91.20 Costs of Radical Cystectomy versus Trimodal Therapy for Patients with Muscle-invasive Bladder Cancer

Posted on January 31, 2019

M. D. Ray-Zack1, Y. Shan1, P. Kerr1, C. Kosarek1, H. Hudgins1, U. Jazzar1, D. Tyler1, S. J. Freedland3, T. Swanson1, A. Kamat2, J. L. Gore4, S. Kaul1, H. Mehta1, S. B. Williams1  1The University of Texas Medical Branch,Surgery/Urology,Galveston, TX, USA 2MD Anderson Cancer Center,Urology,Houston, TX, USA 3Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center,Surgery,Los Angeles, CA, USA 4University Of Washington,Urology,Seattle, WA, USA

Introduction:
In this study, we compared costs associated with trimodal therapy versus the guideline-recommended radical cystectomy among older adults with muscle-invasive bladder cancer.

Methods:
Using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data, we enrolled a total of 2,963 patients aged ≥66 years diagnosed with clinical stage T2-4a bladder cancer between 2002 and 2011. We compared total Medicare costs within one year of diagnosis among patients following radical cystectomy or trimodal therapy using inverse probability of treatment weighted (IPTW) propensity score models, which included a two-part estimator to account for intrinsic selection bias.

Results:
Median total costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83,754 vs. $68,692; median difference $11,805, 95% CI $7,745 to $15,864), 180 days ($187,162 vs. $109,078; median difference $62,370, 95% CI $55,581 to $69,160), and 365 days ($289,142 vs. $148,757; median difference $109,027, 95% CI $98,692 to $119,363). Outpatient, radiology, pharmacy and pathology/laboratory costs contributed largely to the significantly higher costs associated with trimodal therapy (Figure 1). On IPTW-adjusted analyses, patients undergoing trimodal therapy had $142,337 (95% CI $117,423-$175,300) higher costs compared with radical cystectomy one year after treatment.

Conclusion:
Compared to radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. Extrapolating cost figures to the total US population resulted in excess spending of $853 million for trimodal therapy compared with radical cystectomy for patients diagnosed in 2018.

91.19 Disease Severity and Cost in Adhesive Small Bowel Obstruction

Posted on January 31, 2019

M. C. Hernandez1, E. J. Finnesgard1, M. D. Ray-Zack1, O. A. Shariq1, D. Stephens1, J. M. Aho1, A. W. Knight1, N. N. Haddad1, B. D. Kim1, H. J. Schiller1, M. D. Zielinski1  1Mayo Clinic,Surgery,Rochester, MN, USA

Introduction:

Adhesive small bowel obstruction (ASBO) severity is associated with several important clinical outcomes, however the impact of ASBO severity on hospitalization cost is unknown. The American Association for the Surgery of Trauma (AAST) developed an Emergency General Surgery (EGS) grading system for ASBO. We stratified patients’ ASBO severity and captured hospitalization costs hypothesizing that increased disease severity would correlate with greater costs.

Methods:

This was a single-center study of hospitalized adult patients with SBO during 2015-2017. Clinical data and total costs (direct + indirect) were abstracted. AAST EGS grades (I-IV) stratified disease severity. Costs were normalized to the median grade I cost.  Univariate and multivariate analyses evaluated the relationship between normalized cost and AAST EGS grade, length of hospital and ICU stay, operative time, and Charlson comorbidity index.

Results:

There were 214 patients; 119 (56%) were female. AAST EGS grades included: I (62%, n=132), II (23%, n=49), III (7%, n=16), and IV (8%, n=17). Relative to grade I, median normalized cost increased by 1.4 fold for grade II, 1.6 fold for grade III, and 4.3 fold for grade IV disease. No considerable differences in patient comorbidity were observed by grade. Pair-wise comparisons demonstrated that grade I disease cost less than higher grades (corrected p<0.001). Non-operative management was associated with lower normalized cost compared to operative management (1.1 vs 4.5, p<0.0001). In patients failing non-operative management and required an operation, normalized cost was increased 7.2 fold. Collectively, the AAST EGS grade correlated well with cost (Spearman’s ρ=0.7, p<0.001). After adjustment for covariates, regression demonstrated a persistent relationship between AAST EGS grade and cost, Table.

Conclusion:

Increasing ASBO severity is independently associated with greater costs. Efforts to identify and mitigate costs associated with this burdensome disease are warranted.

91.18 The Influence of Tracheostomy Timing on Outcomes in Trauma Patients with Rib Fractures

Posted on January 31, 2019

K. C. Shue1,2, R. Stalder3,5, J. Wycech1,3, A. Tymchak1,2,3, J. Lozada3, A. A. Fokin1, I. Puente1,2,3,4  1Delray Medical Center,Trauma Services,Delray Beach, FL, USA 2Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 3Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA 5Wake Forest University,Winston-Salem, NC, USA

Introduction:
Timing of tracheostomy remains a subject of debate, whether early or late tracheostomy leads to better outcomes in trauma patients. The impact of tracheostomy timing on outcomes in trauma patients with rib fractures (RFX) has not been thoroughly investigated. The aim of this study was to examine the benefits of early tracheostomy (ET) in trauma patients with RFX.

Methods:
This IRB-approved retrospective cohort study, included 124 patients with radiologically-confirmed (X-rays and CT) rib fractures (RFX) admitted to two Level 1 Trauma Centers between January 2012 and December 2017, who have undergone a tracheostomy procedure. ET was defined as being performed within 7 days of mechanical ventilation initiation and late tracheostomy (LT) as being performed after one week. Patients were divided into 2 groups: ET (n = 40) or LT (n = 84). Analyzed variables included age, injury severity score (ISS), number of ribs fractured, number of the total fractures of ribs, presence of flail chest, bilateral rib fractures, pulmonary contusion, presence of traumatic brain injury (TBI), Glasgow Coma Scale (GCS), maxillofacial co-injuries, rate of ventilation-associated pneumonia (VAP), duration of mechanical ventilation (DMV), intensive care unit length of stay (ICULOS) and hospital length of stay (HLOS).

Results:

Between the ET and LT groups, mean age (47.7 vs. 51.6 years), ISS (24.5 vs. 28.9), number of ribs fractured (4.8 vs. 5.4), number of total fractures of ribs (5.4 vs. 6.2), presence of flail chest (5.0% vs. 9.5%), bilateral rib fractures (35.0% vs. 26.8%), incidence of pulmonary contusion (60.0% vs. 56.0%), rate of TBI (42.5% vs. 47.6%), GCS (9.6 vs. 9.3) and maxillofacial co-injuries (52.5% vs. 34.5%) were not statistically different (all p>0.05).

