92.11 “ National Trends in Partial Nephrectomy vs Total Nephrectomy in Solitary Kidney Patients”

Posted on January 31, 2019

M. F. Nunez1, G. Ortega1, A. Zeineddin3, A. R. Metwalli2  1Howard University College Of Medicine,Research Center In Minority Institutions Program,Washington, DC, USA 2Howard University College Of Medicine,Division Of Urology/Robotic Surgery Department Of Surgery,Washington, DC, USA 3Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA

Introduction:  The standard of care treatment for renal cell carcinoma in the solitary kidney is partial nephrectomy. Our objective was to determine if the selection of this procedure differs by demographics, socioeconomic-status, insurance-status, and hospital characteristics among a national sample. 

Methods:  A retrospective analysis of 2005–2014 data from the Nationwide Inpatient Sample (NIS) database was conducted. We sought to identified adult patients with a diagnosis of acquired absence of a kidney (V45.73) according to the International Classification of Disease, 9th Revision, Clinical Manifestation (ICD-9-CM). Cases were dichotomized according to the type of surgery in partial nephrectomy (PNx) (55.4) and total nephrectomy (TNx) (55.5, 55.51, 55.52, and 55.53) for Malignant neoplasm of the kidney (189.0). Groups were compared with unadjusted and adjusted analyses to determine factors that influence the use of the procedures.

Results: Among 175,895 patients identified with an acquired absence of kidney, 513 underwent surgery with a primary diagnosis of kidney cancer.  Of these, 79% underwent PNx, with a mean age of 60.6 years (SD13), and a male-female ratio 2:1. Length of stay for PNx was 4.7 days (SD 3) compare with 6.1 days (SD 8) for TNx (p=0.001). Patients with private insurance and those who underwent the procedure at a metropolitan teaching hospital were more likely to have PNx (OR 1.84 95%CI 1.02 – 3.30) and (OR 4.82 95% CI 1.44 – 16.11), respectively. There were no statistical differences among other factors including age, gender, race and, median household income.

Conclusion: Disparities exist regarding the type of health insurance in patients with solitary kidney undergoing to partial nephrectomy as a treatment for renal cancer.  The need for postoperative dialysis in patients who underwent TNx might incur in higher charges and reflect the longer hospital stay in this group.

 

92.10 Validation of the Medicaid Emergency Room-Specialty Center Equivalence Ratio (MERSCER)

Posted on January 31, 2019

E. C. Hall1,2,3, A. Zeymo1, K. S. Chan1, W. Al-Refaie1,2  1MedStar-Georgetown Surgical Outcomes Research Center,Washington, DC, USA 2MedStar Georgetown University Hospital,Surgery,Washington, DC, USA 3MedStar Washington Hospital Center,Surgery,Washington, DC, USA

Introduction:  Although equal access to quality surgical care has been a longstanding concern, there are no accepted measures of surgical access equity. Our aim is to validate Medicaid Emergency Room-Specialty Center Equivalence Ratio (MERSCER), an extension of our previously published work on surgical access equity, as such a measure.

Methods:  Using the State Inpatient Databases (2012-2014) for a representative population of the United States, we identified high-volume hospitals (HVH) for three sets of complex, elective procedures: gastric, liver, and lung resections. We calculated each HVH’s MERSCER by comparing the ratio of the percentage of Medicaid patients that received complex elective surgery to the percentage of Medicaid patients that received emergent bowel surgery within the same center. MERSCER <1 indicates a center with disproportionately higher number of privately-insured patients relative to Medicaid patients undergoing complex elective procedures, and thus a proxy for access inequity. MERSCER was tested for significance using Mantel-Haenszel approach. Recursive partitioning was used to evaluate hospital and county level characteristics from the Area Resource File associated with lower MERSCER.

Results: 157 HVH were included. Pooled estimates for MERSCER were 0.62 (0.58-0.63) for gastric, 0.61 (0.56-0.67) for liver, and 0.75 (0.7-0.85) for lung resections. 82% of HVH-gastric, 76% of HVH-liver and 67% of HVH-lung had decreased equity (MERSCER <1). Hospitals with lower MERSCER values (decreased equity) were associated with higher proportions of elders, white patients, and patients from higher income areas.

