8.19 Gastric Cancer: Epidemiologial Features and Analyzes of Cases Treates between 2010 ans 2014

Posted on January 18, 2018

P. Abreu-Reis1, A. Bettega1, R. Goolkate1, M. Kato1, F. Tomasich1  1Hospital Erasto Gaertner – Federal University Of Parana,Department Of Surgery,Curitiba, PR, Brazil

Introduction: Present collected data from the Hospitalar Registry of Cancer of Erasto Gaertner Hospital between 2010 and 2014 referring to patients with gastric cancer admitted to the institution. Study the epidemiological features aiming to define risk
factors for the disease and the treatment outcome. 

Methods:  Data were collected from medical records. The used questionnaire was based on the National Cancer Institutes standards. The absolute and relative frequencies were generated from the SISRHC system and tabulated through the EpiInfo system, version 7.1. The survival rate was calculated using the Kaplan-Meier method.

Results: 983 cases of stomach cancer were admitted in the period from 2010 to 2014, representing the sixth most frequent topography. Mosto f the patients were male (67%). There was a higher prevalence above the fifth decade, with a bimodal 
distribution among women between 45-49 years and 55-59 years. The most frequent histological type was adenocarcinoma (60.6%), followed by carcinoma with signet ring cells (25.7%) and other less frequent histologies. More than 66.1% came from Curitiba and the metropolitan region. Regarding TNM (UICC) staging system, there was a predominance of advanced stages (65%). Family history of câncer was found in 56,1%. A positive personal history of alcoholism was found in 55,3% of men, in  contrast to 14.3% of women. A personal history of smoking was positive in 67,7% of men and only 43.4% of women . Concerning the treatment, 28.6% of the patients underwent surgery and 28.9% isolated chemotherapy. The treatment was combined in 39.9% of the cases. At the end of the first phase of treatment, 82.7% of the patients were still alive. Overall
5-year survival rate was 38.1%, ranging from 11.9% in clinical staging IV to 73.3% in clinical staging I.

Conclusion:Despite advances in the diagnosis and treatment of cancer, gastric cancer persists with a low overall 5-year survival rate, even in early clinical stages.

 

8.20 Surgical Site Infection Rates Increase in Transfer Patients for Orthopedic Injuries in a Rural State

Posted on January 18, 2018

N. R. Bruce1, W. C. Beck1, J. R. Taylor1, M. K. Kimbrough1, J. Jensen1, M. J. Sutherland1, R. D. Robertson1, K. W. Sexton1  1University Of Arkansas For Medical Sciences,Department Of Surgery,Little Rock, AR, USA

Introduction:  

Our state contains only one level 1 trauma center and is a rural sate.  This study sought to categorize the rate of surgical site infection (SSI) in trauma surgery patients with orthopedic injuries and identify correlating factors to detect possible areas for performance improvement within our trauma system. 

Methods:  

IRB approval was obtained and de-identified patient information was provided by the local trauma registry for all patients admitted at a single institution with fractures from April 2014 until April 2015.  Initial sample included 520 patients, 1 patient was excluded due to thermal injury and 9 due to mortality.  Fractures were categorized based on anatomic region and based on treatment by an orthopedist with fellowship training in trauma.  Factors examined included patient demographics, number of trips to operating room, and presentation from scene status. Statistical analyses were performed using JMP Pro 13.1.0 (Cary, NC) with significance set at p<.05.

Results: 

Final sample size consisted of 510 patients; 31% were women, 55% arrived from the scene, 70% arrived via ground, 74% were Caucasian, and 20% were African American.  Lower leg shaft fractures (40%), followed by femoral shaft fractures (22%) and forearm fractures (14%) were the most common injuries.  Of these patients 62% were managed initially by orthopedic surgeons with fellowship training in trauma.  Bivariate analysis revealed that there was no difference in bones fractured between those with SSI and those without.  SSI patients were older (47.8  ± 2.8 years compared to 42.6  ± 0.8 years), had less trips to the operating room (2.1  ± 1.4 vs 3.2  ± 2.8), and were more likely to be transferred from an outside hospital (75%).  There was no difference with infection rates comparing orthopedists with and without fellowship training in trauma orthopedics. 

Conclusions: 

Surgical site infections after orthopedic trauma are a significant burden.  Our data suggests that further research and targets for improvement should be across a trauma system to provide more expedient access to definitive care, as there is a higher risk for SSI in patients transferred from another hospital. 

8.16 Children After Motor Vehicle Crashes: Failure of Child Restraint Increases Hospital Cost

Posted on January 18, 2018

A. D. Melucci1, B. Lang1, V. Dombrovskiy1, J. Pierre1, Y. Lee1  1Rutgers Robert Wood Johnson,New Brunswick, NJ, USA

Introduction:  Restraint quality may have a significant impact on injury severity in children after motor vehicle crashes (MVCs). The aim of this study is to analyze if restraint quality and injury severity affect total hospital cost.

Methods:  A retrospective chart and financial record review of 421 children hospitalized in a Pediatric Trauma Center in 2010-2015 after MVC and discharged alive was performed. Because of abnormal distribution, we presented total hospital cost in dollars as a median with interquartile range and compared it between various groups with Wilcoxon rank-sum test. All costs were adjusted by inflation to the cost in the year 2015.