As it comes to the outcome variables, ET group when compared to LT group had significantly shorter ICULOS (16.0 vs. 24.8 days; p<0.001), while rate of VAP (37.5% vs. 34.5%), DMV (24.8 vs. 28.6 days) and HLOS (38.1 vs. 41.4 days) were not statistically different in the ET and LT groups (all p>0.09).  

Conclusion:
Early tracheostomy in trauma patients with rib fractures is associated with a shorter ICULOS when compared to late tracheostomy. Therefore, performing tracheostomy within 7 days of mechanical ventilation initiation should be considered in trauma patients with rib fractures.

91.17 Healthcare Utilization after NICU Discharge: A Descriptive Cost Analysis

Posted on January 31, 2019

J. K. Chica1,2, M. A. Bartz-Kurycki1,2, E. B. Avritscher3, K. Tsao1,2, M. T. Austin1,2  1McGovern Medical School at UTHealth,Department Of Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Department Of Pediatric Surgery,Houston, TX, USA 3McGovern Medical School at UTHealth,Department Of Pediatrics,Houston, TX, USA

Introduction: Infants who are discharged from the neonatal intensive care unit (NICU) are known to be at a higher risk of having an unplanned healthcare visit given the complex care that they often require. Many of these infants have chronic medical conditions that also place them at a higher risk for complications. These unplanned healthcare visits not only have a clinical impact on the infant, but also result in substantial additional healthcare expenditures. We had previously studied factors associated with increased post-discharge healthcare utilization for NICU infants discharged within our healthcare system. In this study, we aimed to estimate the health system costs of unplanned hospital visits in NICU infants up to 90 days post-discharge.

Methods:  A retrospective review had previously been performed of all infants discharged from the NICU between Jan 1, 2017 and March 31, 2017. We identified the subset of infants who had any unplanned hospital visit (readmissions and emergency department (ED) visits) within 90 days of NICU discharge. Patients with NICU stay < 3 days were excluded. Those who had an unplanned hospital visit outside of our healthcare system were not included in our cost analysis as these costs were not available. Costs were estimated in 2017 US dollars based on the health system perspective.  Hospital costs for the unplanned visits were obtained from the institutional accounting system of our hospital system. 

Results: Of the 414 infants discharged from the NICU during the study period, 65 patients (16%) had an unplanned hospital visit within 90 days of discharge. The majority were male (62%), Medicaid insured (71%), with a mean gestational age of 33 weeks at birth. Thirty-five patients had an ED visit, 29 were readmitted to the hospital, and 1 patient had both an ED visit and hospital readmission on separate occasions. The total costs for the 65 infants with unplanned hospital visits were estimated to be $785,804 with a mean of $12,089 (95%CI $2,099-$22,079) per patient. Hospital readmissions accounted for 98% ($768,718) of the total costs and ED visits for 2% ($17,086). The mean cost per readmission and ED visit was $25,624 (95%CI $4,390-$46,858) and $475 (95%CI $233-$716) respectively.

Conclusion: Approximately half of the patients who had an unplanned hospital visit within 90 days after discharge from the NICU were readmitted to the hospital and hospital readmission accounted for 98% of total costs. In a 3 month period, readmissions of recent NICU graduates cost the healthcare system nearly $1 million. In future work, we plan to develop and test a comprehensive transition to home program for parents of NICU graduates that aims to improve patient outcomes and decrease healthcare resource utilization following discharge.  

91.16 Unnecessary Use of Radiology Studies in the Diagnosis of Inguinal Hernias

Posted on January 31, 2019

N. Liu1, T. M. Prout3, Y. Xu1, S. Marowski4, L. M. Funk2,5, J. A. Greenberg2, A. L. Shada2, A. O. Lidor2  2University Of Wisconsin,Department Of Surgery / Division Of Minimally Invasive, Foregut, And Bariatric Surgery,Madison, WI, USA 3University Of Wisconsin,Department Of Radiology,Madison, WI, USA 4University Of Wisconsin,Madison, WI, USA 5William S. Middleton VA Hospital,Madison, WI, USA 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction:  Inguinal hernia repair is one of the most frequently performed general surgery procedures; over 700,000 inguinal hernia repairs are done per year in the United States alone. In current clinical practice, the diagnosis of inguinal hernia is based on physical exam. Smaller hernias not detectable on exam may require imaging for further evaluation. Imaging modalities include MRI, CT, and ultrasound. While ultrasound is considered low risk, other imaging studies have risks of radiation and contrast. However, every study places an economic burden on both individuals and the healthcare system. Recently, the American Board of Internal Medicine initiated the Choosing Wisely campaign, directed towards limiting unnecessary care. The objective of our study was to determine the prevalence of unnecessary imaging in the diagnosis of inguinal hernias.

Methods: We included 2125 patients who underwent elective inguinal hernia surgery at a single institution academic center from 1/6/2010 to 12/29/2017. Within this cohort, we identified the patients that received CT, MRI or Ultrasound Imaging that included the inguinal region within 6 months prior to surgery. Through chart review of primary care, emergency department, and surgery provider notes for physical exam findings and imaging indications, we categorized patients into 4 imaging categories: unrelated (imaging ordered for other indications), necessary (clinically  suspected occult hernia by referring provider), unnecessary (detectable hernia by referring provider), and borderline (undetectable hernia by referring provider but detectable by surgeon).

Results: Of 2125 patients who underwent inguinal hernia surgery, 417 patients had imaging studies 6 months prior to surgery. 167 radiology studies were excluded for having unrelated imaging and excluded, leaving us with a total of 250 patients.  5.7% (n=121) of all patients undergoing inguinal hernia surgery, received unnecessary imaging. Of these, 66.9% were ultrasounds and 33.1% were CTs. 2.8% of all patients had necessary studies, while 3.3% had borderline studies. The majority of the studies identified were ultrasounds ordered by primary care providers (Table 1).

Conclusion: 5.7% of all patients who undergo inguinal hernia surgery have potentially unnecessary diagnostic radiology studies. We can extrapolate that of 700,000 inguinal hernia surgeries done in the US per year, approximately 40,000 patients may be undergoing unnecessary studies. This could not only expose patients to avoidable risks, but also places a significant economic burden on patients and our already strained health system. We aim to utilize these results to develop an algorithm to guide the efficient diagnosis of inguinal hernias.

