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Hooper J, Jervis N, Morgan L, Beckett V, Hand P, Higgs K, Munir A, Prinn J, Pritchard DM, Sarker D, Srirajaskanthan R, Ellis CB. Neuroendocrine neoplasms: Consensus on a patient care pathway. J Neuroendocrinol 2024; 36:e13380. [PMID: 38471798 DOI: 10.1111/jne.13380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/30/2024] [Accepted: 02/22/2024] [Indexed: 03/14/2024]
Abstract
People with neuroendocrine neoplasms (NENs) face a multitude of challenges, including delayed diagnosis, low awareness of the cancer among healthcare professionals and limited access to multidisciplinary care and expert centres. We have developed the first patient care pathway for people living with NENs in England to guide disease management and help overcome these barriers. The pathway was developed in two phases. First, a pragmatic review of the literature was conducted, which was used to develop a draft patient care pathway. Second, the draft pathway was then updated following semi-structured interviews with carefully selected expert stakeholders. After each phase, the pathway was discussed among a multidisciplinary, expert advisory group (which comprised the authors and the Deputy Chief Operating Officer, West Suffolk NHS Foundation Trust), who reached a consensus on the ideal care pathway. This article presents the outputs of this research. The pathway identified key barriers to care and highlighted how these may be addressed, with many of the findings relevant to the rest of the UK and international audiences. NENs are increasing in incidence and prevalence in England, compounding pre-existing inequities in diagnosis and disease management. Effective integration of this pathway within NHS England will help achieve optimal, equitable care provision for all people with NENs, and should be feasible within the existing expert multidisciplinary teams across the country.
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Affiliation(s)
| | | | | | - Vivienne Beckett
- Advanced Accelerators Applications (UK & Ireland) Ltd, a Novartis Company, London, UK
| | - Philippa Hand
- London North West University Healthcare NHS Trust, London, UK
| | | | - Alia Munir
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield Teaching Hospitals European Neuroendocrine Tumor Society Center of Excellence, Sheffield, UK
| | | | - D Mark Pritchard
- University of Liverpool and Liverpool University Hospitals NHS Foundation Trust, Liverpool Regional NET Service (European Neuroendocrine Tumor Society Center of Excellence), Liverpool, UK
| | - Debashis Sarker
- Guy's, St Thomas' and King's College Hospitals, King's Health Partners NET Centre (European Neuroendocrine Tumor Society Center of Excellence), London, UK
| | - Raj Srirajaskanthan
- King's College Hospital NHS Foundation Trust, King's Health Partners NET Centre (European Neuroendocrine Tumor Society Center of Excellence), London, UK
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Olsén MF, Andersson T, Nouh MA, Johnson E, Block L, Vakk M, Wennerblom J. Development of and adherence to an ERAS ® and prehabilitation protocol for patients undergoing pancreatic surgery: An observational study. Scand J Surg 2023; 112:235-245. [PMID: 37461804 DOI: 10.1177/14574969231186274] [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] [Indexed: 12/01/2023]
Abstract
BACKGROUND AND OBJECTIVE There are still gaps in knowledge concerning the adherence to different multimodal pathways in pancreatic surgery. The aim of this trial was to explore and evaluate an Enhanced Recovery After Surgery (ERAS®) and prehabilitation protocol in patients undergoing open pancreatic surgery. METHODS Three groups of patients were included: two prospective series of 75 patients undergoing open pancreatic surgery following an ERAS® protocol with or without prehabilitation, and one group of 55 historical controls. Variables regarding adherence to, and effects of the protocols, were collected from the local database and the patients' hospital records. Patients' adherence to advice given pre-operatively was followed up using a study-specific questionnaire. RESULTS The patients reported high adherence to remembered advice given. The health care professionals' adherence to the various parts of the concepts varied. ERAS® implementation resulted in more frequent gut motility stimulation (p < 0.001) and shorter duration of epidural anesthesia, site drains, and urinary catheter (p = 0.001). With prehabilitation, more patients were screened concerning nutritional status and prescribed preoperative training (p < 001). There was a significant change in weight before surgery, a shorter time to first flatus and a shorter length of stay after implementation of the concepts (p < 0.05). Complications were rare in all three groups and there were no significant differences between the groups. CONCLUSION The implementation of an ERAS® and a prehabilitation protocol increased adherence to the protocols by both patients and healthcare professionals. An implementation of an ERAS® protocol with and without prehabilitation decreases length of stay and may decrease preoperative weight loss and time to bowel movement.
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Affiliation(s)
- Monika Fagevik Olsén
- Department of Physical Therapy, Sahlgrenska University Hospital S-413 45 Gothenburg Sweden
| | - Thomas Andersson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Micheline Al Nouh
- Department of Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Erik Johnson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Linda Block
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Anaesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - My Vakk
- Department of Clinical Nutrition, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johanna Wennerblom
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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Ebrahimian S, Bakhtiyar SS, Verma A, Williamson C, Sakowitz S, Ali K, Chervu NL, Sanaiha Y, Benharash P. Evaluation of hospital readmission rates as a quality metric in adult cardiac surgery. Heart 2023; 109:1460-1466. [PMID: 37258097 DOI: 10.1136/heartjnl-2023-322671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/13/2023] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVE To assess the reliability of 30-day non-elective readmissions as a quality metric for adult cardiac surgery. BACKGROUND Unplanned readmissions is a quality metric for adult cardiac surgery. However, its reliability in benchmarking hospitals remains under-explored. METHODS Adults undergoing elective isolated coronary artery bypass grafting (CABG), surgical aortic valve replacement/repair (SAVR) or mitral valve replacement/repair (MVR) were tabulated from 2019 Nationwide Readmissions Database. Multi-level regressions were developed to model the likelihood of 30-day unplanned readmissions and major adverse events (MAE). Random intercepts were estimated, and associations between hospital-specific risk-adjusted rates of readmissions and were assessed using the Pearson correlation coefficient (r). RESULTS Of an estimated 86 024 patients meeting study criteria across 298 hospitals, 62.6% underwent CABG, 22.5% SAVR and 14.9% MVR. Unadjusted readmission rates following CABG, SAVR and MVR were 8.4%, 9.3% and 11.8%, respectively. Unadjusted MAE rates following CABG, SAVR and MVR were 35.1%, 32.3% and 37.0%, respectively. Following adjustment, interhospital differences accounted for 4.1% of explained variance in readmissions for CABG, 7.6% for SAVR and 10.0% for MVR. There was no association between readmission rates for CABG and SAVR (r=0.10, p=0.09) or SAVR and MVR (r=0.09, p=0.1). A weak association was noted between readmission rates for CABG and MVR (r=0.20, p<0.001). There was no significant association between readmission and MAE for CABG (r=0.06, p=0.2), SAVR (r=0.04, p=0.4) and MVR (r=-0.03, p=0.6). CONCLUSION Our findings suggest that readmissions following adult cardiac surgery may not be an ideal quality measure as hospital factors do not appear to influence this outcome.
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Affiliation(s)
- Shayan Ebrahimian
- Cardiovascular Outcomes Research Laboratories, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
- Department of Surgery, University of Colorado Aurora, Aurora, Colorado, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Catherine Williamson
- Cardiovascular Outcomes Research Laboratories, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Nikhil L Chervu
- Cardiovascular Outcomes Research Laboratories, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
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Alterio RE, Meier J, Radi I, Bhat A, Tellez JC, Al Abbas A, Wang S, Porembka M, Mansour J, Yopp A, Zeh HJ, Polanco PM. Defining the Price Tag of Complications Following Pancreatic Surgery: A US National Perspective. J Surg Res 2023; 288:87-98. [PMID: 36963298 DOI: 10.1016/j.jss.2023.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 01/20/2023] [Accepted: 02/18/2023] [Indexed: 03/26/2023]
Abstract
INTRODUCTION Pancreatic surgery tends to have a high rate of postoperative complications due to its complex nature, significantly increasing hospital costs. Our aim was to describe the true association between complications and hospital costs in a national cohort of US patients. METHODS The National Inpatient Sample was used to conduct a retrospective analysis of elective pancreatic resections performed between 2004 and 2017, categorizing them based on whether patients experienced major complications (MaC), minor complications (MiC), or no complications (NC). Multivariable quantile regression was used to analyze how costs varied at different percentiles of the cost curve. RESULTS Of 37,893 patients, 45.3%, 28.6%, and 26.1% experienced NC, MiC, and MaC, respectively. Factors associated with MaC were a Charlson Comorbidity Index of ≥4, prolonged length of stay, proximal pancreatectomy, older age, male sex, and surgery performed at hospitals with a small number of beds or at urban nonteaching hospitals (all P < 0.01). Multivariable quantile regression revealed significant variation in MiC and MaC across the cost curve. At the 50th percentile, MiC increased the cost by $3352 compared to NC while MaC almost doubled the cost of the surgery, increasing it by $20,215 (both P < 0.01). The association between complications and cost was even greater at the 95th percentile, increasing the cost by $10,162 and $108,793 for MiC and MaC, respectively (P < 0.01). CONCLUSIONS MiC and MaC were significantly associated with increased hospital costs. Furthermore, the relationship between MaC and costs was especially apparent at higher percentiles of the cost curve.
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Affiliation(s)
- Rodrigo E Alterio
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jennie Meier
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Imad Radi
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Archana Bhat
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Juan C Tellez
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Amr Al Abbas
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sam Wang
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthew Porembka
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John Mansour
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Adam Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Herbert J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Patricio M Polanco
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
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Cawich SO, Pearce NW, Naraynsingh V, Shukla P, Deshpande RR. Whipple’s operation with a modified centralization concept: A model in low-volume Caribbean centers. World J Clin Cases 2022; 10:7620-7630. [PMID: 36158490 PMCID: PMC9372853 DOI: 10.12998/wjcc.v10.i22.7620] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 05/05/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
Conventional data suggest that complex operations, such as a pancreaticoduodenectomy (PD), should be limited to high volume centers. However, this is not practical in small, resource-poor countries in the Caribbean. In these settings, patients have no option but to have their PDs performed locally at low volumes, occasionally by general surgeons. In this paper, we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations. Specifically, we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating studies published on outcomes after PD in high volume centers. The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept. In the authors’ opinions, most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries. In these settings, their only options are to have their operations in the resource-poor, low-volume settings in the Caribbean. However, post-operative outcomes may be improved, despite low-volumes, if a modified centralization concept is encouraged.