Results: To evaluate the predictors of greater cost, we performed subgroup analysis by age groups (0-7, 8-12, 13-16, 17-18 years), gender, restraint status (improper and unrestrained [IUR] and properly restrained [PR]), and injury severity score (ISS) classes (mild [1-9], moderate [10-15], severe [16-25], and profound [>25]).  There were no significant differences in total hospital cost between various age groups. Females (n=228) predominated over males (n=193) in the study population and tended to have a higher cost compared to their male counterparts [5230 (3236-11189) and 4829 (3140-8193); P=0.08]. Total hospital cost was significantly higher in IUR compared to PR counterparts [5400 (3413-10954) and 4738 (3128-9105), respectively; P=0.03]. IUR compared to PR had a smaller proportion of children in the mild ISS class (70.3% vs 81.4%; P=0.01), but significantly greater proportions of IUR to PR in the moderate (15.9% vs 10.9%), severe (8.0% vs 6.2%) and profound (5.8% vs 1.5%) classes. The great differences in cost were found between various ISS classes: the higher the ISS, the greater associated total cost. Total cost was minimal in the mild class (3723 [3048-6178], but gradually and significantly increased in the moderate (12456 [7028-21173]; P<0.0001) and severe (18579 [12776-32572]; P=0.01) classes and became maximal in the profound class (43414 [30424-58203]; P=0.004). Overall in the study population, total hospital cost positively correlated with the ISS score (r=0.63; P<0.0001).

Conclusion: Inappropriate restraint significantly increases total hospital cost in children after MVCs proportionally to the injury severity. 
 

8.17 Isolated Rib Fractures in the Elderly; a Disproportionate Burden on the Trauma Service?

Posted on January 18, 2018

A. X. Samayoa1, Y. Shan1, W. Alswealmeen1, O. Kirton1, T. Vu1  1Abington Jefferson Health,Surgery,Abington, PA, USA

Introduction:  The financial burden of isolated rib fractures is often underestimated. This study compared costs incurred by isolated rib fracture patients of different ages to see if the financial burden is greater amongst those older than 65 years of age.

Methods: We conducted a single institution retrospective review of prospective collected data from 2012-2015 in patients that were admitted with isolated rib fractures. Patients were divided into two age groups: A[<65yo] & B[≥ 65yo]. Cost for hospitalization (CH) and cost per day (CD) were reported in 2016 US$ using the Consumer Price Index.

 

Results: 52 patients met inclusion criteria with 23 in Group A and 29 in Group B. The mean age in years for Group A was 50.04 ± 10.7 and for Group B was 80.14 ± 8.3.The mean CH was 11.2±14.4K$ and CD was 3.7±4.5K$. No difference was found in CH between the two groups [Group A: 10.0±9.7K$ vs Group B 12.2±1.7K$] (p=0.60). There was a significant increase in CD in the younger group  [Group A: 5.4±6.1K$ vs Group B 2.5±2.1K$] (p=0.02). There was a significant increase in LOS, disposition to skilled nurse facility and falls in the elderly (p<0.04). No difference was noted in the incidence of pneumothorax, hemothorax, number of ribs fractured, and hospital mortality (p>0.73), Table 1.

Conclusion: Isolated rib fractures are associated with significant hospitalization costs in patients both above and below 65 years of age.  Although hospitalization costs were similar, more patients in the older population were discharged to skilled nursing facilities, suggesting increased long term expenditure. CD was higher in the younger population with decreased length of stay.

 

 

8.18 Value of Wound Care to Prevent Surgical Site Infections in Contaminated Traumatic Abdominal Wounds

Posted on January 18, 2018

A. Acker1, J. Leonard1, M. J. Seamon1, D. N. Holena1, J. Pascual1, B. Smith1, P. M. Reilly1, N. D. Martin1  1University Of Pennsylvania,Surgery,Philadelphia, PA, USA

Introduction:

The incidence of surgical site infection (SSI) has become a key quality indicator following clean and clean/contaminated surgical procedures.   In contrast, contaminated and dirty wounds have garnered little attention with this quality metric because of the expected higher complication incidence.  We hypothesized that wound management strategies in this high risk population vary significantly and might not add value to the overall care.

 

 

Methods:

This is a retrospective, observational study of trauma patients who underwent an exploratory laparotomy at an urban, academic, level 1 trauma center from 2014-2016.    Deaths prior to hospital discharge were excluded.   Wounds were classified using the CDC definition on review of the operative reports.  SSI was determined by review of the medical record, also per CDC definition.   Wound management strategies were categorized as either primary skin closure or closure by secondary intention.  Outcomes were compared using Chi square or Kruskal-Wallis test.

 

Results:

 There were 128 patients that met study criteria.   Fifty-five (42.9%) wounds were left open to close by secondary intention.  In the wounds that were closed primarily (n=73), 8 (10.9%) developed a SSI; whereas 12 of 55 (21.8%) open wounds still developed an SSI.   There were significant differences in the average LOS (24.7 vs 11.6 days, p=0.05), number of office visits (2.8 vs 1.8, p=0.04), and time from surgery to the last office visit (107 vs. 57, p= 0.03) between patients who were treated with secondary intention closure compared to those closed primarily who did not suffer SSI.

 

Conclusions:

 There is significant incidence of SSI in contaminated and dirty traumatic abdominal wounds however, wound management strategies vary widely within this cohort.   Closure by secondary intention, regardless of the presence of infection, requires significantly more resource utilization.  Further research is needed to define the actual value of each wound management strategy weighed against the risk of SSI.

8.14 Admission of pediatric concussion injury patients: is it necessary?

Posted on January 18, 2018

E. Lindholm1, R. D’Cruz3, R. Fajardo2, T. Meckmongkol1, S. Ciullo1, H. Grewal1, R. Prasad1, L. G. Arthur1  1St. Christopher’s Hospital For Children,Division Of Pedatric General, Thoracic & Minimally Invasive Surgery,Philadelphia, PA, USA 2Temple University,Department Of General Surgery,Philadelphia, PA, USA 3Albert Einstein College Of Medicine,Department Of General Surgery,Philadelphia, PA, USA

Introduction:  There is no consensus on the management of patients with concussion and negative computed tomography (CT).  Current protocol at our institution involves admitting any patient with symptoms worrisome for failure of outpatient management.  We hypothesize that pediatric patients presenting to the emergency room with signs of concussion and a negative CT scan do not require routine hospital admission.