 

91.15 How do Surgeons Balance Cost and Effectiveness in Choosing Surgical Instruments?

Posted on January 31, 2019

C. P. Childers1,4, B. Zhao2, J. Tseng3, R. D. Hays4, G. Kominski4, S. L. Ettner4, R. F. Alban3, B. M. Clary2, M. Maggard-Gibbons1  1University Of California – Los Angeles,Surgery,Los Angeles, CA, USA 2University Of California – San Diego,Surgery,San Diego, CA, USA 3Cedars-Sinai Medical Center,Surgery,Los Angeles, CA, USA 4University Of California – Los Angeles,Fielding School Of Public Health, Department Of Health Policy & Management,Los Angeles, CA, USA

Introduction:
The choice of surgical instruments is often left to the surgeon.  But there is a paucity of data to help surgeons balance effectiveness and cost.  Medical devices are a multi-billion dollar industry, yet little is known about how surgeons perceive the effectiveness and cost of the surgical instruments they use.

Methods:
A web-based survey was distributed to 100 attending general and subspecialty (eg, colorectal) surgeons at 3 academic health systems. Surgeons were provided a clinical vignette for a routine elective laparoscopic cholecystectomy and asked to choose their preferred instrument (comparison 1: 5mm (A) vs. 10mm (B) Endoclip applier; comparison 2: Clearify visualization system (A)  vs. anti-fog (B) solution) and to state the relative effectiveness and cost of these items (Figure).  Descriptive and multivariable analyses were performed to assess the impact of cost and effectiveness on choice of instruments.

Results:

Eighty-two (82%) surgeons provided complete data. Surgeons’ preferences varied,  with 29 (36%) choosing the 10mm endoclip (comparison 1) and 35 (43%) choosing Clearify (comparison 2). Virtually all (98%) surgeons knew Clearify was more expensive than anti-fog solution but fewer (63%) knew the 5mm endoclip was more expensive than the 10mm.  Surgeons were divided with respect to perceived effectiveness for both comparisons (comparison 1: A>B 24%, A=B 64%, A B 59%, A = B 40%, A < B 1%).

 

C-statistics for the endoclip choice were 0.75, 0.65, and 0.82 using effectiveness only, cost only, and effectiveness + cost as covariates. Surgeons who knew the 5mm endoclip was more expensive were one-third (RR 0.67, CI 0.48-0.87) less likely to choose the 5mm endoclip, but over half (54%) still chose it as their preferred item.  C-statistics for the Clearify/anti-fog choice were 0.5, 0.83, and 0.82.  Surgeons who viewed the anti-fog as similar or only slightly worse in effectiveness than Clearify were 2.7 times more likely to choose anti-fog (RR 2.66, CI 1.4-6.5). 

Conclusion:
In this multi-institutional study, surgeons were divided in their preference of instruments with effectiveness as the dominant motivator.  Cost appears to have only a small impact on instrument choice. Given the variability in surgeons’ perceived effectiveness, randomized trial evidence may be needed to help guide surgeons in choosing surgical instruments.  

 

91.14 Efficacy of Retrival Bag Use in Prevention of Surgical Site Infections for Laparoscopic Appendectomy

Posted on January 31, 2019

S. A. Turner1, H. Jung1, J. E. Scarborough1  1University of Wisconsin – Madison,General Surgery,Madison, WI, USA

Introduction:  Specimen retrieval bags are routinely used in laparoscopic appendectomy under the assumption that they help to prevent surgical site infection (SSI).  Little if any evidence has been published to support this assumption.

Methods: Patients from the 2016 Appendectomy-Targeted American College of Surgeons National Surgical Quality Improvement Program database who underwent laparoscopic appendectomy for pathology-confirmed appendicitis were included in this study.  The primary predictor variable for our analysis was intraoperative utilization of a specimen retrieval bag for appendix removal (as documented in the operative report).  Additional predictor variables included patient and disease characteristics, including the presence of perforated appendicitis and/or the presence of a peri-appendiceal abscess.  The primary outcome variable for our analysis was 30-day postoperative SSI (including incisional and/or organ/space SSI).  Logistic regression analysis was used to determine the association between specimen retrieval bag utilization and postoperative SSI rate, after adjustment for patient- and disease-related variables. 

Results: A total of 10,357 patients were included for analysis, 9,585 (92.6%) whose procedure included specimen bag utilization (BAG) and 772 (7.5%) whose procedure did not (NO BAG).  The 30-day incidence of postoperative SSI was 4.2% in the NO BAG group and 3.6% in the BAG group [AOR of SSI without bag utilization 1.15 (95% CI 0.78-1.69; P = 0.49)].  The lack of a statistically significant association between bag utilization and postoperative SSI incidence was also demonstrated for a subgroup of patients with perforated appendicitis.

Conclusion: Although widely assumed to prevent postoperative SSI, specimen bag utilization during laparoscopic appendectomy does not appear to provide any overt benefit to patients.  Eliminating the routine use of these devices will improve therefore improve the value of this common operation.
 

91.13 Economic Analysis of Implementation of Enhanced Recovery Protocols at a Community Hospital

Posted on January 31, 2019

A. D. Ardeljan1, D. Manjani1, D. Maurente1,6, S. Willis1,7, H. S. Abdul1,5, A. Johns1,4, S. Sennhauser1, M. Ghali1, A. M. Rashid1,2, M. Perez1,3, O. M. Rashid1,2  1Holy Cross Hospital, Michael And Dianne Bienes Comprehensive Cancer Center, Fort Lauderdale,Fort Lauderdale, FLORIDA, USA 2Massachusetts General Hospital, Cancer Center, Boston,Boston, MASSACHUSETTS, USA 3University Of Miami Miller School Of Medicine, Miami,,Miami, FLORIDA, USA 4East Norriton Community Hospital, Philadelphia,Philadelphia, PENNSYLVANIA, USA 5Kendall Regional Medical Center,Kendall, FLORIDA, USA 6Eastern Virginia Medical School,Norfolk, VA, USA 7Saint Barnabas Hospital Health System,New York, NEW YORK, USA

Introduction:  We have previously demonstrated that implementation of an enhanced recovery protocol (ERP) reduced Length of Stay (LOS) without any change in the readmission rate; however, the economic cost has not been quantified. The aim of this study was to evaluate the economic costs of ERP implementation at a community hospital.

Methods: Diagnostic Related Group (DRG) codes were used to assess costs associated with the hospitalizations of cases in the ERP versus non-ERP groups. The American Hospital Association (AHA) Annual Survey 1999-2015 was used to provide the expenses per day for inpatient hospitalization in the United States. Standard statistical methods were used.