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Affiliation(s)
- Shamir O Cawich
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Neil W Pearce
- University Surgical Unit, Southampton General Hospital, Southampton SO16 6YD, United Kingdom
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Parul Shukla
- Department of Surgery, Weill Cornell Medical College, New York, NY 10065, United States
| | - Rahul R Deshpande
- Department of Surgery, Manchester Royal Infirmary, Manchester M13 9WL, United Kingdom
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Siegel JB, O'Leary R, DeChamplain B, Lancaster WP. The Effect of Goal-Directed Fluid Administration on Outcomes After Pancreatic Surgery. World J Surg 2022; 46:2760-2768. [PMID: 35896759 DOI: 10.1007/s00268-022-06676-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND We evaluated the effect of an Enhanced Recovery After Surgery protocol on intraoperative fluid administration and postoperative outcomes in pancreatic surgery. METHODS Pancreatic cancer resections at our institution from 2012 to 2018 were grouped according to pre- or post-protocol initiation. Preoperative characteristics and postoperative outcomes were compared with Fisher's exact test and chi-square for categorical variables, and Mann-Whitney U test for continuous variables. Further analysis separated patients that had a Whipple from those who had distal pancreatectomy. RESULTS A total of 263 patients underwent pancreatic cancer resection during the study period (169 Whipples, 84 DPs, 92 pre-ERAS and 171 post-ERAS). Intraoperative fluid administration significantly decreased after protocol implementation (mean 6,277 ml vs. 3870 ml, p < 0.001). This held true when separating patients that had a Whipple procedure from those that had a DP (6,929 ml vs. 4,513 ml, p < 0.001, 5,060 ml vs. 2,833 cc, p = 0.002, respectively). Intensive care unit (ICU) admission (41.3% vs. 20.5%, p < 0.001) and length of stay (9.4 vs. 8.1 days, p < 0.01) were significantly reduced after ERAS implementation for all patients and in Whipple patients alone (47.5% vs. 23.6%, p = 0.002 and 10.7 vs. 6.6 days, p = 0.004). DP patients also had significantly decreased ICU admissions (41.3% vs. 20.5%, p = 0.045). All other postoperative outcomes were not significantly different. CONCLUSION For patients undergoing pancreatic cancer resection, goal-directed fluid management is associated with decreased intraoperative fluid administration, decreased ICU admission, and decreased length of stay without an increase in postoperative complications or readmission.
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Affiliation(s)
- Julie B Siegel
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., 96 Jonathan Lucas Street, Charleston, SC, 29425, USA.
| | - Ryan O'Leary
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - Bryce DeChamplain
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - William P Lancaster
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
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Counting the cost: financial implications of complications following pancreaticoduodenectomy. HPB (Oxford) 2022; 24:1177-1185. [PMID: 35078715 DOI: 10.1016/j.hpb.2021.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/15/2021] [Accepted: 12/16/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Morbidity after pancreaticoduodenectomy (PD) has been reported to be about 30-53%. These complications can double hospital costs. We sought to explore the financial implications of complications after PD in a large institutional database. METHODS A retrospective analysis of patients undergoing PD from 2010-2017 was performed. Costs for index hospitalization were divided into categories: operating room, postoperative ward, radiology and interventional radiology. Complications were categorized according to the Clavien-Dindo classification. Univariable and mutivariable analysis were performed. RESULTS Median cost of index admission for 997 patients who underwent PD was $23,704 (range $10,988-$528,531). Patients with major complications incurred significantly greater median costs compared to those without ($40,005 vs $21,306, p < 0.001). Patients with postoperative pancreatic fistula (POPF) grade A, B and C had progressively increasing costs ($32,164, $50,264 and $102,013, p < 0.001). On multivariable analysis ileus/delayed gastric emptying, respiratory failure, clinically significant POPF, thromboembolic complications, reoperation, duration of surgery >240 minutes and male sex were associated with significantly increased costs. CONCLUSION Complications after PD significantly increase hospital costs. This study identifies the major contributors towards increased cost post-PD. Initiatives that focus on prevention of complications could reduce associated costs and ease financial burden on patients and healthcare organizations.
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Lim J, Kim K, Song M, Yoo S, Baek H, Kim S, Park S, Jeong WJ. Assessment of the feasibility of developing a clinical pathway using a clinical order log. J Biomed Inform 2022; 128:104038. [DOI: 10.1016/j.jbi.2022.104038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 01/26/2022] [Accepted: 02/23/2022] [Indexed: 10/18/2022]
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Karunakaran M, Jonnada PK, Chandrashekhar SH, Vinayachandran G, Kaambwa B, Barreto SG. Enhancing the cost-effectiveness of surgical care in pancreatic cancer: a systematic review and cost meta-analysis with trial sequential analysis. HPB (Oxford) 2022; 24:309-321. [PMID: 34848126 DOI: 10.1016/j.hpb.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/21/2021] [Accepted: 11/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical pathways (CP) based on Enhanced recovery after surgery (ERAS®) are increasingly utilised in patients undergoing pancreatoduodenectomy (PD). This systematic review aimed to compare the impact of CPs versus conventional care (CC) on peri-PD costs. METHODS A systematic review of major reference databases was undertaken. Quality assessment was performed using the CHEERS checklist. Incremental cost-effectiveness ratios were calculated as part of the cost-effectiveness analysis. A meta-analysis was performed using random-effects models and Trial sequential analysis (TSA) was used to assess the precision and conclusiveness of the results. RESULTS 14 studies meeting inclusion criteria were included for full qualitative synthesis. All studies reported a reduction in overall costs, length of stay and overall complication rates for CPs when compared to CC. Meta-analysis performed on nine studies demonstrated significantly reduced costs in the CP group, with considerable heterogeneity (Pooled mean difference of $ 4.28 × 103, p < 0.01, I2 = 95%). Cost-effectiveness analysis in relation to complications demonstrated dominance of CPs over CC in being cheaper as well as more effective. TSA supported the cost benefit of enhanced-recovery CPs, displaying minimal type 1 error. CONCLUSION Peri-PD CPs result in significant cost-reduction in comparison to CC.
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Affiliation(s)
- Monish Karunakaran
- Department of Surgical Gastroenterology, SK Hospital, Thiruvananthapuram, India
| | - Pavan K Jonnada
- Department of Surgical Oncology, Basavatarakam Indo-American Cancer Hospital & Research Institute, Hyderabad, India
| | - Sagar H Chandrashekhar
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta- The Medicity, Gurgaon, India
| | | | - Billingsley Kaambwa
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Savio G Barreto
- College of Medicine and Public Health, Flinders University, South Australia, Australia; Division of Surgery and Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia.
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BUßMEYER F, Kneifel F, Eichelmann AK, Palmes D, Hummel R, Lindner K. Effects of therapy modifications during the last decade on the outcome of patients undergoing esophagectomy for esophageal cancer. Minerva Surg 2021; 76:235-244. [PMID: 33855371 DOI: 10.23736/s2724-5691.21.08393-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND During the last decade, numerous therapeutic regimes were assessed to improve the outcome of patients with esophageal carcinoma. We analyzed the impact of therapy alterations, including the establishment of a standardized clinical pathway and the introduction of an interdisciplinary tumor conference on the outcome of patients undergoing esophagectomy because of esophageal cancer. METHODS Three hundred one patients were included (204 adenocarcinoma and 97 squamous cell carcinoma) who underwent an esophagectomy between 2006 and 2015. Patients were divided into 3 groups: interval A (2006-2008), interval B (2009-2011) and interval C (2012-2015) and evaluated separately focusing on therapy management and patients' outcome. RESULTS Over the time periods, the incidence of tumor entity of adenocarcinoma increased from 61% to 76.2% (P=0.059). Patients with an initial tumor stage uT1 increased significantly from 4% to 15.9% over the intervals (P=0.002), while positive nodal involvement remained comparable (P=0.237). Patients in the later interval suffered from greater physical impairments preoperatively, represented by a significantly increased American Society Anesthesiologists (ASA) score (P=0.023) and a reduced Karnofsky Index (P<0.001). The tumor conference was accompanied by an increasing implementation of neoadjuvant therapy (27.1% vs. 42.2%, P=0.097). After establishing the clinical pathway 30-day mortality decreased (P=0.67). Grad III anastomotic leakage decreased significantly from 6.5% to 2% (P=0.01). However, gastrointestinal (P=0.007), pulmonary complications (P<0.001) including pneumonia (P<0.001) increased. Over the past ten years both overall survival and relapse-free survival prolonged (P=0.056 and P=0.063, respectively). CONCLUSIONS Patients' collective suffering from esophageal cancer has changed over the last decade. Continuous further developments of the therapy regimes are needed to meet the requirements of reducing perioperative mortality and extending survival time.
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Affiliation(s)
- Florian BUßMEYER
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Felicia Kneifel
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Ann-Kathrin Eichelmann
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Daniel Palmes
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Richard Hummel
- Department of Surgery, Campus Lübeck, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Kirsten Lindner
- Department of Surgery, Campus Lübeck, University Hospital of Schleswig-Holstein, Lübeck, Germany -
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Development and Impact of an Institutional Enhanced Recovery Program on Opioid Use, Length of Stay, and Hospital Costs Within an Academic Medical Center: A Cohort Analysis of 7774 Patients. Anesth Analg 2021; 132:442-455. [PMID: 33105279 DOI: 10.1213/ane.0000000000005182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Enhanced Recovery (ER) is a change management framework in which a multidisciplinary team of stakeholders utilizes evidence-based medicine to protocolize all aspects of a surgical care to allow more rapid return of function. While service-specific reports of ER adoption are common, institutional-wide adoption is complex, and reports of institution-wide ER adoption are lacking in the United States. We hypothesized that ER principles were generalizable across an institution and could be implemented across a multitude of surgical disciplines with improvements in length of stay, opioid consumption, and cost of care. METHODS Following the establishment of a formal institutional ER program, ER was adopted in 9 distinct surgical subspecialties over 5 years at an academic medical center. We compared length of stay, opioid consumption, and total cost of care in all surgical subspecialties as a function of time using a segmented regression/interrupted time series statistical model. RESULTS There were 7774 patients among 9 distinct surgical populations including 2155 patients in the pre-ER cohort and 5619 patients in the post-ER cohort. The introduction of an ER protocol was associated with several significant changes: a reduction in length of stay in 5 of 9 specialties; reduction in opioid consumption in 8 specialties; no change or reduction in maximum patient-reported pain scores; and reduction or no change in hospital costs in all specialties. The ER program was associated with an aggregate increase in profit over the study period. CONCLUSIONS Institution-wide efforts to adopt ER can generate significant improvements in patient care, opioid consumption, hospital capacity, and profitability within a large academic medical center.