Methods:  A retrospective chart review was conducted for pediatric trauma patients admitted to the hospital for concussion from 2010-2017.  Only patients with negative head CT were included.  All patients with additional injuries that would otherwise require hospital admission were excluded.  Demographics, emergency room evaluation and hospital courses were reviewed.   

Results:  A total of 90 patients were identified (average age 10 years, (3 months-19 years); 72.2% male).  Mechanism of injury included fall (34), sports injury (14), auto-pedestrian (14), MVC (13), assault (9), and auto-bike (3). The average GCS was 14.6 (range 9-15).  LOC was reported by 35.5% (32) of patients.  Reported symptoms included nausea/emesis in 35.5% and altered mental status in 40%.  Additional imaging included cervical spine CT (36.6%), cervical spine radiograph (28.8%) and abdominal CT (11%).  Additional injuries included fractures in 6 patients.  Only 5 patients (5.5%) required hospitalization for longer than 24 hours, with an average stay of 3 days (range 2-4).  Longer stay was required for DHS clearance (1), fever (1) and ability to tolerate diet (3).  47% of all patients were referred to a concussion specialist for follow-up after discharge, of these only 17% (8) came to their clinic appointment. 

Conclusion:  There are a large number of pediatric patients evaluated in the emergency room for concussion injuries.  Very few of these patients require hospital admission regardless of symptoms such as loss of consciousness, nausea/emesis, or altered mental status.  These hospitalizations are frequent in a Level 1, urban trauma center and thus, it would be cost effective to limit admission.   
 

8.15 Immediate & Delayed Complication Rates in Unilateral vs Bilateral Mastectomy: a retrospective review

Posted on January 18, 2018

S. R. DeBiase1, W. Sun2, C. Laronga2, D. Boulware3, J. K. Lee3, M. Lee2  1University Of South Florida College Of Medicine,Tampa, FL, USA 2Moffitt Cancer Center And Research Institute,Moffitt Breast Program,Tampa, FL, USA 3Moffitt Cancer Center And Research Institute,Moffitt Biostatistics,Tampa, FL, USA

Introduction:  Despite recommendations against routine use, contralateral prophylactic mastectomy (CPM) at the time of unilateral breast cancer (BC) surgery is increasing. CPM has been associated with increased immediate complication rates comparative to unilateral mastectomy (UM) with or without reconstruction. We reviewed BC patients receiving mastectomy and immediate reconstruction; our aim was to evaluate complication rates in patients receiving CPM versus UM.

Methods:  An IRB approved, retrospective, case-controlled, single-institution chart review of BC patients receiving mastectomy and immediate reconstruction from Jan 1990 – May 2013 was performed. Cases were matched 1:1 by reconstruction type and age (+/-5 years) to limit procedure and age-related confounding variables. Patients with delayed mastectomy, delayed reconstruction, or bilateral cancer diagnosis at surgery were excluded. Staging, pathology, genetic, diagnostic imaging, and outcome data were collected. Complications were designated as major or minor (table), and immediate or delayed; complications <90 days postop were immediate, and >90 days postop were delayed. Therapeutic mastectomy date was used as the reference time point. Univariate statistical analyses using SAS (v. 9.4) employed Fisher’s exact test, Wilcoxon Rank Sum, and Kruskal Wallis tests.

Results: Forty-five UM cases were matched to bilateral mastectomy (BM). Mean age (n = 90) was 52.2 years (range 21.5-74.9) with mean follow up time of 7.1 years (range 0.2-19.8).There was no significant difference between UM and BM with regards to BMI, pathologic stage, follow up time, distant recurrence, or survival. For BM patients, 24/45 (53.3%) suffered 29 minor complications while 17/45 (37.7%) of UM patients suffered 24 (P=0.20). Among major complications, 11/45 (24.4%) in the BM group had 18, while 14/45 (33.3%) in the UM group had 15 (P=0.64). There was no difference between groups for delayed complications. There was a marginally significant difference in major complications for the prophylactic breast versus not: 5 BM patients (11.1%) had major complications in the prophylactic breast (P=0.056); 38.9% of major and 24.1% of minor complications were in the prophylactic breast. Of 7 major complications on the prophylactic side, 2 were delayed. 

Conclusion: Our results show no significant overall differences between the two groups for complications, which may be related to low sample size and matched reconstructive approaches. However, 5 BM patients in our study had at least one major complication in their prophylactic breast, supporting the risk of adverse outcomes inherent in prophylactic surgery; patients should be adequately counseled regarding these risks in treatment planning.

 

8.12 Use of a Standardized Checklist is a Cost Saving Measure at a New Trauma Center

Posted on January 18, 2018

A. V. Jambhekar1, T. Liu1, R. Lee1, B. Fahoum1, M. Zenilman1, J. Rucinski1  1New York Presbyterian Brooklyn Methodist Hospital,Surgery,Brooklyn, NY, USA

Introduction:  Unnecessary admissions to higher levels of care are an inappropriate use of limited hospital resources and in newly developed trauma centers, patients may be admitted to err on the side of caution. Our hypothesis was to determine if use of a trauma checklist can deter unnecessary admissions to higher levels of care and therefore serve as an important cost saving measure. 

Methods: Data was collected on 1783 trauma patients admitted between April 1, 2015 and April 1, 2017. The patients were divided into 2 groups—pre checklist (n=198) and post checklist (n=1585). Injury Severity Score (ISS), mechanism of injury, and admission disposition were compared using unpaired student t tests and Fisher’s exact test.