Results: The AHA survey estimated the expenses of $2,265 incurred in a day for non-profit hospitals in Florida and $2,346 for the United States. For DRG 329, the reduction in LOS at a community hospital in ERP participating group reduced the cost of hospitalization from $27,297.96 (13.08 days) in the Non-ERP participating group to $7,033.19 (3.37 days); on average DRG 329, ERP reduced the cost by $20,264.77 per patient. For DRG 330, the reduction in LOS at a community hospital in ERP participating group reduced the cost of hospitalization from $22,664.82 (10.86 days) in the Non-ERP participating group to $ 9,558.46 (4.58 days); on average for DRG 330 ERP reduced the cost by $13,106.36 per patient. For DRG 331, the reduction in LOS at a community hospital in ERP participating group reduced the cost of hospitalization from $15,172.49 (7.27 days) in the Non-ERP participating group to $ 7,054.06 (3.38 days); on average for DRG 331, ERP reduced the cost by $8,118.43 per patient. LOS associated cost was compared between ERP and non-ERP groups: for DRG 329 the savings was $162,118.8 (n=12 non-ERP v n=8 ERP, p=4.39×10-18); for DRG 330, $314,552.64 (n=36 non-ERP v n=24 ERP, p=2.72×10-22); and for DRG 331, $89,302.73 (n=11 non-ERP v n=23 for ERP, p=4.19×10-20), respectively.

Conclusion: The implementation of ERP protocols significantly reduced the cost of hospitalization after bowel surgery based on the estimated expenses associated with LOS.

 

91.12 Cost-Effectiveness of Exploratory Laparotomy in Soroti, Uganda

Posted on January 31, 2019

N. Bellamkonda1, G. Motwani2, H. Wange3, C. DeBoer2, F. Kirya3, C. Juillard2, E. Marseille2, M. Ajiko3, R. Dicker1  1David Geffen School Of Medicine, University Of California At Los Angeles,Center For World Health,Los Angeles, CA, USA 2University Of California – San Francisco,Center For Global Surgical Studies, Department Of Surgery,San Francisco, CA, USA 3Soroti Regional Referral Hospital,Department Of Surgery,Soroti, Uganda

Introduction:  Surgical disease increasingly contributes to global mortality and morbidity, particularly in low- and middle-income countries (LMICs). Sub-Saharan Africa as a region has the largest percentage of avertable injury-related surgical disease and surgical digestive diseases; however, estimates suggest that the rate of surgical treatment is drastically lower than the burden of disease. While preliminary modeling shows that global surgery has a more favorable cost-effectiveness ratio relative to HIV treatment, for example, the Lancet Commission on Global Surgery found that global cost-effectiveness data is lacking for a wide range of essential surgical procedures. This study aims to address this gap by defining the cost-effectiveness of exploratory laparotomies in the Ugandan context.

Methods:  Over a four-month time period, the costs of patients undergoing emergency exploratory laparotomies at the Soroti Regional Referral Hospital in Soroti, Uganda were collected. A time-and-motion analysis was utilized to calculate operating theatre personnel costs per case. Ward personnel, medication, overhead, and supply costs were recorded and calculated using a micro-costing approach. The cost in USD per disability-adjusted-life-years (DALY) averted was then determined. 

Results: Data for 60 exploratory laparotomy patients was collected. The most common cause for laparotomy was small bowel obstruction. The average cost per patient was $81.36, which divided into approximately $15 for ward personnel, $20 for medications, $19 for surgical personnel, $20 for admin/ancillary staff, $7 for operative supplies, and $1.32 for utilities. The post-operative mortality rate was 9.8%, and the complication rate was 11.4%. The average number of DALYs averted per patient was 15.44. The cost in USD per DALY averted was $5.27.

Conclusion: This data provides evidence that emergency exploratory laparotomy is cost-effective compared with other surgical interventions and basic public health interventions, such as bed nets for malaria prevention ($6.48-22.04/DALY averted), TB, tetanus, measles, and polio vaccines ($12.96-25.93/DALY averted), and HIV treatment with multidrug antiretroviral therapy ($453.74-648.20/DALY). Given that injury-related surgical disease causes more death than malaria, TB, and HIV combined, this provides a strong argument for greater investment in surgical care on a global scale.

 

91.11 Trends in Treatment of Appendicitis: Analysis of National Inpatient Sample

Posted on January 31, 2019

T. Chkhikvadze1, J. Shi2, P. Sinha3  3NYU Langone Hospital-Brooklyn,Department Of Surgery, NYU School Of Medicine,Brooklyn, NY, USA 1NYU Langone Hospital-Brooklyn,Department Of Medicine, NYU School Of Medicine,Brooklyn, NY, USA 2Ohio State University,The Research Institute At Nationwide Children’s Hospital,Columbus, OH, USA

Aim of the study: To assess if attempts of conservative management of acute appendicitis (AA) have changed delivery of surgical care for this disease in the United States.

Methods: We analyzed 10 years of National Inpatient Sample (NIS) database by extracting all discharges across 2005-2014yy with associated ICD-9 diagnosis and procedure codes for appendicitis (540, 541, 542) and appendectomy, including drainage of appendiceal abscesses (DAA) (47.0, 47.01, 47.2).  National estimates were calculated.  Trends and available demographics were reviewed. Mean length of stay (LOS) and mean charges (MC) adjusted by inflation index were analyzed and stratified by age groups. Open and laparoscopic appendectomy discharges were analyzed separately for all billable data provided in each discharge abstract.

Results: Number of total appendicitis discharges (NTAD) has decreased throughout the examined years from 318,022 to 217,490. We observed increase in MC from $26,453 to $45,441 for each AA discharge (Table 1). Number of open appendectomies (OAP) has significantly decreased, while number of laparoscopic appendectomies (LAP) has remained the same after initial increase (Figure 1). DAA has increased from 1,515 to 2,780 with no significant change in diagnosis for AA with peritoneal abscess. Despite significant decrease in OAP, the cost of treatment has doubled across all ages and LOS has increased (Table 2).  Cost of LAP increased as well.

Conclusion: Hospitalizations with diagnosis of AA have decreased throughout 2005-2014yy while mean charges have increased per discharge.  Number of OAP has decreased by 80% and cost has doubled from $25,000 to $53,000. Number of LAP procedures remained the same across all age groups with increase in cost. DAA has increased. Overall mean cost of treatment of AA has increased from $26,453 to $45,441US. Above data is reflecting the shift of AA diagnosis and treatment away from inpatient status. The patients that end up hospitalized tend to have more severe disease requiring complex care, which translates into increased cost and LOS.

91.10 Economic Evaluations of Minimally Invasive HPB Resections: Nothing to CHEER About

Posted on January 31, 2019

I. Lareef1, S. Wong1,2  2Dartmouth Hitchcock,Department Of Surgery,Lebanon, NH, USA 1Geisel School of Medicine at Dartmouth,Hanover, NH, USA

Introduction:

Minimally invasive hepatopancreaticobiliary (HPB) surgery has heralded economic advantages such as reduced length of stay and this must be balanced with increased device and intraoperative costs. Therefore, the literature assessing cost effectiveness has proliferated. Reporting quality in health economics literature is variable due to the broad nature of such evaluations. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guideline was created to improve the quality of reporting in health economics literature, and we used it to assess the HPB literature.

