuable for identifying modifiable expenditure drivers to target and curtail costs while improving the quality of care. We aimed to define the cost-complication relationship after esophagectomy and delineate the incremental contributions to costs. AIM To assess the relationship between the hospital costs and potential cost drivers post esophagectomy and investigate the relationship between the cost-driving variables (predicting variables) and hospital costs (dependent variable). METHODS In this retrospective single center study, the severity of complications was graded using the Clavien-Dindo (CD) classification system. Key esophagectomy complications were categorized and defined according to consensus guidelines. Raw costing data included the in-hospital costs of the index admission and any unplanned admission within 30 postoperative days. We used correlation analysis to assess the relationship between key clinical variables and hospital costs (in United States dollars) to identify cost drivers. A mediation model was used to investigate the relationship between these variables and hospital costs. RESULTS A total of 110 patients underwent primary esophageal resection. The median admission cost was $47822.7 (interquartile range: 35670.2-68214.0). The total effects on costs were $13593.9 (95%CI: 10187.1-17000.8, P < 0.001) for each increase in CD severity grade, $4781 (95%CI: 3772.7-5789.3, P < 0.001) for each increase in the number of complications, and $42552.2 (95%CI: 8309-76795.4, P = 0.015) if a key esophagectomy complication developed. Key esophagectomy complications drove the costs directly by $11415.7 (95%CI: 992.5-21838.9, P = 0.032). CONCLUSION The severity and number of complications, and the development of key esophagectomy complications significantly contributed to total hospital costs. Continuous institutional initiatives and strategies are needed to enhance patient outcomes and minimize costs.
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Affiliation(s)
- Vered Buchholz
- Department of Surgery, Austin Health, Melbourne 3084, Victoria, Australia
| | - Dong Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Seoul 14566, Goyang, South Korea
| | - David S Liu
- Department of Surgery, Austin Health, The University of Melbourne, Melbourne 3084, Victoria, Australia
| | - Ahmad Aly
- Department of Surgery, Austin Health, The University of Melbourne, Melbourne 3084, Victoria, Australia
| | - Stephen A Barnett
- Department of Surgery, Austin Health, The University of Melbourne, Melbourne 3084, Victoria, Australia
| | - Riley Hazard
- Department of Anesthesia, Austin Health, Melbourne 3084, Victoria, Australia
| | - Peter Le
- Department of Anesthesia, Austin Health, Melbourne 3084, Victoria, Australia
| | - Benjamin Kioussis
- Department of Anesthesia, Austin Health, Melbourne 3084, Victoria, Australia
| | | | - Laurence Weinberg
- Department of Anesthesia, Austin Hospital, Heidelberg 3084, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne 3084, Victoria, Australia
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Soliman YY, Soliman M, Reddy S, Lin J, Kachaamy T. Organ and function preservation in gastrointestinal cancer: Current and future perspectives on endoscopic ablation. World J Gastrointest Endosc 2024; 16:282-291. [PMID: 38946859 PMCID: PMC11212517 DOI: 10.4253/wjge.v16.i6.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/13/2024] [Accepted: 05/06/2024] [Indexed: 06/13/2024] Open
Abstract
The escalating prevalence of gastrointestinal cancers underscores the urgency for transformative approaches. Current treatment costs amount to billions of dollars annually, combined with the risks and comorbidities associated with invasive surgery. This highlights the importance of less invasive alternatives with organ preservation being a central aspect of the treatment paradigm. The current standard of care typically involves neoadjuvant systemic therapy followed by surgical resection. There is a growing interest in organ preservation approaches by way of minimizing extensive surgical resections. Endoscopic ablation has proven to be useful in precursor lesions, as well as in palliative cases of unresectable disease. More recently, there has been an increase in reports on the utility of adjunct endoscopic ablative techniques for downstaging disease as well as contributing to non-surgical complete clinical response. This expansive field within endoscopic oncology holds great potential for advancing patient care. By addressing challenges, fostering collaboration, and embracing technological advancements, the gastrointestinal cancer treatment paradigm can shift towards a more sustainable and patient-centric future emphasizing organ and function preservation. This editorial examines the evolving landscape of endoscopic ablation strategies, emphasizing their potential to improve patient outcomes. We briefly review current applications of endoscopic ablation in the esophagus, stomach, duodenum, pancreas, bile ducts, and colon.