 

Results: The pre checklist group had higher percentages of activations and penetrating trauma. In the pre checklist group, 21.2% of patients were admitted to the Surgical Intensive Care Unit (SICU) and 47.5% were admitted to the Surgical Stepdown Unit (SSD) compared to 9.4% and 27.6% respectively post checklist (p < 0.0001). The overall ISS decreased (7.0 +/- 5.6 vs. 5.7 +/- 7.1, p = 0.01) but the ISS of patients admitted to higher levels of care trended up (Table 1). There were no upgrades from the floor to higher levels of care in either group. At an average cost of $4,400 per night for a floor bed, $5720 per SSD bed, and $9130 per SICU bed, the use of the trauma checklist saved the hospital approximately $3,510,362.9 in admission costs alone.

 

Conclusion: The trauma checklist organizes the initial evaluation of trauma patients leading to fewer unnecessary admissions to higher levels of care leading to more appropriate allocation of healthcare resources and decreased hospital costs.
 

8.13 Cost Burden and Mortality in Rural EGS Transfer Patients

Posted on January 18, 2018

D. Keeven1, C. Harris1, D. Davenport1, A. Bernard1  1University Of Kentucky,Lexington, KY, USA

Introduction: Emergency general surgery (EGS) patients that require greater resource utilization have worse outcomes compared to trauma patients.  Patients from rural areas have poor EGS and trauma outcomes due in part to regionalization of care from community hospitals to tertiary care centers. We hypothesize that patients transferred after inpatient admission at community hospitals are associated with higher healthcare utilization and worse outcomes compared to those who were not. 

Methods: Discharge data was collected retrospectively for patients admitted to the acute care surgery service during calendar 2015 for nine common EGS diagnoses (obstruction, appendicitis, pancreatitis, hernia, ischemia, volvulus, diverticular disease, perforation and peritonitis).  Patients were grouped by admission source as local patients admitted from our ED, urgent care or primary care clinics (LAs), transferred from an outside ED (EDTs), or transferred from an inpatient unit at another hospital (IPTs). Demographic data, length of stay at originating site, insurance status, and Charlson Comorbidity Index (CCI) were obtained for all patients along with financial outcomes from the finance system. 

Results:A total of 352 patients were reviewed: 125 LAs, 176 EDTs, and 51 IPTs. Compared with EDTs and LAs, IPTs were more frequently treated for pancreatitis (26% of cases vs. 10% and 10%) and less frequently for appendicitis (2% of cases vs. 22% and 26%, p = .005). More IPTs were insured by Medicare or Medicaid (92% vs. 81% and 74%, p = .001).  IPTs had a longer length of stay, higher direct costs, and a higher case mix index leading to higher revenue, but still averaged a net loss (Table). Inpatient transfers have more comorbidities (CCI 3.20 versus 2.69 and 2.13), were older (60.8 vs. 56.15 and 50.24), and had a higher mortality rate (9.8% vs. 1.7% and 0.8%).

Conclusion:Patients who present to a tertiary care emergency general surgery service as a direct admit from an inpatient ward at another hospital have more comorbidities, a higher mortality rate, require more resources and have a net financial loss compared to those who present directly from the ED.  As healthcare shifts to value-based care, development of new approaches to determine optimal timing of transfer is imperative. 

 

8.10 Variation in supply cost for appendectomy and cholecystectomy across a healthsystem.

Posted on January 18, 2018

M. E. Mallah1, M. Barringer2, M. E. Thomason1, E. Ross3, B. Matthews1, C. E. Reinke1  3Carolinas Healthcare System,Cost Analytics,Charlotte, NC, USA 1Carolinas Medical Center,Department Of Surgery,Charlotte, NC, USA 2Carolinas Medical Center-Cleveland,Shelby, NC, USA

Introduction: Supply cost variation for surgical procedures is poorly described in the literature.  Prior studies have demonstrated that implementation of a standardized preference card was able to reduce costs.  Our aim was to describe variation in supply cost across a cohort of surgeons within a large healthcare system.  

Methods: Cost of operative supplies is prospectively recorded for all cases.  Total operating room supply cost was calculated for all laparoscopic appendectomy and laparoscopic cholecystectomy cases performed between January 2016 and June 2017.  Other variable and fixed operating room costs were not included. The primary surgeon was identified for each case and the number of cases and mean cost per case was calculated per surgeon.   Surgeons who had performed less than 5 cases in either category during the 18-month period were excluded from that analysis.  

Results:Across 8 facilities in our healthcare system 3,250 cholecystectomies and 1,678 appendectomies were performed by 79 surgeons over an 18-month period.  Low volume surgeons were excluded (16 for cholecystectomy, 18 for appendectomy).  Mean OR supply cost was $528 for a cholecystectomy (mean cost/surgeon ranged from $303-1091) and $885 for an appendectomy (mean cost/surgeon range $585-1374).  There was significant variation by surgeon, with the mean cost/case for the most expensive surgeon being more than three times more expensive than the lowest cost surgeon for a cholecystectomy and almost more than 2 times as much for a cholecystectomy.  Surgeon volume was not significantly correlated with mean cost (Figure 1, p>0.05 for both).  Increased OR supply cost was significantly associated with increased OR time for cholecystectomies (p<0.01) but not for appendectomies (p=0.44).  

Conclusion:We identified wide variation in mean supply cost per case for laparoscopic appendectomies and laparoscopic cholecystectomies across a large healthcare system.  Higher cost cases were associated with longer operative time for cholecystectomies but not appendectomies.  Future studies to assess methods to decrease variation and the effect of operating room supply cost on patient outcomes are needed.

 

8.11 Surgical Cost Correlation within Hospitals

Posted on January 18, 2018

S. P. Shubeck1,2,3, U. Nuliyalu3, J. B. Dimick1,3, H. Nathan1,3  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,National Clinician Scholars Program,Ann Arbor, MI, USA 3University Of Michigan,Center For Healthcare Outcomes & Policy,Ann Arbor, MI, USA

Introduction: The Centers for Medicare and Medicaid Services have implemented many bundled payment programs focused on reducing the costs of specific surgical procedures or service lines. These bundled payment models hold hospitals accountable for the costs of entire episodes of surgical care, thereby encouraging efficiency and cost containment. However, little is known about whether hospital costs across different procedures are correlated. If so, hospital-wide efforts to improve efficiency might be useful; if not, these efforts would need to be targeted and service-specific. We therefore sought to determine the degree of cost correlation for surgical procedures within hospitals.  