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Kim DH, Yoon YS, Han HS, Cho JY, Lee JS, Lee B. Effect of Enhanced Recovery After Surgery program on hospital stay and 90-day readmission after pancreaticoduodenectomy: a single, tertiary center experience in Korea. Ann Surg Treat Res 2021; 100:76-85. [PMID: 33585352 PMCID: PMC7870429 DOI: 10.4174/astr.2021.100.2.76] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/15/2020] [Accepted: 11/08/2020] [Indexed: 01/04/2023] Open
Abstract
Purpose Despite increasing number of reports on Enhanced Recovery After Surgery program (ERAS) and readmission after pancreaticoduodenectomy (PD) from Western countries, there are very few reports on this topic from Asian countries. This study aimed to evaluate the effects of ERAS on hospital stay and readmission and to identify reasons and risk factors for readmission after PD. Methods This retrospective cohort study included 670 patients who underwent open PD from January 2003 to December 2017. The patients were classified into ERAS (n = 352) and non-ERAS (n = 318) groups. Patients' characteristics, perioperative outcomes, and readmission rates were compared. Results There were no significant differences in the postoperative complication rates between the groups. The mean postoperative hospital stay was significantly shorter in the ERAS group (24.5 vs. 18.0 days, P < 0.001), but the 90-day readmission rate was similar in the 2 groups (9.1% vs. 8.5%, P = 0.785). Complications associated with pancreatic fistula (42.4%) were the most common cause for readmission. In the multivariate analysis, diabetes mellitus (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.05–3.24; P = 0.034), preoperative non-jaundice (OR, 0.45; 95% CI, 0.25–0.82; P = 0.009) and severe postoperative complications (OR, 4.12; 95% CI, 2.34–7.26; P < 0.001) were identified as risk factors for readmission. Conclusion The results confirmed that the ERAS program for PD was beneficial in reducing postoperative stay without increasing readmission risks. To decrease readmission rates, prudent discharge planning and medical support should be considered in patients who experience severe complications.
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Affiliation(s)
- Doo-Hun Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jai-Young Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jun-Seo Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Boram Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Joliat GR, Hübner M, Roulin D, Demartines N. Cost Analysis of Enhanced Recovery Programs in Colorectal, Pancreatic, and Hepatic Surgery: A Systematic Review. World J Surg 2020; 44:647-655. [PMID: 31664495 DOI: 10.1007/s00268-019-05252-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery programs (ERPs) have been shown to improve postoperative outcomes after abdominal surgery. This study aimed to review the current literature to assess if ERPs in colorectal, pancreas, and liver surgery induce cost savings. METHODS A systematic review was performed including prospective and retrospective studies comparing conventional management versus ERP in terms of costs. All kinds of ERP were considered (fast-track, ERAS®, or home-made protocols). Studies with no mention of a clear protocol and no reporting of protocol compliance were excluded. RESULTS Thirty-seven articles out of 144 identified records were scrutinized as full articles. Final analysis included 16 studies. In colorectal surgery, two studies were prospective (1 randomized controlled trial, RCT) and six retrospective, totaling 1277 non-ERP patients and 2078 ERP patients. Three of the eight studies showed no difference in cost savings between the two groups. The meta-analysis found a mean cost reduction of USD3010 (95% CI: 5370-650, p = 0.01) in favor of ERP. Among the five included studies in pancreas surgery (all retrospective, 552 non-ERP vs. 348 ERP patients), the mean cost reduction in favor of the ERP group was USD7020 (95% CI: 11,600-2430, p = 0.003). In liver surgery, only three studies (two retrospective and 1 RCT, 180 non-ERP vs. 197 ERP patients) were found, which precluded a sound cost analysis. CONCLUSIONS The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management. Cost data in liver surgery are scarce.
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Affiliation(s)
- Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Didier Roulin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Chen B, He Y, Xiao Y, Guo D, Liu P, He Y, Sun Q, Jiang P, Liu Z, Liu Q. Heated fennel therapy promotes the recovery of gastrointestinal function in patients after complex abdominal surgery: A single-center prospective randomized controlled trial in China. Surgery 2020; 168:793-799. [PMID: 32682507 DOI: 10.1016/j.surg.2020.05.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/13/2020] [Accepted: 05/19/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Postoperative gastrointestinal dysfunction remains a major determinant of the duration of stay after complex abdominal surgery. This study was performed to evaluate the effectiveness of heated fennel therapy in accelerating the recovery of gastrointestinal function. METHODS This surgeon-blinded, prospective randomized controlled study included 381 patients with hepatobiliary, pancreatic, and gastric tumors who were divided into 2 groups. The patients in the experimental groups received heated fennel therapy, and those in the control groups received heated rice husk therapy. We compared the baseline characteristics, time to first postoperative flatus and defecation, fasting time, duration of postoperative hospital stay, grading of abdominal pain, classification of abdominal distension, inflammatory markers, and nutritional status indicators. RESULTS The time to first flatus and first defecation and the fasting time were statistically significantly less in the heated fennel therapy group than those in the control groups (P < .05 each); and abdominal distension was also relieved in the experimental groups (P < .001). Heated fennel therapy had no obvious beneficial effect on inflammatory markers but improved the serum albumin (ALB) level of the patients at postop day 9 (P < .001). Among the patients with alimentary tract reconstruction, those in the heated fennel therapy group had a clinically important, lesser hospital stay than those in the control group (9.2 5 ± 5.1 versus 11.1 ± 6.4; P < .023). CONCLUSION Heated fennel therapy facilitated the gastrointestinal motility function of patients early postoperatively.
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Affiliation(s)
- Baiyang Chen
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Yukun He
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Yusha Xiao
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Deliang Guo
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Pengpeng Liu
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Yueming He
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Quan Sun
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Ping Jiang
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Zhisu Liu
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Quanyan Liu
- Department of General Surgery, General Hospital of Tianjin Medical University, Tianjin, PR China.
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Boisen ML, McQuaid AJ, Esper SA, Holder-Murray J, Zureikat AH, Hogg ME, Paronish J, Subramaniam K. Intrathecal Morphine Versus Nerve Blocks in an Enhanced Recovery Pathway for Pancreatic Surgery. J Surg Res 2019; 244:15-22. [DOI: 10.1016/j.jss.2019.05.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 05/01/2019] [Accepted: 05/30/2019] [Indexed: 01/31/2023]
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Multicenter Observational Study Examining the Implementation of Enhanced Recovery Within the Virginia Surgical Quality Collaborative in Patients Undergoing Elective Colectomy. J Am Coll Surg 2019; 229:374-382.e3. [DOI: 10.1016/j.jamcollsurg.2019.04.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/26/2019] [Accepted: 04/26/2019] [Indexed: 01/03/2023]
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Abstract
PURPOSE The purpose of this paper is to identify actual (as-is) patient pathway variation among breast cancer patients and to investigate the relationship between pathways and the cost incurred by patients. DESIGN/METHODOLOGY/APPROACH Both quantitative and qualitative methods were employed to analyze data from four Swedish hospital groups. Quantitative methods include event-log data mining and statistical analyses on the related patient cost from the Swedish breast cancer quality registry and case-costing system. Qualitative methods included collaboration with and interviewing domain experts. FINDINGS Unique pathways, followed by only one patient, were generally costlier than the most and less frequent pathways. Earlier study findings are confirmed for mastectomy patients, with more frequent pathways having a lower cost, whereas contradicting and inconclusive results emerged for the partial mastectomy patient groups. Highest variation in pathways was identified for patients receiving chemotherapy. PRACTICAL IMPLICATIONS The common belief - if one follows a standardized patient pathway, then the cost will be lower - should be re-examined based on the actual pathways that occur in reality. ORIGINALITY/VALUE The relationships between patient pathways and patient cost allow more complex insights, beyond the general causal relationship between successfully implementing a "to-be" care pathway and lower cost. This highlights data-driven research's importance, where actual pathways (as-is) provide more useful information than to-be care pathways.
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Affiliation(s)
- Sara Dahlin
- Department of Technology Management and Economics, Chalmers University of Technology , Gothenburg, Sweden
| | - Hendry Raharjo
- Department of Technology Management and Economics, Chalmers University of Technology , Gothenburg, Sweden
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18
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Izrailov RE, Tsvirkun VV, Alikhanov RB, Andrianov AV. [Eras protocol for laparoscopic Frey procedure (in Russian only)]. Khirurgiia (Mosk) 2019:60-64. [PMID: 30938358 DOI: 10.17116/hirurgia201903160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To assess the use of ERAS in laparoscopic Frey procedure. MATERIAL AND METHODS From August 2012 to November 2017 laparoscopic Frey procedure were performed in 35 patients. Fully laparoscopic were performed 31 (88.5%) procedures. We use fast-track protocol from 13 patients. We included from statistic analyses patients where procedure was changed or was conversion or was simultaneous procedure. The total number of patients analyzed was 27. The patients were divided into two groups: I - before the fast-track protocol (n=11), II - after the protocol implementation (n=16). RESULTS The operating time was 460 (365-530) minutes in I group and 420 (295-540) minutes in II group. Blood loss was 150 (5-300) and 150 (40-700) ml. The median postoperative stay period was 10 (5-25) days and 6.5 (3-11) days (p=0.007). CONCLUSION The combination of laparoscopic technologies and fast-track protocol reduces the duration of the postoperative stay period.
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Affiliation(s)
- R E Izrailov
- Moscow Clinical Scientific Center, 86 Shosse Entuziastov, 111123, Moscow, Russia
| | - V V Tsvirkun
- Moscow Clinical Scientific Center, 86 Shosse Entuziastov, 111123, Moscow, Russia
| | - R B Alikhanov
- Moscow Clinical Scientific Center, 86 Shosse Entuziastov, 111123, Moscow, Russia
| | - A V Andrianov
- Moscow Clinical Scientific Center, 86 Shosse Entuziastov, 111123, Moscow, Russia
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20
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Boteon APCS, Boteon YL, Hodson J, Osborne H, Isaac J, Marudanayagam R, Mirza DF, Muiesan P, Roberts JK, Sutcliffe RP. Multivariable analysis of predictors of unplanned hospital readmission after pancreaticoduodenectomy: development of a validated risk score. HPB (Oxford) 2019; 21:26-33. [PMID: 30049642 DOI: 10.1016/j.hpb.2018.06.1802] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/20/2018] [Accepted: 06/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Unplanned hospital readmission after pancreaticoduodenectomy (PD) is usually due to surgical complications and has significant clinical and economic impact. This study developed a risk score to predict 30-day readmission after PD. METHODS Patients undergoing PD between 2009 and 2016 were reviewed from a prospective database. Predictors of readmission were identified using a multivariable logistic regression model, from which a points-based risk scoring system was derived. RESULTS 81 of 518 patients (15.6%) were readmitted within 30 days. History of cardiac disease ([odds ratio] OR = 2.12; 95% CI: 1.12-4.56), CRP>140 mg/L on post-operative day 3 (OR = 2.34; 95% CI: 1.37-4.35) and comprehensive complication index >14 (OR = 1.74; 95% CI: 1.03-2.85) were independent predictors of readmission. The regression coefficients were used to generate a risk score with excellent calibration (p = 0.917) and good discrimination (c-index = 0.65; 95% CI: 0.58-0.71; p < 0.001). Patients were categorised as low, moderate and high risk, with readmission rates of 6.4%, 13.4% and 23.0% respectively (p < 0.001). CONCLUSION The risk score identifies patients at high risk of readmission after pancreaticoduodenectomy. Such patients may benefit from pre-discharge imaging and/or enhanced follow-up, which may potentially reduce the impact of readmissions.