Methods:

A systematic review of PubMed, Web Of Science, Science Direct, and EconLit was conducted to identify articles that evaluated economic outcomes for robotic or laparoscopic oncologic HPB procedures. 2458 abstracts were reviewed and subject to the following exclusion criteria: non-peer reviewed, non-original source data (though reference lists of systematic reviews were checked), non-English language articles, no cost data reported, and non-cancer resections. A full text review of the remaining 98 articles excluded laparoscopic cholecystectomy and operations performed with non-curative intent.

Results:

A total of 44 articles were assessed for adherence to a total of 27 CHEERS checklist criteria, which are divided into the following sections: “Title and Abstract”, “Introduction”, “Methods”, “Results”, “Discussion”, and “Other”(2, 1, 16, 5, 1, and 2 items, respectively).

20/44 (45.5%) articles reported that minimally invasive surgery was more cost effective compared to the open approach, 9/44 (20.5%) reported lower cost effectiveness (higher costs), 14/44 (31.8%) reported no difference, and 1/44 (2.3%) article did not report any comparative data. The average number of total criteria met was 14.5 out of 27. Adherence to the criteria was highly variable (range 7-22). The least adhered to criteria were the inclusion of effectiveness measurement methodology and the elicitation of outcome preferences from patients. The most adhered to criteria were the inclusion of an abstract, background, objectives, and discussion. None of the articles met all of the CHEERS criteria; in fact, 21/44 (47%) did not even meet 50% of the checklist criteria. Furthermore, the average number of Methods criteria, indicative of a robust cost effectiveness evaluation, that were met was less than half of the total (7.2/16 criteria).

Conclusion:

The reporting quality around the cost effectiveness of minimally invasive HPB surgery can be improved. We found that most of these articles that claim to be cost effectiveness evaluations are, in reality, cost reporting studies. Greater adherence to CHEERS, specifically its Methods section, would improve reporting quality, as would accuracy around the classification of reporting type. Alternatively, the CHEERS criteria may be too rigid and not reflective of the quality of economic studies.

91.09 Electrolyte Analysis and Replacement: Challenging a Paradigm in Surgical Patients

Posted on January 31, 2019

K. Dammann1, M. Timmons1, C. Pierce2, E. Higdon2, M. Edelman1, A. Bernard1  1University Of Kentucky,Acute Care Surgery And Trauma, Department Of Surgery,Lexington, KY, USA 2University Of Kentucky,Pharmacy Services,Lexington, KY, USA

Introduction: Postoperative patients have increased susceptibility to alterations in electrolyte homeostasis. Although electrolytes are replaced in the critically ill, cultural norms in clinical practice today prompts the treatment of abnormal electrolytes in stable asymptomatic ward patients. Here we hypothesized that although there is no proven benefit in asymptomatic patients, electrolyte analysis and replacement is associated with significant cost. 

Methods: The study was IRB-approved. Using the electronic medical records and pharmacy database at a University academic medical center for 2016, the frequency and cost of electrolyte analysis (BMP, ion-Ca, Mg, Phos) and replacement (KCl, Mg, oral/IV Ca, oral/IV Phos) was characterized in perioperative trauma and general surgery (GS) patients. Patients without an oral diet order, with creatinine >1.4, age <16 y, admitted to ICU or with length of stay >1wk were excluded. Nursing costs were calculated as a fraction of hourly wages per each lab order or electrolyte replacement.

Results: Over the 11-month study period, forty-five of 62 patients analyzed met our criteria. Fifty-two percent were male and 48% female with an average length of stay of 4 ± 1.8 days; mean age 54 ± 14 years; and creatinine 0.67 ± 0.26. Thirty-one GS and 14 trauma patients had 421 electrolyte analysis lab orders at a cost of $2850; BMP was most frequent of these with median of (2: 1-6) per stay, accounting for 33% of lab costs. GS and trauma subjects combined received 253 doses of electrolytes at a total pharmacy cost of $928; with KCl (47), Phos (20), Ca (18), and Mg (14) percent of pharmacy costs. Mg was most frequently replaced (84% GS vs 71% trauma); followed by KCl (71% of GS vs 29% trauma); then Phos (29% GS vs 17% trauma). Electrolyte replacement was 38% more frequent in GS vs trauma subjects. Nursing costs associated with electrolyte analysis/replacement amounted to $3040.

Conclusion: There is little evidence to support electrolyte analysis and replacement in stable asymptomatic ward patients, but its prevalence and cost ($6818) in this study was substantial in a small proportion of patients. BMP’s, pharmacy charges for potassium, and nursing staff costs accounted for the most significant portion of total cost. Electrolyte replacement by house staff occurred more frequently in GS patients when compared to trauma patients managed by surgical attending providers. Considering these data, further research should determine whether these practices are truly warranted.

91.08 Wide Provider Variation in Cost for Thyroidectomy: Potential Benefits of Standardizing Practice?

Posted on January 31, 2019

B. R. Herring1, S. Jang1, Z. Aburjania1, H. Chen1  1University Of Alabama at Birmingham,Department Of Surgery, School Of Medicine,Birmingham, Alabama, USA

Introduction: Identifying provider variation in surgical costs could control rising healthcare expenditure and deliver cost-effective care. While these efforts have mostly focused on complex and expensive operations, provider-level variation in costs of thyroidectomy has not been well examined.

Methods:  We retrospectively evaluated 989 consecutive total thyroidectomies performed by 14 surgeons at our institution between September 2011 and July 2016. Data were extracted from the McKesson Business Insight program. Total length of stay and cost were evaluated using the Mann-Whitney U and the Kruskal-Wallis tests. Categorical variables were evaluated with chi-square.

Results: Median patient age was 48 years (range 8-90), 81% were females, 64% were Caucasians, and 77% were outpatients. The number of thyroidectomies performed by the 14 surgeons ranged from 4 to 635 (mean = 71). The median costs per provider varied widely from $4,390.94 to $16,754.15 (P < 0.001). The mean length of stay was 1.2d ± 8.2 with wide variation among providers (0d to 5.5d). Providers whose hospital cost exceeded the institutional mean demonstrated a significantly higher ICU admission rate, anesthesia fees, and lab costs (P < 0.001).