Methods: Using 100% Medicare claims data for 2010-2013, we identified patients aged 65-99 years undergoing elective surgical procedures including: colectomy, proctectomy, coronary artery bypass grafting (CABG), total hip replacement (THR), total knee replacement (TKR), esophagectomy, pancreatectomy, and abdominal aortic aneurysm repair (AAA). We calculated price-standardized, risk-adjusted Medicare payments for the entire “surgical episode” from the index admission through 30 days after discharge. The average cost for each procedure at each hospital was then calculated. We quantified cost associations between procedures for hospitals in the highest quintile of spending using Kappa statistics, ranging from 0-1, that take into account the possibility of agreement by chance alone. 

Results: This study included 3530 hospitals performing colectomy, 2399 performing proctectomy, 1158 performing CABG, 3176 performing THR, 3390 performing TKR, 792 performing esophagectomy, 875 performing pancreatectomy, and 1645 performing AAA. Hospitals in the highest quintile of costs in one procedure were seldom high-cost in others. As expected, clinically unrelated procedures had weakly related costs (pancreatectomy and esophagectomy, K=0.12; proctectomy and TKR, K=0.06; esophagectomy and AAA, K=0.01, Figure 1A). Surprisingly, even some clinically similar procedures demonstrated only moderate cost relationship, such as colectomy and proctectomy (K=0.16,  Figure 1B). The strongest relationship was found for THR and TKR, K=0.5 (Figure 1C). 

Conclusion: We found that almost all procedures included in this study had weak cost relationships with other common procedures. The main exception to this finding was THR and TKR. Our findings suggest that broader inferences about hospital efficiency cannot be based on the institution’s performance in a single surgical procedure or service line. Additionally, initiatives to reduced surgical spending that are targeted at certain procedures are unlikely to have spillover effects on unrelated procedures in the same hospital.

 

8.08 Are Work Relative Value Units Driving Surgeon Behavior?

Posted on January 18, 2018

E. C. Poli1, F. S. Dahdaleh1, S. Sherman1, K. K. Turaga1  1University Of Chicago,Department Of Surgery,Chicago, IL, USA

Introduction: Surgeon reimbursement for procedures depends on billing for work relative value units (wRVUs), which are assigned based on current procedure terminology (CPT) codes. Often, different CPT codes can describe similar procedures, with large differences in WRVUs. This potentially creates incentives to perform and code for the higher-WRVU procedure. This study sought to examine whether evidence of such upcoding exists.

Methods: Yearly frequencies of CPT codes for similar but differentially-reimbursed procedures were determined from NSQIP Participant Use Data Files from 2012 to 2015. Included codes and WRVUs were: 47100-wedge biopsy of liver (12.91 WRVU); 47120-hepatectomy/partial lobectomy (39.01 WRVU); 49560-repair initial incisional hernia, reducible (11.92 WRVU); 49561-repair initial incisional hernia, strangulated or incarcerated (15.38 WRVU); 49565-repair recurrent incisional hernia, reducible (12.37 WRVU); 49566-repair recurrent ventral hernia, incarcerated or strangulated (15.53 WRVU); 49568-implantation of mesh for open incisional hernia repair (4.88 WRVU); 15734-component separation repair (19.86 WRVU).  CPTs listed under primary CPT, additional CPT and concurrent CPT were counted for each procedure. To account for increasing volume and additional hospitals captured in the database in subsequent years, the proportion of each CPT per year was compared using Fisher’s exact test.

Results: Over the four years, there were 155,790 hernia repairs and 18,875 liver resections of the CPT codes of interest. The proportion of liver resections coded as partial hepatectomies compared to wedge liver biopsies increased over the four years from 60.42% to 64.51% (p value <0.0001). In ventral hernia repairs, the proportion of procedures coded as component separation and repair of initial strangulated or incarcerated incisional hernia, (both with higher WRVU), increased (8.21% to 10.09% and 12.38% to 14.21% respectively, p<0.0001 for heterogeneity).

Conclusion: For the procedures included, there was a small increase in use of CPTs linked to higher WRVUs during the study period.

 

8.09 Cost-effectiveness of DAAs among HCV+ Kidney Transplant Candidates: Treat pre- or post-transplant?

Posted on January 18, 2018

M. N. Mustian1, B. A. Shelton1, R. M. Hungerpiller1, D. L. Sawinski2, R. D. Reed1, P. A. MacLennan1, J. E. Locke1  1University Of Alabama At Birmingham,Birmingham, AL, USA 2University Of Pennsylvania,Philadelphia, PA, USA

Introduction:   Hepatitis C virus (HCV) positive kidney transplant (KT) candidates can be successfully treated with direct acting antivirals (DAAs) either pre- or post-transplantation. However, following treatment for HCV, patients lose access to HCV+ organs, which are associated with significantly shorter time to transplant. The purpose of this study was to determine the most cost-effective treatment option for this patient population.

Methods:   A Markov model comparing two strategies (pre vs. post-transplant treatment with DAAs) was developed using probabilities from the Scientific Registry of Transplant Recipients (SRTR) database and published literature with a three-year time horizon. Costs were expressed in 2017 US dollars from the societal perspective, and utility was measured in quality-adjusted life years (QALYs). Strategies were compared using incremental cost-effectiveness ratios (ICERs). One-way probabilistic sensitivity analyses were conducted.