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Affiliation(s)
- Amanda P C S Boteon
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Yuri L Boteon
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - James Hodson
- Medical Statistics, Institute of Translational Medicine, University Hospitals Birmingham, UK
| | - Helen Osborne
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - John Isaac
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Ravi Marudanayagam
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Darius F Mirza
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Paolo Muiesan
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - John K Roberts
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Robert P Sutcliffe
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK.
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21
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The Impact of Postoperative Complications on a Timely Return to Intended Oncologic Therapy (RIOT): the Role of Enhanced Recovery in the Cancer Journey. Int Anesthesiol Clin 2018; 54:e33-46. [PMID: 27623128 DOI: 10.1097/aia.0000000000000113] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Brown EG, Bateni SB, Burgess D, Li CS, Bold RJ. Interhospital Variability in Quality Outcomes of Pancreatic Surgery. J Surg Res 2018; 235:453-458. [PMID: 30691829 DOI: 10.1016/j.jss.2018.10.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/04/2018] [Accepted: 10/22/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Assessment of optimal patient outcomes from health care delivery is critical for success amidst current reform. We developed a composite index of quality for pancreaticoduodenectomy (PD) and compared high and low performers nationwide. METHODS We performed a retrospective analysis of 17,220 patients undergoing elective PD between October 2010 and June 2014 using the Vizient database. A quality index score (QIS) was developed from five variables associated with optimal outcomes: postoperative complication rate, length of stay, 30-d readmission rate, mortality rate, and hospital volume. Value was defined as hospital-based QIS divided by mean hospital charges. High-value centers (top quintile) were compared to low-value centers (bottom quintile). RESULTS The majority of high-value centers (79%) achieved top performer status in 1-2 of five quality categories though only 11% were low performer in at least one category. Conversely, 41% of low-value centers were top performers in at least one category, although rarely more than one (8%); 63% of low-value centers were low performers in two or more categories. There was no significant association between QIS and hospital charges (-570, 95% CI -1308 to 168, P = 0.13). CONCLUSIONS High-value centers infrequently provided high quality surgical care across all five metrics but instead excelled in a few quality metrics while avoiding low performance in any quality metric. Although low-value centers could achieve excellence in one quality metric, they were frequently low performers in two or more outcomes. Improvements in value of PD can be achieved by a consistent effort across all quality metrics rather than efforts at constraining financial expenditures of health care delivery.
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Affiliation(s)
- Erin G Brown
- Division of Surgical Oncology, UC Davis Comprehensive Cancer Center, Sacramento, California
| | - Sarah B Bateni
- Division of Surgical Oncology, UC Davis Comprehensive Cancer Center, Sacramento, California
| | - Debra Burgess
- Division of Surgical Oncology, UC Davis Comprehensive Cancer Center, Sacramento, California
| | - Chin-Shang Li
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, California
| | - Richard J Bold
- Division of Surgical Oncology, UC Davis Comprehensive Cancer Center, Sacramento, California.
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Lee MJ, Freer C, Adegbola S, Elkady S, Parkes M, Hart A, Fearnhead NS, Lobo AJ, Brown SR. Patients with perianal Crohn's fistulas experience delays in accessing anti-TNF therapy due to slow recognition, diagnosis and integration of specialist services: lessons learned from three referral centres. Colorectal Dis 2018; 20:797-803. [PMID: 29569419 DOI: 10.1111/codi.14102] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 03/01/2018] [Indexed: 12/30/2022]
Abstract
AIM Crohn's anal fistula should be managed by a multidisciplinary team. There is no clearly defined 'patient pathway' from presentation to treatment. The aim of this study was to describe the patient route from presentation with symptomatic Crohn's anal fistula to starting anti-tumour necrosis factor (anti-TNF) therapy. METHOD Case note review was undertaken at three hospitals with established inflammatory bowel disease services. Patients with Crohn's anal fistula presenting between 2010 and 2015 were identified through clinical coding and local databases. Baseline demographics were captured. Patient records were interrogated to identify route of access, and clinical contacts during the patient pathway. RESULTS Seventy-nine patients were included in the study, of whom 54 (68%) had an established diagnosis of Crohn's disease (CD). Median time from presentation to anti-TNF therapy was 204 days (174 vs 365 days for existing and new diagnosis of CD, respectively; P = 0.019). The mean number of surgical outpatient attendances, operations and MRI scans per patient was 1.03, 1.71 and 1.03, respectively. Patients attended a mean of 1.49 medical clinics. Seton insertion was the most common procedure, accounting for 48.6% of all operations. Where care episodes ('clinical events per 30 days') were infrequent this correlated with prolongation of the pathway (r = -0.87; P < 0.01). CONCLUSION This study highlights two key challenges in the treatment pathway: (i) delays in diagnosis of underlying CD in patients with anal fistula and (ii) the pathway to anti-TNF therapy is long, suggesting issues with service design and delivery. These should be addressed to improve patient experience and outcome.
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Affiliation(s)
- M J Lee
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - C Freer
- Addenbrookes Hospital, Cambridge, UK
| | | | - S Elkady
- St Mark's Hospital, Harrow, UK.,University of Alexandria, Alexandria, Egypt
| | - M Parkes
- Addenbrookes Hospital, Cambridge, UK
| | - A Hart
- St Mark's Hospital, Harrow, UK
| | | | - A J Lobo
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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What Are the Most Significant Cost and Value Drivers for Pancreatic Resection in an Integrated Healthcare System? J Am Coll Surg 2018; 227:45-53. [PMID: 29580880 DOI: 10.1016/j.jamcollsurg.2018.02.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/15/2018] [Accepted: 02/17/2018] [Indexed: 11/22/2022]
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Denbo JW, Bruno M, Dewhurst W, Kim MP, Tzeng CW, Aloia TA, Soliz J, Speer BB, Lee JE, Katz MHG. Risk-stratified clinical pathways decrease the duration of hospitalization and costs of perioperative care after pancreatectomy. Surgery 2018; 164:424-431. [PMID: 29807648 DOI: 10.1016/j.surg.2018.04.014] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/21/2018] [Accepted: 04/09/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is associated with adverse events, increased duration of stay and hospital costs. We developed perioperative care pathways stratified by postoperative pancreatic fistula risk with the aims of minimizing variations in care, improving quality, and decreasing costs. STUDY DESIGN Three unique risk-stratified pancreatectomy clinical pathways-low-risk pancreatoduodenectomy, high-risk pancreatoduodenectomy, and distal pancreatectomy were developed and implemented. Consecutive patients treated after implementation of the risk-stratified pancreatectomy clinical pathways were compared with patients treated immediately prior. Duration of stay, rates of perioperative adverse effects, discharge disposition, and hospital readmission, as well as the associated costs of care, were evaluated. RESULTS The median hospital stay after pancreatectomy decreased from 10 to 6 days after implementation of the risk-stratified pancreatectomy clinical pathways (P < .001), and the median cost of index hospitalization decreased by 22%. Decreased changes in median hospital stay and costs of hospitalization were observed in association with low-risk pancreatoduodenectomy (P < .05) and distal pancreatectomy (P < .05), but not high-risk pancreatoduodenectomy. The rates of 90-day adverse events, grade B/C postoperative pancreatic fistula, discharge to a facility other than home, or readmission did not change after implementation. CONCLUSION Implementation of risk-stratified pancreatectomy clinical pathways decreased median stay and cost of index hospitalization after pancreatectomy without unfavorably affecting rates of perioperative adverse events or readmission, or discharge disposition. Outcomes were most favorably improved for low-risk pancreatoduodenectomy and distal pancreatectomy. Additional work is necessary to decrease the rate of postoperative pancreatic fistula, minimize variability, and improve outcomes after high-risk pancreatoduodenectomy.
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Affiliation(s)
- Jason W Denbo
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX; Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Morgan Bruno
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Whitney Dewhurst
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael P Kim
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ching-Wei Tzeng
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jose Soliz
- Department of Anesthesia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Barbara Bryce Speer
- Department of Anesthesia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey E Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew H G Katz
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.
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Nassour I, Wang SC, Christie A, Mokdad AA, Porembka MR, Choti MA, Augustine MM, Yopp AC, Xie XJ, Mansour JC, Minter RM, Polanco PM. Nomogram to predict non-home discharge following pancreaticoduodenectomy in a national cohort of patients. HPB (Oxford) 2017; 19:1037-1045. [PMID: 28867297 DOI: 10.1016/j.hpb.2017.07.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/13/2017] [Accepted: 07/19/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite the development of pathways to enhance recovery and discharge to home, a significant proportion of patients are discharged to inpatient facilities after pancreaticoduodenectomy (PD). The aim of this study was to determine the rate of non-home discharge (NHD) following PD in a national cohort of patients and to develop predictive nomograms for NHD. METHODS The National Surgical Quality Improvement Program was used to construct and validate pre- and postoperative nomograms for NHD following PD. RESULTS A total of 6856 patients who underwent PD were identified, of which 927 (13.5%) had an NHD. The independent preoperative predictors of NHD were being female, older age, higher BMI, low serum albumin, >10% weight loss, ASA class III/IV, and being diagnosed with a bile duct/ampullary neoplasm or neuroendocrine tumor. A preoperative nomogram was constructed with a concordance index of 0.77. When postoperative variables were added to the model, the concordance index increased to 0.82. The postoperative predictors of NHD were return to the operating room, length of stay of ≥14 days, and any inpatient complications. CONCLUSIONS These nomograms could be useful risk assessment tools to predict NHD after PD and therefore facilitate patient counseling and improve resource utilization and discharge planning.