Conclusion: We found substantial variation in hospital cost among providers for thyroidectomy despite practicing in the same academic institution, with some surgeons spending 4x more for the same operation. Implementing institutional standards of practice could reduce variation and the costs of surgical care.
 

91.07 Validation and Extension of the Ventral Hernia Repair Cost Prediction Model

Posted on January 31, 2019

M. J. Nisiewicz1, M. Plymale2,3, D. Davenport2, S. Saleh1, T. Buckley1, Z. Hassan1, J. S. Roth2,3  1University of Kentucky,College Of Medicine,Lexington, KY, USA 2University of Kentucky,Department Of Surgery,Lexington, KY, USA 3University Of Kentucky,Division Of General Surgery,Lexington, KY, USA

Introduction:
Repair of ventral and incisional hernias (VHR) remains a costly challenge for healthcare systems. In a prior study of a single surgeon’s elective inpatient open VHR practice, a cost model was developed which predicted over 70% of hospital cost variation, and included CDC wound class, hernia defect size, age, ASA class, number of mesh pieces, and use of biologic mesh. The purpose of the current study was to evaluate the ventral hernia cost model with multiple surgeons’ elective inpatient open VHR cases and to extend to include non-elective/urgent/emergent, outpatient and laparoscopic VHR.

Methods:
With IRB approval, elective and emergent cases of open and laparoscopic VHR (CPT codes 49560, 49561, 49565, 49566, 49654, 49655, 49656, 49657) performed at a single facility by multiple surgeons from October 1, 2014 to December 31, 2017 were identified. Cases in which VHR was done as a secondary procedure were excluded. Demographics, comorbidity status, ASA class, CDC wound class, length of stay, and 30 day outcomes were obtained from the local NSQIP database. Medical record review determined hernia defect size. Hospital cost data was obtained from the hospital cost accounting system. Forward multivariable regression of log transformed costs identified independent drivers of cost (p for entry < .05, for exit > .10).

Results:
Of the 387 VHRs, 74% were open repairs, 35.4% included separation of components, and 14.7% were non-elective. Mean age was 55 years, and 52% of patients were female. The base cost for an outpatient primary small VHR without mesh implantation was $4114. Including only the open, elective VHR cases, the previously reported six-factor cost model predicted 50% of the total cost variation. With all VHRs included, ten variables were found to independently drive costs, predicting 60% of the total cost variation from the base cost. Biggest cost drivers (≥ 15% increase) were preoperative open wound (+$1207), preoperative SIRS/sepsis (+$740), hernia defect size (+$616), inpatient status (+$875), use of absorbable mesh vs. synthetic or no mesh (+$752), use of biologic mesh (+$1000), and utilization of multiple mesh pieces (+$795). Other cost drivers included age, obesity, morbid obesity, and recurrent hernia.

Conclusion:
Elective hernia repair cost variability may be predicted utilizing a six-factor model. In the broader context of all VHR repair at our institution, recurrent hernia, inpatient and non-elective surgery are greater cost drivers than wound class. Obesity, the presence of an open wound and systemic inflammation, relatively rare in the elective group due to optimization but more common in urgent/emergent cases, replaced ASA class as cost drivers.  Age, defect size, mesh type and number of meshes utilized were common to both models. A hernia cost model utilizing readily identifiable preoperative factors can be utilized to predict resource utilization.
 

91.06 Financial Burden of Respiratory Complications Following Intermediate and High-Risk Surgeries

Posted on January 31, 2019

S. M. Stokes1, B. S. Brooke2, R. E. Glasgow1, S. R. Finlayson1, T. K. Varghese3  1University Of Utah,Department Of Surgery, Division of General Surgery,Salt Lake City, UT, USA 2University Of Utah,Department Of Surgery, Division Of Vascular Surgery,Salt Lake City, UT, USA 3University Of Utah,Department Of Surgery, Division Of Cardiothoracic Surgery,Salt Lake City, UT, USA

Introduction:  Respiratory complications following high and intermediate-risk surgeries are known to have a substantial impact on a patient’s clinical post-operative course, although the resulting financial impact on the health care system is not well characterized. The objective of this study was to assess hospital costs when patient’s experience respiratory complications.

Methods:  A single institution’s database was queried to identify all patients undergoing elective intermediate (colectomy, lung resection, infra-inguinal bypass, carotid endarterectomy, and ventral hernia repair) and high-risk (esophagectomy, pancreatectomy, valve replacement, coronary bypass, and open abdominal aorta) surgeries. Urgent and emergent operations were excluded. Patient demographic, inpatient, and direct cost data were collected. The primary outcome measure was the proportional increase in total cost due to a pneumonia complication, expressed as the relative increase of the total hospital cost between pneumonia and non-pneumonia cases. Secondary outcomes were cost divisions between facility, lab, imaging, and supply costs, as well as surgical outcomes. Mixed-effects, multivariate, regression models were constructed, with patients clustered by procedure, to identify independent risk factors associated with increased hospital costs of treating pulmonary complications.

Results: We identified a total of 2,834 patients who underwent at least one of the ten selected elective surgeries. The rates of pneumonia were greater for high-risk procedures (9.3% vs. 3.8%, p < 0.001) as compared to intermediate procedures. After adjustment in regression models, the occurrence of pneumonia was found to result in an overall 1.5-fold increase in hospital costs. This cost difference was greater for intermediate-risk (1.8-fold) vs. high-risk (1.3-fold) surgeries. For high-risk procedures, pneumonia, length of stay, ASA class, and surgery length all predisposed to higher hospital costs (p<0.05 for all associations). For intermediate-risk procedures, pneumonia, failure to wean from mechanical ventilation, length of stay, Charlson-Deyo comorbidity index, and surgery length predisposed to higher hospital costs (p<0.001 for all associations). In patients who experienced a pneumonia complication, the largest contribution to costs was facility cost (33%), followed by pharmacy (19%), other services (15%), and laboratory costs (12%).

Conclusion: Our data shows that respiratory complications have a profound impact on hospital costs, especially for intermediate-risk procedures. Focusing efforts on preventing respiratory complications can have a significant impact on both patient outcomes and the financial burden to the healthcare system.  

 

91.05 The Laparoscopic Approach to Pancreaticoduodenectomy is Cost Neutral in Very HighVolume Centers

Posted on January 31, 2019

E. Eguia1, P. C. Kuo2, P. J. Sweigert1, M. H. Nelson1, G. V. Aranha1, G. Abood1, C. V. Godellas1, M. S. Baker1  1Loyola University Chicago Stritch School Of Medicine,General Surgery,Maywood, IL, USA 2University Of South Florida College Of Medicine,General Surgery,Tampa, FL, USA

Introduction:
Little is known regarding the impact of minimally invasive approaches to pancreaticoduodenectomy (PD) on the aggregate costs of care for patients undergoing PD.  