Results:  When the probability of undergoing KT within 3 years of listing while HCV+ was less than 50%, the cost-effectiveness of pre-transplant DAA therapy was $136,073/QALY, compared with $179,135/QALY for post-transplant HCV treatment. DAA treatment post-transplant was dominated (i.e. more costly while yielding less benefit), with an ICER of -$679,290/QALY. Given a >50% probability of transplantation within 3 years of listing while HCV+, pre-transplant treatment had an associated cost of $138,320/QALY, while post-transplant treatment was $151,302/QALY. However, treatment post-transplant was no longer dominated (ICER: $235,670/QALY), indicating greater effectiveness of treating HCV post-transplant.

Conclusion:  These preliminary analyses suggest that as the probability of transplantation while HCV+ increases, the strategy to treat HCV with DAAs post-transplant becomes more cost-effective. When the probability of receiving a KT while HCV+ within 3 years was <50%, DAA therapy pre-transplant is more cost-effective. Conversely, HCV+ candidates at centers with >50% probability of KT achieve greater benefit from post-transplant DAA treatment. Moreover, these findings indicate that the cost-effectiveness of the two distinct treatment approaches may be affected by wait list times at the center-level, but further analysis is still needed, accounting for other potential cofounders such as progression to liver disease and coinfection with HIV. 

8.06 Prehabilitation Prior to Living Donor Kidney Transplant May Have Beneficial Financial Implications

Posted on January 18, 2018

M. J. Holmes1, M. J. McCarroll1, R. J. Berkowitz1, J. S. Lee1, L. E. Junge1, B. C. Kenney1, S. C. Wang1, R. S. Sung1, M. J. Englesbe1, K. J. Woodside1  1University Of Michigan,Ann Arbor, MI, USA

Introduction: The Michigan Surgical & Health Optimization Program (MSHOP) is an economically cost efficient program that ‘trains’ patients for surgery. MSHOP is designed to help patients make incremental adjustments in their daily routine that can have a large effect on their recovery following surgery. The program focuses on increasing physical activity via a pedometer, breathing exercise to improve lung function using an incentive spirometer and helping smokers make a plan to quit, developing a balanced diet plan, and managing emotional and psychological stressors by practicing in relaxation techniques. We examined the impact of the program on living donor kidney recipients’ length of stay, hospital readmission within 90 days, postoperative complications, and charges and expected payment.

 

Methods: Retrospective clinical, program participation, demographic, and financial data from 106 living donor kidney transplant recipients enrolled in MSHOP between June 2015 and July 2017 were obtained.  Patients that recorded steps at a minimum of 3 times per week for the majority of weeks enrolled were defined as adherent to the program. Categorical variables were compared using Fisher’s exact test. Continuous variables were compared using Student's t-test and the Mann-Whitney U test. Primary measures are, length of stay, hospital readmission within 90 days, postoperative complications, and charges and expected payment.

 

Results: Of the total 106 patients, 83 were enrolled in MSHOP, and 23 were not. Of the 83 enrolled, 66 were compliant and 17 were not compliant. MSHOP compliant patients had a trend towards decreased rate of readmission within 90 days, postoperative complications, and charges with expected payment (Table).

 

Conclusion: While strong conclusions are limited by modest sample size, we found an intriguing emerging trend towards potential hospital cost saving implications associated with patient participation in MSHOP.  It is possible that this trend is the result of decreased postoperative complications hospital readmissions.   

8.07 Time is Money-Quantifying Savings in Outpatient Appendectomy

Posted on January 18, 2018

E. T. Bernard1, D. L. Davenport1, B. Benton1, A. C. Bernard1  1University Of Kentucky,General Surgery,Lexington, KY, USA

Introduction:  Recent evidence suggests laparoscopic appendectomy can be performed on a fast-track, short stay, or even outpatient basis. This outpatient appendectomy protocol has been proven to provide high success rates, low morbidity, and low readmissions rates, in addition to a shorter length of hospital stay. Cost savings from outpatient appendectomy have not been reported in the United States. We hypothesize that outpatient laparoscopic appendectomy is associated with cost savings.

Methods:  We performed a retrospective analysis of patients undergoing laparoscopic appendectomy between July 2013 and April 2017 at our academic medical center before and after implementation of an outpatient protocol which began on January 1, 2016. We assessed direct costs (OR costs, ED costs, diagnostics, pharmaceuticals), indirect costs, net revenue, contribution margin, and net profit.

Results: The percent of PACU to home discharges increased from 3.4% during the pre-implementation period to 27.0% in the post-implementation period (Chi-square P < .001). The proportion of inpatient and post-OR observation cases decreased by 12.1% and 5.4% respectively. On average, the PACU to home group had a total hospital cost of $4,734 versus $5,787 in the post-OR observation group, for savings of $1,053 per patient. Before and after implementation of the protocol, the average total observation time (pre and post-OR) decreased by 4 hours in those placed in observation post-OR, by 3 hours in those discharged from PACU and 1 hour in those admitted: across all groups total observation time decreased by 2 hours on average (P<.001).

Conclusion: Outpatient appendectomy is associated with approximately $1,000 cost savings per patient. Implementation of an outpatient appendectomy pathway is likely to effect gradual results, but improved resource utilization should occur immediately with respect to shorter observation hours, even for those who are assigned a bed. Considering previous reports that have established safety of the laparoscopic outpatient appendectomy method, our data strongly support widespread implementation of an outpatient appendectomy protocol. 

 

8.03 The Role of Repeat Imaging in Hepatic Trauma For Identification of Post-Injury Pseudoaneurysm

Posted on January 18, 2018

T. Bongiovanni1, C. A. Wybourn1, B. Del Buono1, A. Mendoza1, R. Callcut1  1University Of California San Francisco,Surgery,San Francisco, CALIFORNIA, USA

Introduction:

  Post-injury pseudoaneurysm formation is a potentially life threatening complication following hepatic trauma, however, the role of routine post-injury imaging surveillance is undefined.    The aim of this study is to investigate if repeat CT imaging altered clinical practice for those suffering either blunt or penetrating hepatic trauma.   