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Affiliation(s)
- Ibrahim Nassour
- University of Texas Southwestern Medical Center, Division of Surgical Oncology, USA
| | - Sam C Wang
- University of Texas Southwestern Medical Center, Division of Surgical Oncology, USA
| | - Alana Christie
- University of Texas Southwestern Medical Center, Division of Biostatistics, Simmons Cancer Center, USA
| | - Ali A Mokdad
- University of Texas Southwestern Medical Center, Division of Surgical Oncology, USA
| | - Matthew R Porembka
- University of Texas Southwestern Medical Center, Division of Surgical Oncology, USA
| | - Michael A Choti
- University of Texas Southwestern Medical Center, Division of Surgical Oncology, USA
| | - Mathew M Augustine
- University of Texas Southwestern Medical Center, Division of Surgical Oncology, USA
| | - Adam C Yopp
- University of Texas Southwestern Medical Center, Division of Surgical Oncology, USA
| | - Xian-Jin Xie
- University of Texas Southwestern Medical Center, Division of Biostatistics, Simmons Cancer Center, USA
| | - John C Mansour
- University of Texas Southwestern Medical Center, Division of Surgical Oncology, USA
| | - Rebecca M Minter
- University of Texas Southwestern Medical Center, Division of Surgical Oncology, USA
| | - Patricio M Polanco
- University of Texas Southwestern Medical Center, Division of Surgical Oncology, USA; Department of Veterans Affairs North Texas Health Care System, USA.
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Linghu E, Du C, Chai N, Li H, Wang Z, Sun Y, Xu W, Guo X, Ning B, Sun L, Zhang W, Wang X, Tang P, Feng J. A prospective study on the safety and effectiveness of using lauromacrogol for ablation of pancreatic cystic neoplasms with the aid of EUS. Gastrointest Endosc 2017; 86:872-880. [PMID: 28365355 DOI: 10.1016/j.gie.2017.03.1525] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 03/20/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS With the development of imaging techniques, the detection rate of pancreatic cystic neoplasms (PCNs) has increased. The surgical morbidity and mortality rates of PCNs are quite high. This study is intended to evaluate the safety and effectiveness of a minimally invasive treatment, EUS-guided PCN ablation with lauromacrogol. METHODS From April 2015 to May 2016, 120 patients with PCNs were enrolled to undergo EUS. We prospectively studied 29 of the 120 patients who underwent EUS-guided ablation with lauromacrogol. The follow-up contrast-enhanced CT or magnetic resonance image was conducted at 3 months and then 6 months after ablation. We determined the effectiveness of ablation by the changes in the volume of the cysts. RESULTS Twenty-nine patients were enrolled in the study, and 7 of them underwent a second ablation; therefore, there were 36 treatments. The mean tumor diameter was 28.6 ± 14.5 mm preoperation, whereas the diameter postoperation was 13.4 ± 10.5 mm. Mild pancreatitis occurred in 2 patients and moderate fever in 1; they occurred in the cysts located in the head/uncinate. Among the 29 treatments with complete follow-up of 9 months (range, 3-15), 11 had complete response and 9 had partial response. The resolution rate was 37.9% (11/29) with 36.4% (8/22) in the cysts of the head/uncinate and 42.9% (3/7) in the body/tail (P > .05). CONCLUSIONS EUS-guided PCN ablation with lauromacrogol is safe and efficient. Adverse event rates seem to be higher in the head/uncinate than in the body/tail, but their resolution rates are similar. Further studies involving larger populations and longer follow-ups are warranted.
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Affiliation(s)
- Enqiang Linghu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Chen Du
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Ningli Chai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Huikai Li
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Zhiqiang Wang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Yufa Sun
- Department of Health Care, Central Guard Bureau, Beijing, China
| | - Wei Xu
- Department of Health Care, Central Guard Bureau, Beijing, China
| | - Xu Guo
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Bo Ning
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Lihua Sun
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Wei Zhang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Xiangdong Wang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Ping Tang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Jia Feng
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
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Kagedan DJ, Devitt KS, Tremblay St-Germain A, Ramjaun A, Cleary SP, Wei AC. The economics of recovery after pancreatic surgery: detailed cost minimization analysis of an enhanced recovery program. HPB (Oxford) 2017; 19:1026-1033. [PMID: 28865739 DOI: 10.1016/j.hpb.2017.07.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 07/10/2017] [Accepted: 07/26/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical pathways (CPW) are considered safe and effective at decreasing postoperative length of stay (LoS), but the effect on economic costs is uncertain. This study sought to elucidate the effect of a CPW on direct hospitalization costs for patients undergoing pancreaticoduodenectomy (PD). METHODS A CPW for PD patients at a single Canadian institution was implemented. Outcomes included LoS, 30-day readmissions, and direct costs of hospital care. A retrospective cost minimization analysis compared patients undergoing PD prior to and following CPW implementation, using a bootstrapped t test and deviation-based cost modeling. RESULTS 121 patients undergoing PD after CPW implementation were compared to 74 controls. Index LoS was decreased following CPW implementation (9 vs. 11 days, p = 0.005), as was total LoS (10 vs. 11 days, p = 0.003). The mean total cost of postoperative hospitalization per patient decreased in the CPW group ($15,678.45 CAD vs. $25,732.85 CAD, p = 0.024), as was the mean 30-day cost including readmissions ($16,627.15 CAD vs. $29,872.72 CAD, p = 0.016). Areas of significant cost savings included laboratory tests and imaging investigations. CONCLUSIONS CPWs may generate cost savings by reducing unnecessary investigations, and improve quality of care through process standardization and decreasing practice variation.
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Affiliation(s)
- Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Katharine S Devitt
- Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | | | - Aliya Ramjaun
- Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Sean P Cleary
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Alice C Wei
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
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Radomski M, Zenati M, Novak S, Tam V, Steve J, Bartlett DL, Zureikat AH, Zeh HJ, Hogg ME. Factors associated with prolonged hospitalization in patients undergoing pancreatoduodenectomy. Am J Surg 2017; 215:636-642. [PMID: 28958654 DOI: 10.1016/j.amjsurg.2017.06.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/06/2017] [Accepted: 06/15/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Complex surgeries such as a pancreatoduodenectomy (PD) traditionally have long hospital stays (LOS). METHODS Patients who underwent elective PD at our institution from 8/2011-6/2015 were retrospectively examined. Interquartile ranges were calculated from LOS. Patient were compared between the highest quartile and the remainder of the cohort. RESULTS 492 patients had a median LOS of 9 days, with 106 (22%) admitted for >14 days. Characteristics associated with prolong hospitalization include age (p = 0.004) and preoperative albumin <3.5 (p = 0.007). Significant intra-operative measures associated with prolonged LOS were blood loss (EBL, p = 0.004) and increased operative time (p = 0.008). Any complication extended hospitalizations (p < 0.001). Patients in the top quartile were less likely to be discharged home (p < 0.0001) and more likely to be readmitted (p < 0.0001). CONCLUSION Older patients with hypoalbuminemia are at higher risk of prolonged LOS following PD as well as high EBL, operative time, and surgical complications. Focused efforts to counsel and optimize patients pre-operatively and minimize intra-operative complications may shorten hospital stays.
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Affiliation(s)
- Michal Radomski
- Department of Surgery, George Washington University, 2150 Pennsylvania Ave. NW, Suite 6B, Washington, DC 20037, United States.
| | - Mazen Zenati
- Department of Surgery, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Stephanie Novak
- Division of Surgical Oncology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Vernissia Tam
- Division of Surgical Oncology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Jennifer Steve
- Division of Surgical Oncology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - David L Bartlett
- Division of Surgical Oncology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Herbert J Zeh
- Division of Surgical Oncology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Melissa E Hogg
- Division of Surgical Oncology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, United States.
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Satoi S, Yamamoto T, Yoshitomi H, Motoi F, Kawai M, Fujii T, Wada K, Arimitsu H, Sho M, Matsumoto I, Hirano S, Yanagimoto H, Ohtsuka M, Unno M, Yamaue H, Kon M. Developing better practices at the institutional level leads to better outcomes after pancreaticoduodenectomy in 3,378 patients: domestic audit of the Japanese Society of Pancreatic Surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:501-510. [PMID: 28749593 DOI: 10.1002/jhbp.492] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The aim of the present study was to assess recent trends in pancreaticoduodenectomy (PD) and the role of institutional standardization on the development of postoperative complications in 3,378 patients who underwent PD in Japan. METHODS Data were collected from 3,378 patients who underwent PD in 2006, 2010 and 2014 at 53 institutions. A standardized institution (SI) was defined as one that implements ≥7 of 13 quality initiatives according to departmental policy. There were 1,223 patients in the SI group and 2,155 in the non-SI group. Clinical parameters were compared over time, and between groups. Risk factors for morbidity and mortality were assessed by logistic regression analysis with a mixed-effects model. RESULTS The number of patients who underwent PD in SIs increased from 16.5% in 2006 to 46.4% in 2014. The SI group experienced an improved process of care and a lower frequency of severe complications vs. the non-SI group (P < 0.001). Multivariate analysis revealed that the SI group was associated with a lower incidence of delayed gastric emptying (odds ratio -0.499, P = 0.008) and incisional surgical site infection (odds ratio -0.999, P < 0.001). CONCLUSION Standardization of care in PD may be important in reducing post-PD complications, and is a critical element for improving clinical outcomes.
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Affiliation(s)
- Sohei Satoi
- Department of Surgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Tomohisa Yamamoto
- Department of Surgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Hideyuki Yoshitomi
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Fuyuhiko Motoi
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Manabu Kawai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Toyama, Japan
| | - Keita Wada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Hidehito Arimitsu
- Division of Gastroenterological Surgery, Chiba Cancer Center Hospital, Chiba, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Ippei Matsumoto
- Department of Surgery, Kindai University, Faculty of Medicine, Higashiosaka, Osaka, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Hiroaki Yanagimoto
- Department of Surgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masanori Kon
- Department of Surgery, Kansai Medical University, Hirakata, Osaka, Japan
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Tremblay St-Germain A, Devitt KS, Kagedan DJ, Barretto B, Tung S, Gallinger S, Wei AC. The impact of a clinical pathway on patient postoperative recovery following pancreaticoduodenectomy. HPB (Oxford) 2017; 19:799-807. [PMID: 28578825 DOI: 10.1016/j.hpb.2017.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/28/2017] [Accepted: 04/29/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreaticoduodenectomies (PD) are complex surgical procedures. Clinical pathways (CPW) are surgical process improvement tools that guide postoperative recovery and are associated with high quality care. Our objective was to report the quality of surgical care following implementation of a CPW. METHODS We developed and implemented a CPW for patients undergoing PD at a single high volume hepato-pancreato-biliary (HPB) centre. Patient outcomes were collected prospectively during the implementation period. A comparator cohort was selected by identifying patients that underwent a PD prior to CPW development. RESULTS 122 patients underwent a PD during the CPW implementation period; 83 patients were initiated on the CPW. 74 patients underwent PD during the 12-month period prior to the CPW. The median hospital stay decreased after the implementation of the CPW (11 vs 8 days, p < 0.01) with no significant changes to mortality, morbidity, reoperation, or readmission rates. In-hospital complications were significantly higher in patients that were not initiated on the CPW (54% vs 74%, p = 0.03). CONCLUSION Results suggest the CPW reduced variability and allowed a greater proportion of patients to receive all elements of care, resulting in improved quality and efficiency of care based on current best evidence recommendations.