Methods:
We queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing laparoscopic (LPD) or open (OPD) pancreaticoduodenectomy in FL, MD, NY and WA between 2014 and 2016. Multivariable regression (MVR) was used to evaluate the association between surgical approach and rates of postoperative complication, overall lengths of stay (LOS) and aggregate costs of care including readmissions to 90 days following PD. Candidate variables were determined a priori using best variable subsets and included: age, gender, insurance, race/ethnicity, Charlson comorbidity index (CCI), pathology (benign vs. malignant), hospital PD volume broken to terciles  (low: <17 PD/year; moderate to high: 17<PD/year <127; very high volume: >127 PD/year) and overall LOS. 

Results:

513 (10.8%) patients underwent LPD; 4,746 (89.2%) underwent OPD. On univariate analysis, patients undergoing LPD had higher CCI (5 vs. 3, p<0.001) and higher rates of readmission (35% vs. 30%, p=0.04), malignant pathology (89% vs. 76%; p<0.001), and aggregate costs of care ($41,669 vs. $37,580, p<0.02) than those undergoing OPD.

On MVR adjusted for age, CCI, pathologic diagnosis, and hospital volume, LPD was associated with a lower risk of prolonged LOS (OR 0.77; 95% CI [0.61,0.97]) but greater risk of readmission (OR 1.24; 95% CI [1.02, 1.51). Rates of perioperative morbidity and overall LOS for patients undergoing LPD were identical to those for patients undergoing OPD.

On MVR adjusted for age, pathology, CCI, LOS, and volume, factors associated with being in the highest quartile for aggregate costs of care included: male gender (OR 1.19; 95% CI [1.04, 1.37]), CCI (OR 1.07; 95% CI [1.03, 1.11]), black race (OR1.41; 95% CI [1.12, 1.78]), Hispanic ethnicity (OR 1.90; 95% CI [1.50, 2.42]), Medicare insurance (OR 1.28 95% CI [1.05, 1.55]), readmission (OR 4:44; 95% CI [3.87, 5.09]) and low hospital volume (OR 2.46; 95% CI [1.97, 3.06]). Patients undergoing LPD in low (+$9,390; 95% CI [$2,948, $15,831]) and moderate to high (+$5,579; 95% CI [$1,783, $9,376]) volume centers had higher costs than those undergoing OPD in the same centers. In very high-volume centers, aggregate costs of care for patients undergoing LPD were identical to those undergoing OPD in the same centers (+$616; 95% CI [-$1,703, $2,936])). 

Conclusion:
Rates of morbidity and overall LOS for patients undergoing LPD are statistically identical to those undergoing OPD. At low to moderate volume centers, the laparoscopic approach to PD is associated with higher aggregate costs of care relative to OPD whereas at very high-volume centers LPD is cost neutral. This finding suggests that high volume centers are able develop efficiencies of scale that act to mitigate costs inherent to adoption of the laparoscopic approach to PD. 

91.04 Cost-Effectiveness of Sentinel Lymph Node Biopsy for Head and Neck Cutaneous Squamous Cell Carcinoma

Posted on January 31, 2019

P. Quinn1, J. Oliver1, O. Mahmoud1, R. Chokshi1  1Rutgers New Jersey Medical School,Newark, NJ, USA

Introduction:
While sentinel lymph node biopsy (SLNB) has been established as a useful tool in the staging of melanoma, its utility in cutaneous squamous cell carcinoma (CSCC) has yet to be elucidated. Analysis has shown that SLNB may have an emerging role in patients with high-risk lesions. The purpose of this study was to determine the cost-effectiveness of performing SLNB in all head and neck CSCC patients as well as by TNM staging.

Methods:
A decision model was developed to analyze costs and survival in head and neck CSCC patients based on their tumor and nodal metastasis staging and whether or not they received a SLNB. The decision model placed patients into two groups, those undergoing SLNB and those undergoing only wide local excision. Those that were found to have any positive lymph node underwent a neck dissection, then those with N2 disease were treated with radiation therapy and those with N3 disease were treated with chemotherapy and radiation based on treatment guidelines according to the National Comprehensive Cancer Network. Values for disease stage, morbidity, mortality as well as SLNB sensitivity and specificity were derived from the published literature. Costs were derived using Medicare outpatient costs (FY 2018). Survival values were calculated with the declining exponential approximation of life expectancy (DEALE) method using available data on disease-specific death rate. The average age of patients with CSCC was found to be 70, with a life expectancy of 14.3 years according to Social Security life tables. Incremental cost-effectiveness ratios (ICER) were calculated based on the change in quality adjusted life years (QALYs) and costs (US$) between the different options, with a threshold of $100,000 to determine the most cost-effective strategy. One-way and two-way sensitivity analysis was performed to validate the results.

Results:
Sensitivity and specificity of SLNB was found to be 77% and 100%. The disease incidence was 77%, 5%, and 18% for T1, T2, and T3 specifically, and the rate of node positivity was 0.4%, 12.2%, and 14.1% for each T stage. Not performing a SLNB results in 12.26 QALYs and a cost of $3,712.98. Performing a SLNB resulted in a 0.59 decrease in QALYs and an increase in cost of $1,379.58 for an ICER of -2,338.27. This trend remained the same across all tumor stages. Sensitivity analysis of tumor stage distribution, nodal stage distribution, nodal positivity rates, and SLNB sensitivity did not alter the outcome.

Conclusion:
In patients with head and neck cutaneous squamous cell carcinoma, the most cost-effective strategy is to not perform sentinel lymph node biopsies, regardless of the patient’s stage. Low rates of nodal metastasis in addition to low disease-specific death rates were the significant factors in this outcome. Increasing the sensitivity of SLNB would not impact this recommendation unless the rate of nodal metastasis were significantly higher.
 

91.03 Resource Overutilization in the Diagnosis of Lymphedema Praecox

Posted on January 31, 2019

A. A. Shah1,3, J. Roberson2, M. Petrosyan2,3, P. Guzzetta2,3  1Howard University College Of Medicine,Surgery,Washington, DC, USA 2George Washington University School Of Medicine And Health Sciences,Surgery,Washington, DC, USA 3Children’s National Medical Center,Surgery,Washington, DC, USA

Introduction: Primary lymphedema presenting in adolescence is known as lymphedema praecox.  It is a rare disorder leading to failure of the lymphatic system to drain properly, almost exclusively in the lower extremities. The ensuing limb swelling can be debilitating and associated with adverse physical and psychosocial consequences. Patients are often subjected to a myriad of diagnostic tests which often have little influence on management. The purpose of this study is to review a large cohort of patients with a rare disorder presenting to a high-volume tertiary care children’s hospital, as well as to determine the fiscal impact of testing on these patients.