Methods:
 

A retrospective analysis of an urban level 1 trauma center surveillance registry was queried to identify all patients with hepatic trauma between September 2015 and December 2016.  All patients with hepatic trauma that survived more than 24 hours were included.  Grading of liver injury was done based on the AAST organ injury scale. A positive CT was defined as having a new pathologic finding. Invasive intervention was defined as operative management or angioembolization.

 

Results:

 

During the 16 month study period, 99 patients were treated for hepatic injury including 37 (37%) suffering penetrating injury. Mean age was 39,  ISS was 22 and 77 were male.  There were 15 (15%) grade 1 injuries, 42 (43%) grade 2, 18 (18%) grade 3, 19 (19%) grade 4, 5 (5%) grade 5.  Median ICU length of stay was 3.5 days and total hospital length of stay was 6 days.   Non-operative management was performed in 67  .    Fifty-six of 99 patients did not have repeat imaging.  The median time to repeat CT was 5 days. Repeat imaging changed management in 3/43 (7%) of those re-imaged, including in 3/19 (15.7%) suffering a Grade 4 injury.     An addition patient  had clinical signs of hemorrhage prior to a repeat CT scan and underwent angioembolization. 

 

Conclusion:

This data suggests that routine follow up CT scan did not change management in those suffering low grade hepatic injuries and it may be safe to avoid radiation exposure for this patient group unless there is a change in clinical status.  However, in those with Grade 4-5 injuries, post-injury imaging surveillance changed management in a significant percentage of patients.  Further study is warranted to define the optimum timing of post-injury surveillance for these high grade injuries. 

 

8.04 Overutilization of Helicopter EMS in the Central Gulf Coast Region

Posted on January 18, 2018

M. V. Purvis1, A. R. Beckett1, J. R. Beasley2, H. E. Reed2, A. Haiflich1, Y. Lee1, L. Ding1, S. E. Bowden3, E. A. Panacek3, S. B. Brevard1, J. D. Simmons1  1University Of South Alabama,Department Of Surgery, Division Of Acute Care Surgery And Burns,Mobile, AL, USA 2University Of South Alabama,School Of Medicine,Mobile, AL, USA 3University Of South Alabama,Department Of Emergency Medicine,Mobile, AL, USA

Introduction: In the state of Alabama, utilization of helicopter emergency medical services (HEMS) is based on criteria established by the Alabama Department of Public Health (ADPH) in conjunction with the Alabama Trauma Communications Center (ATCC). These protocols delineate specific anatomic and mechanistic criteria for which consideration should be given for HEMS transport. We hypothesized that a significant number of trauma patients are being over-triaged to HEMS in our region and that many of the criteria the ATCC uses for HEMS triage guidance would have limited predictive value for truly severe injuries.

 

Methods: We conducted a retrospective review of all adult trauma patients arriving to our level one trauma center by HEMS from January 2015 to April 2017. Interfacility transfers were excluded. Triage decisions were deemed inappropriate (i.e. admission to the ward or discharged home without admission) or appropriate (i.e. admission to the intensive care unit, required emergent operation, or death). Additionally, we analyzed ATCC, HEMS and hospital records of each patient to determine demographics, hospital outcomes, scene details, triage decision criteria, and transport times. Data was analyzed via binary logistic regression to identify predictive factors.

 

Results: Over 28 months, 381 adult trauma patients arrived to our emergency department by HEMS. Two hundred forty-eight patients (65%) were deemed appropriate while 133 (35%) were considered inappropriate for HEMS transport. Of the 35% of patients grouped inappropriate for HEMS, 8% (30 patients) were discharged home without admission to the hospital. Glasgow Coma Scale (GCS), multiple extremity fractures, age, and gender were significant predictors at the 5% level for appropriate transport by HEMS [Chi-Square=70.372, df=14 and p=0.0001] after controlling for all other variables (GCS Exp(B)=0.714, p=0.0001; multiple extremity fractures Exp(B)=0.211, p=0.050; age Exp(B)=1.019, p=0.028; gender Exp(B)=0.398, p=0.005). The other nine criteria were not found to be significant predictors of appropriate HEMS transport (tachycardia, hypotension, respiratory distress, flail chest, amputation, paralysis, pelvic instability, other patient death in compartment and mechanism). Finally, the insurance demographics of the cohort were similar to that of all trauma patients arriving to our trauma center.

 

Conclusion: Our findings suggest current ATCC triage criteria for HEMS should be revised to reduce the over-triaging of trauma patients which would avoid unnecessary healthcare expenditure. Based on the average cost of a HEMS transport in our area, approximately 5.4 million dollars was unnecessarily wasted over a 28-month period due to over-triage. Large, adequately-powered, multi-center studies should be prioritized to determine the optimal criteria for selecting HEMS. 

 

8.05 Frailty As Measured By the Trauma Specific Frailty Index Predicts Hospital Costs in Trauma Patients

Posted on January 18, 2018

F. S. Jehan1, M. Hamidi1, N. Kulvatunyou1, A. Tang1, A. Jain1, L. Gries1, T. O’Keeffe1, E. Zakaria1, B. Joseph1  1University Of Arizona,Tucson, AZ, USA

Introduction:
Frailty has been identified as a predictor of adverse post-operative clinical outcomes; however, the financial impact of frailty still remains relatively undetermined in trauma patients. The aim of our study is to evaluate the relationship between frailty and hospital costs among trauma patients treated in a level I trauma center.

Methods:
We performed a two-year (2013-2014) analysis of our prospectively maintained frailty database. We included all trauma patients ≥ 65 years old who underwent laparotomy at our Level 1 trauma center. Patient’s frailty status was calculated utilizing the validated Trauma Specific Frailty Index (TSFI) within 24 hours of admission. Patients were stratified into: non-frail and frail. Multivariate regression analysis was performed to assess the relationship between frailty and total hospital costs and control for confounders.