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Affiliation(s)
| | - Katharine S Devitt
- Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Beverly Barretto
- Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Stephanie Tung
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Steven Gallinger
- Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alice C Wei
- Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
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Rosemurgy AS, Downs DJ, Swaid F, Ryan CE, Smart AE, Spence JD, Ross SB. Regional differences for pancreaticoduodenectomy in Florida: Location matters. Am J Surg 2017; 214:862-870. [PMID: 28760357 DOI: 10.1016/j.amjsurg.2017.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 06/27/2017] [Accepted: 07/03/2017] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Regionalization of care raises potential for differences in cost of care and outcome. This study was undertaken to determine if costs and outcome after pancreaticoduodenectomy vary by region in Florida, and whether costs and outcome are related. METHODS Inpatient data for pancreaticoduodenectomy in Florida during 2010-2012 were obtained from the Florida Agency for Health Care Administration. Seven geographically different regions were designated based on "cost of living index" and "urban to rural population ratio". Hospital costs, LOS, in-hospital mortality, and the frequency with which surgeons performed pancreaticoduodenectomy were evaluated for these regions. RESULTS Median hospital costs for pancreaticoduodenectomy by region ranged from $101,436-$214,971. Median hospital costs by region correlated positively with LOS (p < 0.0001) and in-hospital mortality (p < 0.0001), and negatively with the frequency of pancreaticoduodenectomies performed by high-volume surgeons (p < 0.0001). CONCLUSIONS There are regional differences for hospital costs and outcome with pancreaticoduodenectomy in Florida. Regions with lower costs had more pancreaticoduodenectomies performed by high-volume surgeons, shorter LOS, and lower in-hospital mortality rates. Regional differences in cost and quality-of-care need to be studied and abrogated to provide uniform optimal care.
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Affiliation(s)
- Alexander S Rosemurgy
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA.
| | - Darrell J Downs
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Forat Swaid
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Carrie E Ryan
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Amanda E Smart
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Janelle D Spence
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Sharona B Ross
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
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Yin L, Huang Z, Dong W, He C, Duan H. Utilizing Electronic Medical Records to Discover Changing Trends of Medical Behaviors Over Time. Methods Inf Med 2017; 56:e49-e66. [PMID: 28474729 PMCID: PMC5435874 DOI: 10.3414/me16-01-0047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 12/12/2016] [Indexed: 12/31/2022]
Abstract
Objectives Medical behaviors are playing significant roles in the delivery of high quality and cost-effective health services. Timely discovery of changing frequencies of medical behaviors is beneficial for the improvement of health services. The main objective of this work is to discover the changing trends of medical behaviors over time. Methods This study proposes a two-steps approach to detect essential changing patterns of medical behaviors from Electronic Medical Records (EMRs). In detail, a probabilistic topic model, i.e., Latent Dirichlet allocation (LDA), is firstly applied to disclose yearly treatment patterns in regard to the risk stratification of patients from a large volume of EMRs. After that, the changing trends by comparing essential/critical medical behaviors in a specific time period are detected and analyzed, including changes of significant patient features with their values, and changes of critical treatment interventions with their occurring time stamps. Results We verify the effectiveness of the proposed approach on a clinical dataset containing 12,152 patient cases with a time range of 10 years. Totally, 135 patients features and 234 treatment interventions in three treatment patterns were selected to detect their changing trends. In particular, evolving trends of yearly occurring probabilities of the selected medical behaviors were categorized into six content changing patterns (i.e, 112 growing, 123 declining, 43 up-down, 16 down-up, 35 steady, and 40 jumping), using the proposed approach. Besides, changing trends of execution time of treatment interventions were classified into three occurring time changing patterns (i.e., 175 early-implemented, 50 steady-implemented and 9 delay-implemented). Conclusions Experimental results show that our approach has an ability to utilize EMRs to discover essential evolving trends of medical behaviors, and thus provide significant potential to be further explored for health services redesign and improvement.
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Affiliation(s)
| | - Zhengxing Huang
- Zhengxing Huang, College of Biomedical Engineering and Instrument Science, Zhejiang University, Zhou Yiqin building 510, Zheda road 38#, Hangzhou 310008, China, E-mail:
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Sheth SG, Conwell DL, Whitcomb DC, Alsante M, Anderson MA, Barkin J, Brand R, Cote GA, Freedman SD, Gelrud A, Gorelick F, Lee LS, Morgan K, Pandol S, Singh VK, Yadav D, Mel Wilcox C, Hart PA. Academic Pancreas Centers of Excellence: Guidance from a multidisciplinary chronic pancreatitis working group at PancreasFest. Pancreatology 2017; 17:419-430. [PMID: 28268158 PMCID: PMC5525332 DOI: 10.1016/j.pan.2017.02.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 02/22/2017] [Accepted: 02/26/2017] [Indexed: 12/11/2022]
Abstract
Chronic pancreatitis (CP) is a progressive inflammatory disease, which leads to loss of pancreatic function and other disease-related morbidities. A group of academic physicians and scientists developed comprehensive guidance statements regarding the management of CP that include its epidemiology, diagnosis, medical treatment, surgical treatment, and screening. The statements were developed through literature review, deliberation, and consensus opinion. These statements were ultimately used to develop a conceptual framework for the multidisciplinary management of chronic pancreatitis referred to as an academic pancreas center of excellence (APCOE).
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Affiliation(s)
- Sunil G. Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - David C. Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, United States
| | | | - Michelle A. Anderson
- Division of Gastroenterology, University of Michigan Hospital and Health Systems, Ann Arbor, MI, United States
| | - Jamie Barkin
- University of Miami, Miller School of Medicine, Miami, FL, United States
| | - Randall Brand
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, United States
| | - Gregory A. Cote
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, United States
| | - Steven D. Freedman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Andres Gelrud
- Center for Endoscopic Research and Therapeutics, University of Chicago, Chicago, IL, United States
| | - Fred Gorelick
- Section of Digestive Diseases, Yale University and VA Healthcare, West Haven, CT, United States
| | - Linda S. Lee
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, MA, United States
| | - Katherine Morgan
- Division of Gastrointestinal and Laparoscopic Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Stephen Pandol
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Vikesh K. Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, United States
| | - C. Mel Wilcox
- Division of Gastroenterology, University of Alabama, Birmingham, AL, United States
| | - Phil A. Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, United States,Corresponding author. Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 410 West Tenth Avenue, Columbus, OH 43210, United States., (P.A. Hart)
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Perinel J, Adham M. ERAS and pancreatic surgery: a review. Updates Surg 2016; 68:253-255. [PMID: 27807815 DOI: 10.1007/s13304-016-0406-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 10/18/2016] [Indexed: 12/24/2022]
Abstract
Pancreatic surgery is still considered as a high-risk abdominal surgery. While the mortality rate is low, the morbidity remains high ranging from 30 to 60%. In 2012, the ERAS study group published the official recommendations to implement the enhanced recovery after surgery (ERAS) program in patients undergoing PD. Non-randomized studies have shown that ERAS was safe and feasible. They reported a significantly shortened LOS with lower morbidity in ERAS group. However, the level of evidence remains low due to absence of randomized study and because of a substantial heterogeneity in the content of ERAS protocols. Future studies should be prospective, multicentric and designed with a structured implementation of standardized ERAS pathway.
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Affiliation(s)
- J Perinel
- Hospices Civils de Lyon & Lyon Sud Faculty of Medicine, UCBL1, E Herriot Hospital, Department of Digestive Surgery, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
| | - M Adham
- Hospices Civils de Lyon & Lyon Sud Faculty of Medicine, UCBL1, E Herriot Hospital, Department of Digestive Surgery, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France.
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Abstract
Enhanced recovery after surgery (ERAS) protocols were first introduced to help recovery after colorectal surgery. They have now been applied to multiple surgical specialties, including pancreatic surgery. ERAS protocols in pancreatic surgery have been shown to decrease length of stay and possibly postoperative morbidity.
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Mosquera C, Koutlas NJ, Fitzgerald TL. A Single Surgeons Experience with Enhanced Recovery after Surgery: An Army of One. Am Surg 2016. [DOI: 10.1177/000313481608200724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The benefits of enhanced recovery after surgery (ERAS) have been demonstrated for multiple surgical procedures in high-volume programs. However, resources required for its implementation may be daunting to individual surgeons. Patients undergoing elective abdominal procedures from June 2013 to April 2015 by a surgical oncologist before and after the implementation of an ERAS protocol were reviewed. A total of 179 patients were included. The mean age of the patients was 63 years, and a majority of them were females (53.6%), white (61.5%), had a Charlson score of 0 to 2 (45.8%), and a Clavien complication grade of 0 to I (60.1%). The univariate analysis revealed that the ERAS protocol was associated with shorter length of stay (LOS) (6.2 vs 9.6 days), lower cost ($21,674 vs $30,380), and lower mortality (0 vs 3.3%); P < 0.05. Differences were noted in LOS and costs for all procedures, the differences were the greatest for hepatic resection (3.8 vs 8.4 days and $16,770 vs $28,589), intestinal resection/stoma closure (4.8 vs 7.6 days and $18,391 vs $22,239), and other abdominal procedures (5.0 vs 10.8 and $17,713 vs $30,900); P < 0.05. The differences were less for patients undergoing procedures for which postoperative pathways were already in place such as pancreatic (9 vs 10.8 days and $30,524 vs $34,291) and colorectal (5.3 vs 6.5 days and $20,733 vs $25,150) surgeries. P > 0.05. An ERAS program can be instituted by an individual surgeon with the benefits of decreased LOS, cost, and mortality.
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Affiliation(s)
- Catalina Mosquera
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Nicholas J. Koutlas
- Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Timothy L. Fitzgerald
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina
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Abstract
OBJECTIVES Endoscopic ultrasonography-guided ethanol ablation therapy for pancreatic cystic lesions is a minimally invasive treatment but still is an experimental therapy. The aims were to investigate the safety and efficacy of endoscopic ultrasonography-guided ethanol ablation therapy. METHODS The inclusion criteria were the following: clinically indeterminate pancreatic cystic lesions in radiologic imaging studies, 2 to 5 cm unilocular or oligolocular cysts without communication to main pancreatic duct, and patients with high-risk operation. RESULTS There were 91 study patients with median follow-up of 40 months. The response rate was as follows: complete resolution, 41 (45%); partial resolution, 37; and persistent cysts, 13. Pancreatic cystic lesions were categorized based on cystic fluid analysis: 9 intraductal papillary mucinous neoplasms (IPMNs), 12 mucinous cystic neoplasms, 33 serous cystic neoplasms, and 28 uncategorized cysts. The success rate was significantly different according to cystic fluid analysis (serous cystic neoplasm, 58%; mucinous cystic neoplasm, 50%; IPMN, 11%; uncategorized cysts, 39%; P < 0.0001). There were 3 patients with mild pancreatitis after the treatment. CONCLUSIONS Endoscopic ultrasonography-guided ethanol ablation therapy seems to be a safe treatment modality. However, it was only effective in 11% of IPMNs. Therefore, the clinical application should be very limited for certain patients who could not tolerate the surgical treatment.