Methods: A 13-year retrospective institutional review was performed of patients between the ages of 7 and 21 with a diagnosis of lymphedema praecox. Information was obtained on demographic parameters, diagnostic studies performed, pre-morbid conditions, and clinical outcomes. Descriptive analyses were performed. This study was approved by the hospital’s IRB.

Results: Data were extracted from 49 patient records. The median age was 14 (range: 7-21) years. Participants were predominantly female (n=40, 81.6%).  Thirty-one patients (64%) were African-Americans, although more than 50% of our outpatients are African-American. 19 patients had bilateral disease. In patients with unilateral disease, 16 were on the right and 14 were on the left. The diagnosis was made on clinical exam only in 14 patients. 19 patients had Doppler ultrasound (US) exams of which in 12 it was the only exam, 3 had US and MRI, 3 had US, MRI and lymphoscintigraphy, and 1 had US and lymphoscintigraphy.  11 patients had only MRI and physical exam for diagnosis.  The charges for lower extremity Doppler ultrasound, lymphoscintigraphy, and MRI with contrast were $1,715, $1,269, and $6006 respectively.

Conclusion: We believe that in the adolescent female with physical findings consistent with lymphedema praecox, diagnostic imaging should be limited to a Doppler ultrasound to rule out deep venous thrombus or a mass as the cause of the swelling. Additional imaging does not aide in the diagnosis, but does add to the expense to and inconvenience of the patient and should be avoided.

91.02 Less is More: Routine Postoperative Lab Testing in Elective General Surgery Patients

Posted on January 31, 2019

E. D. Porter1, J. L. Kelly1, A. R. Wilcox1, S. W. Trooboff1, J. D. Phillips1, C. V. Angeles1  1Dartmouth Hitchcock Medical Center,Surgery,Lebanon, NH, USA

Introduction: Overutilization of laboratory testing in hospitalized patients continues to challenge cost-effective care. Prior efforts to reduce unnecessary lab testing in the surgical population have been limited to preoperative testing and critical care patients. We sought to investigate our institution’s post-operative lab (POL) ordering practice on adult elective general surgery patients and its impact on clinical decision-making and outcomes.

Methods: Retrospective cohort study at a single academic center. All adult elective general surgery patients with a <48 hour admission from April-June 2018 were selected. Patients with a condition requiring lab testing (e.g. on coumadin) were excluded. We reviewed patient charts for demographics, comorbidities, POL orders, documentation of POL abnormalities, and 30-day complications. We compared patients receiving or not receiving POLs using student’s t-test, chi-square and one-way analysis of variance for continuous, dichotomous, and categorical covariates, respectively. Significance was set at p<0.05.

Results: In our study period, 171 patients were admitted for <48 hours after elective general surgery. Surgical procedures were classified as intestinal (n=116), solid abdominal organ (n=9), hernia (n=9), thoracic (n=22), breast (n=11), and other (n=4). Routine POLs were ordered on 89% of patients (153/171), with significant differences in frequency of ordering labs by surgery type (Figure 1). On univariate analysis, patients who did not have POLs had significantly lower BMI (p<0.004); there was no difference in age, demographics, comorbidities, blood loss, or ASA status. Of those who had POLs, 88% had an abnormality (134/153), and the abnormality was commented on in 20% of progress notes (27/134). A POL only changed care in 12% of patients (19/153). Change in care included electrolyte correction (15/19), medication held (2/19), additional test (1/19), and fluid resuscitation (1/19). White blood cell count and/or hemoglobin levels were abnormal in 84% (128/153); however, none of these abnormalities prompted a change in care. Electrolytes were abnormal in 14% of cases (21/153) and led to a change in care for 76% (16/21).  Creatinine was elevated in 3% (5/153) and led to a change in care for 80% (4/5). There was no significant difference in 30-day complication or readmission rates for those who received POLs.

Conclusion: POL testing is common among adult elective general surgery patients who have brief hospitalizations. While most labs yielded abnormal results in our cohort, these were unlikely to be commented on and even less likely to change care. Routine POL testing without clinical indication is overutilized and interventions to reduce this practice are needed.

91.01 Targeted-physician Interventions Reduce Surgical Expense and Improve Value-Driven Health Outcomes

Posted on January 31, 2019

R. Xie1, B. Lindeman1, H. Chen1, T. N. Wang1  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA

Introduction:  Increasing health care costs in the U.S. have not translated to superior outcomes in comparison to other developed countries. The implementation of physician-directed intervention to reduce cost may improve value-driven health outcomes. This study aimed to evaluate the effectiveness of cost-targeted interventions to reduce surgical expense and improve care for patients undergoing total thyroidectomies.

Methods:  Two separate face-to-face interventions with individual surgeons focusing on surgical expense around thyroidectomy were implemented in two surgical services (Endocrine Surgery and Otolaryngology) at a tertiary medical center. The pre-intervention period was from Dec 2014 to Jun 2016 (19 months, 352 operations). The post-intervention period was from July 2016 to January 2018 (19 months, 360 operations). Multivariable generalized linear regression analyses and difference-in-difference analyses were conducted to compare the pre- and post-intervention outcomes including cost outcomes (total costs, fixed costs, and variable costs per thyroidectomy) and clinical outcomes (30-day readmission rate, days to readmission, and total length of stay).

Results: Patient demographics and characteristics were similar before and after the interventions. Post-intervention operative costs were significantly reduced as compared to pre-intervention costs. The percentage savings in the average total, fixed, and variable costs per surgery were 8% (from $6,571 to $6,033, p=0.03), 7% (from $4,062 to $3,781, p=0.04), and 10% (from $2,509 to $2,251, p=0.03), respectively. Additionally, the clinical outcome parameter of total length of stay improved from 1.3 days (STD: 1.9) to 1.0 day (STD: 0.2, p<0.01). Readmission rates and days to readmission were not significantly different. The effectiveness of the interventions regarding cost reductions differed between the two surgical divisions. Compared to Otolaryngology, Endocrine Surgery saved an additional average total cost of $517.30 (STD: 877.7; p=0.08), average fixed cost of $238.40 (STD: 526.9; p=0.18), and average variable cost of $279.00 (STD: 423.2; p=0.05) per surgery since the intervention.

Conclusion: Targeted-physician interventions can be an effective tool for reducing cost and improving health outcomes. The effectiveness of interventions may vary depending on the type of specialty training. Future implementation of physician interventions needs to be standardized in order to critically evaluate its effectiveness on patient outcomes.
 

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