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Affiliation(s)
| | - Megan Soliman
- Department of Medicine, Medical Consulting, Goodyear, AZ 85395, United States
| | - Shravani Reddy
- Department of Gastroenterology, University of California Irvine, Irvine, CA 92697, United States
| | - James Lin
- Department of Gastroenterology, City of Hope National Medical Center, Duarte, CA 91010, United States
| | - Toufic Kachaamy
- Department of Gastroenterology, City of Hope Phoenix, Goodyear, AZ 85338, United States
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Wyse R, Smith S, Zucca A, Fakes K, Mansfield E, Johnston SA, Robinson S, Oldmeadow C, Reeves P, Carey ML, Norton G, Sanson-Fisher RW. Effectiveness and cost-effectiveness of a digital health intervention to support patients with colorectal cancer prepare for and recover from surgery: study protocol of the RecoverEsupport randomised controlled trial. BMJ Open 2023; 13:e067150. [PMID: 36878662 PMCID: PMC9990701 DOI: 10.1136/bmjopen-2022-067150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
INTRODUCTION Surgery is the most common treatment for colorectal cancer (CRC) and can cause relative long average length of stay (LOS) and high risks of unplanned readmissions and complications. Enhanced Recovery After Surgery (ERAS) pathways can reduce the LOS and postsurgical complications. Digital health interventions provide a flexible and low-cost way of supporting patients to achieve this. This protocol describes a trial aiming to evaluate the effectiveness and cost-effectiveness of the RecoverEsupport digital health intervention in decreasing the hospital LOS in patients undergoing CRC surgery. METHODS AND ANALYSIS The two-arm randomised controlled trial will assess the effectiveness and cost-effectiveness of the RecoverEsupport digital health intervention compared with usual care (control) in patients with CRC. The intervention consists of a website and a series of automatic prompts and alerts to support patients to adhere to the patient-led ERAS recommendations. The primary trial outcome is the length of hospital stay. Secondary outcomes include days alive and out of hospital; emergency department presentations; quality of life; patient knowledge and behaviours related to the ERAS recommendations; health service utilisation; and intervention acceptability and use. ETHICS AND DISSEMINATION The trial has been approved by the Hunter New England Research Ethics Committee (2019/ETH00869) and the University of Newcastle Ethics Committee (H-2015-0364). Trial findings will be disseminated via peer-reviewed publications and conference presentations. If the intervention is effective, the research team will facilitate its adoption within the Local Health District for widespread adaptation and implementation. TRIAL REGISTRATION NUMBER ACTRN12621001533886.
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Affiliation(s)
- Rebecca Wyse
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Stephen Smith
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Alison Zucca
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Kristy Fakes
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Elise Mansfield
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Sally-Ann Johnston
- Department of Surgery, Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia
| | - Sancha Robinson
- Department of Surgery, Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia
- Department of Anaesthetics, John Hunter Hospital, Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | - Christopher Oldmeadow
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Penny Reeves
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Mariko L Carey
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Grace Norton
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Rob W Sanson-Fisher
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
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Weinberg L, Ratnasekara V, Tran AT, Kaldas P, Neal-Williams T, D’Silva MR, Hua J, Yip S, Lloyd-Donald P, Fletcher L, Ma R, Perini MV, Nikfarjam M, Lee DK. The Association of Postoperative Complications and Hospital Costs Following Distal Pancreatectomy. Front Surg 2022; 9:890518. [PMID: 35711711 PMCID: PMC9195500 DOI: 10.3389/fsurg.2022.890518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/13/2022] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Understanding the financial implications associated with the complications post-distal pancreatectomy (DP) may be beneficial for the future optimisation of postoperative care pathways and improved cost-efficiency. The primary outcome of this retrospective study was the characterisation of the additional cost associated with postoperative complications following DP. The secondary outcome was the estimation of the prevalence, type and severity of complications post-DP and the determination of which complications were associated with higher costs. METHODS Postoperative complications were retrospectively examined for 62 adult patients undergoing distal pancreatectomy at an Australian university hospital between January 2012 and July 2021. Complications were defined and graded using the Clavien-Dindo (CVD) classification system. In-hospital cost of index admission was calculated using an activity-based costing methodology and was reported in US dollars at 2021 rates. Regression modelling was used to investigate the relationships among selected perioperative variables, complications and costs. RESULTS 45 patients (72.6%) experienced one or more postoperative complications. The median (IQR) hospital cost in US dollars was 31.6% greater in patients who experienced complications compared to those who experienced no complications ($40,717.8 [27,358.0-59,834.3] vs. $30,946.9 [23,910.8-46,828.1]). Costs for patients with four or more complications were 43.5% higher than for those with three or fewer complications (p = 0.015). Compared to patients with no complications, the median hospital costs increased by 17.1% in patients with minor complications (CVD grade I/II) and by 252% in patients who developed major complication (i.e., CVD grade III/IV) complications. CONCLUSION Postoperative complications are a key target for cost-containment strategies. Our findings demonstrate a high prevalence of postoperative complications following distal pancreatectomy with number and severity of postoperative complications being associated with increased hospital costs. (Registered in the Australian New Zealand Clinical Trials Registry [No. ACTRN12622000202763]).