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Delitto D, Black BS, Cunningham HB, Sliesoraitis S, Lu X, Liu C, Sarosi GA, Thomas RM, Trevino JG, Hughes SJ, George TJ, Behrns KE. Standardization of surgical care in a high-volume center improves survival in resected pancreatic head cancer. Am J Surg 2016; 212:195-201.e1. [PMID: 27260793 DOI: 10.1016/j.amjsurg.2016.03.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 02/27/2016] [Accepted: 03/01/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Durable clinical gains in surgical care are frequently reliant on well-developed standardization of practices. We hypothesized that the standardization of surgical management would result in improved long-term survival in pancreatic cancer. METHODS Seventy-seven consecutive, eligible patients representing all patients who underwent pancreaticoduodenectomy and received comprehensive, long-term postoperative care at the University of Florida were analyzed. Patients were divided into prestandardization and poststandardization groups based on the implementation of a pancreatic surgery partnership, or standardization program. RESULTS Standardization resulted in a reduction in median length of stay (10 vs 12 days; P = .032), as well as significant gains in disease-free survival (17 vs 11 months; P = .017) and overall survival (OS; 26 vs 16 months; P = .004). The improvement in overall survival remained significant on multivariate analysis (hazard ratio = .46, P = .005). CONCLUSIONS Standardization of surgical management of pancreatic cancer was associated with significant gains in long-term survival. These results suggest strongly that management of pancreatic head adenocarcinoma be standardized likely by regionalization of care at high performing oncologic surgery programs.
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Affiliation(s)
- Daniel Delitto
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Brian S Black
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Holly B Cunningham
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Sarunas Sliesoraitis
- Department of Medicine, College of Medicine, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - Xiaomin Lu
- Department of Biostatistics & Children's Oncology Group, College of Public Health and Health Professions, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - Chen Liu
- Department of Pathology, College of Medicine, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - George A Sarosi
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA; North Florida/South Georgia Veterans Health System, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Ryan M Thomas
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA; North Florida/South Georgia Veterans Health System, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Jose G Trevino
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Steven J Hughes
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Thomas J George
- Department of Medicine, College of Medicine, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - Kevin E Behrns
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA.
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Xiong J, Szatmary P, Huang W, de la Iglesia-Garcia D, Nunes QM, Xia Q, Hu W, Sutton R, Liu X, Raraty MG. Enhanced Recovery After Surgery Program in Patients Undergoing Pancreaticoduodenectomy: A PRISMA-Compliant Systematic Review and Meta-Analysis. Medicine (Baltimore) 2016; 95:e3497. [PMID: 27149448 PMCID: PMC4863765 DOI: 10.1097/md.0000000000003497] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Enhanced recovery after surgery (ERAS) pathways are multimodal, evidence-based approaches to optimize patient outcome after surgery. However, the use of ERAS protocols to improve morbidity and recovery time without compromising safety following pancreaticoduodenectomy (PD) remains to be elucidated.We conducted a systemic review and meta-analysis to assess the safety and efficacy of ERAS protocols compared with conventional perioperative care (CPC) in patients following PD.PubMed, Medline, Embase, and Science Citation Index Expanded and Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library were searched between January 2000 and June 2015.The patients who underwent PD with ERAS protocols or CPC were eligible. The studies that compared postoperative length of hospital stay (PLOS), postoperative complications, or in-hospital costs in the 2 groups were included.A meta-analysis, meta-regression, sensitivity analysis, and subgroup analysis were performed to estimate the postoperative outcomes between the 2 groups and identified the potential confounders. We used the methodological index for nonrandomized studies checklist to assess methodological qualities. Weighted mean differences (WMD) or odds ratios (OR) were calculated with their corresponding 95% confidence intervals (CI). The publication bias tests were also performed through the funnel plots.In total, 14 nonrandomized comparative studies with 1409 ERAS cases and 1310 controls were analyzed. Implementation of an ERAS protocol significantly reduced PLOS (WMD: -4.17 days; 95%CI: -5.72 to -2.61), delayed gastric emptying (OR: 0.56; 95%CI: 0.44-0.71), overall morbidity (OR: 0.63; 95% CI: 0.54-0.74), and in-hospital costs compared to CPC (all P < 0.001). There were no statistically significant differences in other postoperative outcomes. Age, gender, and ERAS component implementation did not significantly contribute to heterogeneity for PLOS as shown by meta-regression analysis.Our study suggested that ERAS was as safe as CPC and improved recovery of patients undergoing PD, thus reducing in-hospital costs. General adoption of ERAS protocols during PD should be recommended.
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Affiliation(s)
- Junjie Xiong
- From the Department of Pancreatic Surgery (JJX, WMH, XBL); Department of Integrated Traditional and Western Medicine (WH, QX), Sichuan Provincial Pancreatitis Center, West China Hospital, Sichuan University, Chengdu, China; NIHR Liverpool Pancreas Biomedical Research Unit (PS, QMN, RS, MGR), Royal Liverpool University Hospital, Liverpool, UK; and Department of Gastroenterology and Hepatology (DI-G), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
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Bai X, Zhang X, Lu F, Li G, Gao S, Lou J, Zhang Y, Ma T, Wang J, Chen W, Huang B, Liang T. The implementation of an enhanced recovery after surgery (ERAS) program following pancreatic surgery in an academic medical center of China. Pancreatology 2016; 16:665-70. [PMID: 27090583 DOI: 10.1016/j.pan.2016.03.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 02/16/2016] [Accepted: 03/29/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The experience of implementing enhanced recovery after surgery (ERAS) programs in pancreatic surgery is limited. The aim of this study was to evaluate the feasibility of ERAS program in pancreatic surgery in an academic medical center of China. METHODS Between May 2014 and August 2015, 124 patients managed with an ERAS program following pancreatic surgery (ERAS group), were compared to a historical cohort of 63 patients, treated with traditional perioperative care between August 2013 and April 2014 (no-ERAS group). Postoperative hospital stay (POPH), unplanned reoperation, unplanned readmissions, mortality and complications were compared between the two groups. RESULTS Mean POPH of all patients was significantly reduced (p = 0.007) from 17.1 days (no-ERAS group) to 11.7 days (ERAS group). Especially, mean POPH was reduced significantly in ERAS group of patient with no (7.0 vs. 8.7, p = 0.020) or grade I-II (10.6 vs. 14.4, p = 0.001) complications. There was no difference of complication grades and types between two groups, as well as the rate of mortality, unplanned reoperation and readmission. CONCLUSION The ERAS program is safe and feasible for patients undergoing pancreatic surgery, and it can decrease the postoperative hospital stay.
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Affiliation(s)
- Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoyu Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Fangyan Lu
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guogang Li
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shunliang Gao
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianying Lou
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tao Ma
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ji Wang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Chen
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bingfeng Huang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Collaborative Innovation Center for Cancer Medicine, Zhejiang University, Hangzhou, China.
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Zouros E, Liakakos T, Machairas A, Patapis P, Agalianos C, Dervenis C. Improvement of gastric emptying by enhanced recovery after pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2016; 15:198-208. [PMID: 27020637 DOI: 10.1016/s1499-3872(16)60061-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has improved postoperative outcomes particularly in colorectal surgery. This study aimed to assess compliance with an ERAS protocol and evaluate its effect on postoperative outcomes in patients undergoing pancreaticoduodenectomy. METHODS Fifty patients who had received conventional perioperative management from 2005 to 2009 (conventional group) were compared with 75 patients who had received perioperative care with an ERAS protocol (fast-track group) from 2010 to 2014. Mortality, complications, readmissions and length of hospital stay were evaluated and compared in the groups. RESULTS Compliance with each element of the ERAS protocol ranged from 74.7% to 100%. Uneventful patients had a significant higher adherence to the ERAS protocol (87.5% vs 40.7%; P<0.001). There were no significant differences in demographics and perioperative characteristics between the two groups. Patients in the fast-track group had a shorter time to remove the nasogastric tube, start liquid diet and solid food, pass flatus and stools, and remove drains. No difference was found in mortality, relaparotomy, readmission rates and overall morbidity. However, delayed gastric emptying and length of hospital stay were significantly reduced in the fast-track group. The independent effect of the ERAS protocol in reducing delayed gastric emptying and length of hospital stay was confirmed by multivariate analysis. CONCLUSION ERAS pathway was feasible and safe in improving gastric emptying, yielding an earlier postoperative recovery, and reducing the length of hospital stay.
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Affiliation(s)
- Efstratios Zouros
- Department of Surgery, "Konstantopouleio" General Hospital, 3-5 Agias Olgas Str., 14233 Athens, Greece.
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Schulze T, Heidecke CD. [Treatment of postoperative impairment of gastrointestinal motility, cholangitis and pancreatitis]. Chirurg 2016; 86:540-6. [PMID: 25986675 DOI: 10.1007/s00104-015-0004-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Although the mortality associated with major hepatopancreaticobiliary surgery has continuously decreased during the last decades, the morbidity of these procedures remains high. Functional disturbances of normal gastrointestinal motility as well as inflammation and infections of surgically treated organs are frequent complications resulting in considerably prolonged lengths of stay in hospital and increased healthcare costs. This review article highlights the therapeutic approaches and recent developments in the treatment of delayed gastric emptying, prolonged postoperative ileus, postoperative cholangitis and pancreatitis after hepatopancreaticobiliary surgery. Current practice is discussed on the basis of recent results in basic and clinical research, review articles, meta-analyses and guidelines.