Results:
325 patients were enrolled, of which 36% (n=117) were frail, and 64% (n=208) were non-frail. Frail status was associated with an average increase of $10,894 in the total hospital cost (median covariate-adjusted cost, frail versus non-frail: $37,174 vs $26,280 p=0.01). Patients who were frail demonstrated a higher total hospital cost within the subgroup of patients who developed a postoperative complication (frail versus non-frail: $45,145 vs $32,210) and among those patients who did not develop a postoperative complication (frail versus non-frail: $29,134 vs $21,673, both p=0.01). Similarly, total hospital costs were higher among patients who were frail regardless of the length of stay for index admission (observed: expected, length of stay > 1: frail versus non-frail: $39,874 vs $28,985; observed: expected, length of stay < 1: frail versus non-frail: $32,512 vs $22,441, both p=0.01).

Conclusion:
Frailty as measured by the TSFI independently predicts hospital costs in trauma patients. TSFI represents a novel tool for estimating patient outcomes and operative costs and can be used to inform quality improvement and cost containment strategies. Once frail patients are identified, appropriate resource allocation can reduce complications and hospital length of stay and can ultimately reduce hospital costs.
 

8.02 Cost of Operating Room Time: An Analysis of California Hospital Financial Statements

Posted on January 18, 2018

C. P. Childers1, M. Maggard-Gibbons1  1University Of California – Los Angeles,Los Angeles, CA, USA

Introduction: Increasing value in surgery requires improving quality, decreasing costs, or both.  Estimates of operating room (OR) cost have ranged from $12 to over $100 per minute.  To date, the validity of these values has not been tested. This study sought to calculate the cost of a minute of OR time using statewide hospital financial data, to evaluate how this cost varies by setting and facility characteristics, and to ascertain the proportion of costs that are modifiable.

Methods: Financial disclosures were compiled from all short-term general and specialty care hospitals in California in fiscal year (FY) 2014.  Each report contains over 16,000 data points on a broad array of variables including facility characteristics, utilization measures, and financial statements.  For each facility, total expenses for the “surgery and recovery” revenue center were divided by the number of OR minutes (defined as the start to end of anesthesia time) to generate the cost per minute.  These estimates were then aggregated into a median cost for a minute of OR time and stratified by setting and teaching status.  Expenses were broken into direct and indirect components, with direct expenses further sub classified into salary, wages, non-billable supplies, and other. Bivariate comparisons were made using non-parametric tests.

Results: In FY2014, financial statements were extracted from 294 hospitals; of which, 58% were not-for-profit, 26% were for-profit, and 16% were government owned.  Median cost of one minute of OR time was $33.78 (inpatient) and $34.18 (ambulatory).  There was no difference in the cost of a minute of OR time between for-profit, not-for-profit, and government owned facilities, in either setting (inpatient, p=0.08; ambulatory p=0.65). Teaching hospitals had lower median expenditures in the inpatient setting ($27.68 vs. $34.69, p<0.01), but were no different in the ambulatory setting (p=0.59).  Of the $34 per minute, 56-59% are direct costs including 39-40% wages and benefits, 4-5% non-billable supplies, and 7-9% other direct expenses (Table).

Conclusion: This study estimates the cost of a minute of OR time at $34 ($2,040/hour), with minimal variation by setting and ownership.  The majority of this is non-modifiable over the short-term such as indirect costs (e.g. security, parking), staff benefits, and other direct expenses (e.g. equipment depreciation).  These values are the first empirical estimates of OR cost. Further, understanding the composition of costs allows identification of high-value targets for value-improvement efforts. 

 

8.01 Value Analysis of the Costliest Elective Invasive Procedures at an Academic Medical Center

Posted on January 18, 2018

A. Reisman1, K. Farrell1, I. Leitman1  1Mount Sinai School Of Medicine,New York, NY, USA

Introduction:  When evaluating the cost of a lifesaving procedure, it is also important to consider the relative value. One way to evaluate the economic value might be the relative cost of that procedure per additional year of life lived following. This evaluation might provide useful information for planning the application of these costly in-hospital procedures. The objective of this study was to determine the cost per year of life saved for the costliest complex elective surgical procedures performed at an urban academic medical center. 

Methods:  Total hospital charges were categorized by diagnosis related group (DRG) for patients discharged between January 1, 2015 and December 31, 2016. The average cost and patient age for each procedure were calculated. The average lifespan following successful outcomes for these procedures was determined based upon published benchmarks. Cost per year of life saved was calculated for each procedure. Emergent procedures and those done for chronic pain or interference with life style were excluded, leaving only those elective procedures necessary to prolong life. 

Results: 114,448 hospital admissions were reviewed. The 12 most costly elective procedures were identified and ranked according to cost per year of life saved from lowest to highest: Coronary bypass ($1,345.45), portacaval shunt procedure ($2,261.70), cardiac valve/other major cardiothoracic procedure ($2,733.78), major bladder procedure ($2,733.78), cardiac defibrillator implant ($5,047.65), bone marrow transplant ($5,181.80), craniotomy/intracranial procedures ($8,572.05), kidney transplant ($9,024.87), liver transplant ($11,112.73), endovascular cardiac valve replacement ($12,842.25), simultaneous pancreas/kidney transplant ($14,087.50), and heart transplant ($20,472.11). 

Conclusion: Among the costliest elective invasive procedures, coronary bypass surgery was the most economic. In addition to having the lowest cost per year of life saved ($1,345.45), coronary bypass surgery also had the longest post procedure life expectancy (17.6 years). These economic findings combined with further analysis of the identified procedures may allow us to better determine their relative value.
 

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