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Affiliation(s)
- Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
- Department of Critical Care, The University of Melbourne, Austin Health, Heidelberg, Australia
- Department of Surgery, The University of Melbourne, Austin Health, Heidelberg, Australia
| | | | - Anthony T. Tran
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | - Peter Kaldas
- Department of Surgery, The University of Melbourne, Austin Health, Heidelberg, Australia
| | | | | | - Jackson Hua
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | - Sean Yip
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | | | - Luke Fletcher
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health, Heidelberg, Australia
| | - Ronald Ma
- Business Intelligence Unit, Austin Health, Heidelberg, Australia
| | - Marcos V. Perini
- Department of Surgery, The University of Melbourne, Austin Health, Heidelberg, Australia
| | - Mehrdad Nikfarjam
- Department of Surgery, The University of Melbourne, Austin Health, Heidelberg, Australia
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
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A Randomized, Multicenter, Open-Label, Blinded End Point, Phase 2, Feasibility, Efficacy, and Safety Trial of Preoperative Microvascular Protection in Patients Undergoing Major Abdominal Surgery. Anesth Analg 2021; 133:1036-1047. [PMID: 34269720 DOI: 10.1213/ane.0000000000005667] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The endothelial glycocalyx, a carbohydrate-rich layer coating all endothelial surfaces, plays a fundamental role in the function of microcirculation. The primary aim of this study was to evaluate the feasibility of using dexamethasone and albumin to protect the endothelial glycocalyx in patients undergoing abdominal surgery. Secondary and exploratory outcomes included efficacy and safety. METHODS We conducted a multicenter, open-label, blinded end point, phase 2, randomized trial. Patients undergoing colorectal, pancreas, or liver surgery were recruited and randomized to receive either intravenous dexamethasone (16 mg) and 20% albumin (100 mL) at induction of anesthesia, then 200 mL of 20% albumin with each subsequent 1000 mL of crystalloid administered (dexamethasone and albumin [Dex-Alb] group), or crystalloid fluid only with no dexamethasone (control group). Feasibility end points included patient recruitment and retention, consent rate, and successful study drug administration. The primary efficacy end point was the measurement of plasma syndecan-1 level on postoperative day (POD) 1, and secondary end points were heparan sulfate levels and inflammatory markers measured at 4 perioperative timepoints. Safety end points included errors in administration of the intervention, hyperglycemia, occurrence of postoperative complications, and patient retention. RESULTS Seventy-two patients were randomized. All feasibility end points were achievable. There were no statistically significant differences observed in median (interquartile range) syndecan-1 levels on POD 1 (39 ng·mL-1 [20-97] in the Dex-Alb group versus 41 ng·mL-1 [19-84] in the control group; difference in medians -2.1, 95% confidence interval [CI], -13 to 8.6; P = .69). The Dex-Alb group had lower POD 1 heparan sulfate levels (319 ng·mL-1 [161-717] in the Dex-Alb group versus 1422 [670-2430] ng·mL-1 in the control group; difference in medians -1085, 95% CI, -1779 to -391) and C-reactive protein (CRP) levels on POD 1 (48 [29-77] mg·L-1 in the Dex-Alb group versus 85 mg·L-1 [49-133] in the control group; difference in medians -48, 95% CI, -75 to -21). Fewer patients had one or more postoperative complication in the Dex-Alb group than in the control group (6 [17%] vs 18 patients [50%]; odds ratio = 0.2, 95% CI, 0.06-0.6). CONCLUSIONS Intravenous dexamethasone and albumin administration was feasible but did not reduce syndecan-1 on POD 1 in patients undergoing abdominal surgery. Given the clinically important CIs observed between the groups for heparan sulfate, CRP, and postoperative complications, a larger trial assessing the associations between dexamethasone and albumin administration and these outcomes is warranted.
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