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Affiliation(s)
- T Schulze
- Klinik und Poliklinik für Allgemeine Chirurgie, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsmedizin Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Deutschland,
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Clark CJ, Ali SM, Zaydfudim V, Jacob AK, Nagorney DM. Safety of an Enhanced Recovery Pathway for Patients Undergoing Open Hepatic Resection. PLoS One 2016; 11:e0150782. [PMID: 26950852 PMCID: PMC4780831 DOI: 10.1371/journal.pone.0150782] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 02/17/2016] [Indexed: 01/22/2023] Open
Abstract
Background Enhanced recovery pathways (ERP) have not been widely implemented for hepatic surgery. The aim of this study was to evaluate the safety of an ERP for patients undergoing open hepatic resection. Methods A single-surgeon, retrospective observational cohort study was performed comparing the clinical outcomes of patients undergoing open hepatic resection treated before and after implementation of an ERP. Morbidity, mortality, and length of hospital stay (LOS) were compared between pre-ERP and ERP groups. Results 126 patients (pre-ERP n = 73, ERP n = 53) were identified for the study. Patient characteristics and operative details were similar between groups. Overall complication rate was similar between pre-ERP and ERP groups (37% vs. 28%, p = 0.343). Before and after pathway implementation, the median LOS was similar, 5 (IQR 4–7) vs. 5 (IQR 4–6) days, p = 0.708. After adjusting for age, type of liver resection, and ASA, the ERP group had no increased risk of major complication (OR 0.38, 95% CI 0.14–1.02, p = 0.055) or LOS greater than 5 days (OR 1.21, 95% CI 0.56–2.62, p = 0.627). Conclusions Routine use of a multimodal ERP is safe and is not associated with increased postoperative morbidity after open hepatic resection.
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Affiliation(s)
- Clancy J. Clark
- Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, United States of America
- * E-mail:
| | - Shahzad M. Ali
- Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Victor Zaydfudim
- Department of General Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Adam K. Jacob
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - David M. Nagorney
- Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota, United States of America
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Abstract
With the increasing complexity of modern medical therapies, it is becoming imperative to recognize the marginal cost and gains of increasingly sophisticated (and expensive) interventions. By understanding the incremental cost of a given intervention, investigators must help answer questions about healthcare resource utilization that are not answered by randomized clinical trials. The continued funding of biomedical research and pharmaceuticals will require more objective study of the return on investment for any given treatment modality, and cost-effectiveness analyses will be instrumental in providing solutions to the inequalities in healthcare delivery.
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Raman V, Kaiser LR, Erkmen CP. Clinical pathway for esophagectomy improves perioperative nutrition. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2015; 4:166-72. [PMID: 27637822 DOI: 10.1016/j.hjdsi.2015.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 09/01/2015] [Accepted: 11/25/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND Clinical pathways reduce hospitalization and costs in colorectal and pancreatic cancer. We describe creating an esophagectomy pathway and analyze its implementation and effects. METHODS We documented the process of developing an esophagectomy clinical pathway. We performed a retrospective review of prospectively collected data on 12 patients before pathway implementation and 12 patients after. RESULTS Pathway Implementation: more patients were presented at tumor board (9 pathway vs. 2 pre-pathway; p=0.012) and chose their postoperative care facility before surgery (8 vs. 0; p=0.0013) OUTCOMES: There were no changes in mortality (0 vs. 0), major complications (5 vs. 5), hospitalization (median 9.5 vs. 12 days; p=0.82), and total charges ($ 98,395 vs. $ 96,946; p=0.96). Pathway patients lost significantly less weight preoperatively (2.3% vs. 7.6%; p=0.01) and perioperatively (6.3% vs. 12%; p=0.02). CONCLUSIONS This is the first study to report the process of designing and implementing an esophagectomy pathway. While there was no significant decrease in mortality, complications, hospitalization, or charges, our pathway significantly decreased pre- and perioperative weight loss, which we attribute to coordinated patient education and care.
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Affiliation(s)
- Vignesh Raman
- Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, United States
| | - Larry R Kaiser
- Temple University School of Medicine, Temple University Health System, United States
| | - Cherie P Erkmen
- Division of Thoracic Surgery, Department of Surgery, Temple University Health Systems, Parkinson Pavilion, Suite C-100, Philadelphia, PA 19140, United States.
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Joliat GR, Labgaa I, Petermann D, Hübner M, Griesser AC, Demartines N, Schäfer M. Cost-benefit analysis of an enhanced recovery protocol for pancreaticoduodenectomy. Br J Surg 2015; 102:1676-83. [PMID: 26492489 DOI: 10.1002/bjs.9957] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 05/04/2015] [Accepted: 08/28/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programmes have been shown to decrease complications and hospital stay. The cost-effectiveness of such programmes has been demonstrated for colorectal surgery. This study aimed to assess the economic outcomes of a standard ERAS programme for pancreaticoduodenectomy. METHODS ERAS for pancreaticoduodenectomy was implemented in October 2012. All consecutive patients who underwent pancreaticoduodenectomy until October 2014 were recorded. This group was compared in terms of costs with a cohort of consecutive patients who underwent pancreaticoduodenectomy between January 2010 and October 2012, before ERAS implementation. Preoperative, intraoperative and postoperative real costs were collected for each patient via the hospital administration. A bootstrap independent t test was used for comparison. ERAS-specific costs were integrated into the model. RESULTS The groups were well matched in terms of demographic and surgical details. The overall complication rate was 68 per cent (50 of 74 patients) and 82 per cent (71 of 87 patients) in the ERAS and pre-ERAS groups respectively (P = 0·046). Median hospital stay was lower in the ERAS group (15 versus 19 days; P = 0·029). ERAS-specific costs were €922 per patient. Mean total costs were €56 083 per patient in the ERAS group and €63 821 per patient in the pre-ERAS group (P = 0·273). The mean intensive care unit (ICU) and intermediate care costs were €9139 and €13 793 per patient for the ERAS and pre-ERAS groups respectively (P = 0·151). CONCLUSION ERAS implementation for pancreaticoduodenectomy did not increase the costs in this cohort. Savings were noted in anaesthesia/operating room, medication and laboratory costs. Fewer patients in the ERAS group required an ICU stay.
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Affiliation(s)
- G-R Joliat
- Department of Visceral Surgery, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - I Labgaa
- Department of Visceral Surgery, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - D Petermann
- Department of Visceral Surgery, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - M Hübner
- Department of Visceral Surgery, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - A-C Griesser
- Medical Directorate, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - N Demartines
- Department of Visceral Surgery, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - M Schäfer
- Department of Visceral Surgery, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
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Das A, Brugge W, Mishra G, Smith DM, Sachdev M, Ellsworth E. Managing incidental pancreatic cystic neoplasms with integrated molecular pathology is a cost-effective strategy. Endosc Int Open 2015; 3:E479-86. [PMID: 26528505 PMCID: PMC4612224 DOI: 10.1055/s-0034-1392016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 03/02/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Current guidelines recommend using endoscopic ultrasound (EUS), carcinoembryonic antigen (CEA) testing and cytology to manage incidental pancreatic cystic neoplasms (PCN); however, studies suggest a strategy including integrated molecular pathology (IMP) of cyst fluid may further aid in predicting risk of malignancy. Here, we evaluate several strategies for diagnosing and managing asymptomatic PCN using healthcare economic modeling. PATIENTS AND METHODS A third-party-payer perspective Markov decision model examined four management strategies in a hypothetical cohort of 1000 asymptomatic patients incidentally found to have a 3 cm solitary pancreatic cystic lesion. Strategy I used cross-sectional imaging, recommended surgery only if symptoms or risk factors emerged. Strategy II considered patients for resection without initial EUS. Strategy III (EUS + CEA + Cytology) referred only those with mucinous cysts (CEA > 192 ng/mL) for resection. Strategy IV implemented IMP; a commercially available panel provided a "Benign," "Mucinous," or "Aggressive" classification based on the level of mutational change in cyst fluid. "Benign" and "Mucinous" patients were followed with surveillance; "Aggressive" patients were referred for resection. Quality-adjusted life-years (QALY), relative risk with 95 %CI, Number Needed to Treat (NNT), and incremental cost-effectiveness ratios were calculated. RESULTS Strategy IV provided the greatest increase in QALY at nearly identical cost to the cheapest approach, Strategy I. Relative risk of malignancy compared to the current standard of care and nearest competing strategy, Strategy III, was 0.18 (95 %CI 0.06 - 0.53) with an NNT of 56 (95 %CI 34 - 120). CONCLUSIONS Use of IMP was the most cost-effective strategy, supporting its routine clinical use.
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Affiliation(s)
- Ananya Das
- Arizona Center for Digestive Health, Gilbert, Arizona, United States,Corresponding author Ananya Das, MD Arizona Center for Digestive Health2680 S Valvista Drive, Suite #116Gilbert, Arizona 85295United States+1-480-507-5677
| | - William Brugge
- Digestive Healthcare Center, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Girish Mishra
- Department of Gastroenterology, Wake Forest Baptist Health, Winston-Salem, North Carolina, United States
| | - Dennis M. Smith
- RedPath Integrated Pathology, Pittsburgh, Pennsylvania, United States
| | - Mankanwal Sachdev
- Arizona Center for Digestive Health, Gilbert, Arizona, United States
| | - Eric Ellsworth
- RedPath Integrated Pathology, Pittsburgh, Pennsylvania, United States
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Braga M, Pecorelli N, Ariotti R, Capretti G, Greco M, Balzano G, Castoldi R, Beretta L. Enhanced recovery after surgery pathway in patients undergoing pancreaticoduodenectomy. World J Surg 2015; 38:2960-6. [PMID: 24870390 DOI: 10.1007/s00268-014-2653-5] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS(®)) pathways have reduced morbidity and length of hospital stay (LOS) in orthopedics, bariatric, and colorectal surgery. New perioperative care protocols have been tested in patients undergoing pancreaticoduodenectomy (PD), with controversial results on morbidity. Incomplete data about ERAS items compliance have been reported. The aim of this study was to assess compliance with an ERAS protocol and its impact on short-term outcome in patients undergoing PD. METHODS A comprehensive ERAS protocol was applied in 115 consecutive patients undergoing PD. Each ERAS patient was matched with one patient who received standard perioperative care. Match criteria were age, gender, malignant/benign disease, and PD-specific prognostic score. RESULTS No adverse effect related to ERAS items occurred. Compliance with postoperative items ranged between 38 and 66 %. The ERAS group had an earlier recovery of mobilization (p < 0.001), oral feeding (p < 0.001), gut motility (p < 0.001), and an earlier suspension of intravenous fluids (p = 0.041). No difference between ERAS and control group was found in mortality, overall morbidity, and major complication rates. Subgroup analysis showed that 43/60 (71 %) patients with early postoperative low compliance with the ERAS pathway had complications. The ERAS pathway significantly shortened LOS in uneventful patients or those with minor complications (11.2 vs. 13.7 days, p = 0.001). CONCLUSION The ERAS pathway was feasible and safe, yielding an earlier postoperative recovery. An ERAS protocol should be implemented in patients undergoing PD; however, patients with early postoperative low compliance should be carefully managed.
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Affiliation(s)
- Marco Braga
- Department of Surgery, San Raffaele Hospital, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy,
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