Conclusion: For selected elective, complex procedures there were trends of inequity in surgical access across high-volume surgical centers, evidenced by disproportional numbers of privately-insured vs. Medicaid patients receiving complex elective surgery at high volume centers (MERSCER <1). The development of measures of equity is an important step to track and reward hospitals for providing equal access to all patients.

 

Figure 1: MERSCER Distribution Among High Volume Hospitals for Gastric Procedures. MERSCER <1 indicates disproportionately higher number of privately-insured patients undergoing complex elective procedures.

 

 

92.09 Age: Still a Relevant Independent Predictor of Outcomes in Emergency General Surgery

Posted on January 31, 2019

J. T. Langford1, M. M. Fleming1, Y. Zhang2,3, J. Luo2, K. Y. Pei1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale University School Of Medicine,Section Of Surgical Outcomes And Epidemiology, Department Of Surgery,New Haven, CT, USA 3Yale School of Public Health,Department Of Environmental Health Sciences,New Haven, CT, USA

Introduction: The average age in the US is increasing every year and as the population gets older so does the patient population undergoing surgery. A growing body of literature is urging against using age alone as a risk stratifying tool and to rely on frailty instead. While frailty has been demonstrated as a good predictor of post-operative outcomes in elective surgery it is uncertain whether this holds true for elderly patients undergoing emergency general surgery. The aim of our study was to determine if age alone could be used to predict post-operative outcomes in elderly patients undergoing emergency general surgery.

Methods: Using the ACS-NSQIP database from 2010-2016 we selected patients that underwent 1 of the 7 surgeries that make up 80% of the field emergency general surgery. These include partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy and laparotomy. The primary outcomes measured were overall complication rate and 30 day mortality based on age cohort while controlling for comorbidities and frailty.

Results: 310,643 patients were included in the analysis. Compared to the reference group (age 60-69) there is an increased risk for all complications in the 70-79, 80-89, and ≥ 90 cohorts (OR  1.14 [95%CI 1.11-1.16], OR 1.37 [95%CI 1.34-1.41], OR 1.65 [95%CI 1.57-1.73], respectively). Similarly, there is an increased risk for 30-day mortality (OR 1.47 [95%CI 1.40-1.54], OR 2.37 [95%CI 2.25-2.49], OR 3.69 [95%CI 3.41-3.98], respectively). This trend for increased 30-day mortality is also significant for the 7 procedures individually.

Conclusion: Age can be used as an independent predictor of complications and 30 day mortality in elderly patients undergoing emergency general surgery.

 

92.08 Quality of Life of in Geriatric Patients after Cholecystectomy

Posted on January 31, 2019

A. Z. Agathis1, J. J. Aalberg1, C. M. Divino1  1Mount Sinai School Of Medicine,New York, NY, USA

Introduction:  Gallbladder disease remains the most common cause of acute abdominal pain in older populations. Despite current recommendations, elderly patients undergo cholecystectomy procedure at lower rates. While literature demonstrates a relatively higher incidence of morbidity and mortality, the procedure is shown to be safe in older patients. However, few studies to date describe quality of life after cholecystectomy in elderly patients, and none within the American population. This study examines quality of life in geriatric patients after cholecystectomy.

Methods:  Patients ≥  65 years of age who underwent laparoscopic cholecystectomy at a single academic hospital were administered the 12-Item Short Form Survey (SF-12) and a gastrointestinal-specific survey. The surveys were administered pre-operatively (visit type 0) and post-operatively at two time points, once within 6 months and another within 18 months (visit type 1 and 2). A mixed model was used for statistical analysis. Pain severity, pain frequency, the SF-12 aggregate physical functioning score, and the SF-12 aggregate mental health score were compared amongst visit types using Wilcoxon tests in a univariate and multivariate setting. 

Results: The study population included n = 23 patients. In the multivariate analysis, visit type was significantly correlated with pain severity, pain frequency, and the SF-12 mental health aggregate score. Specifically, pain frequency improved from visit type 0 to 1 by a difference of 1.182 (p = 0.017) and from 0 to 2 by a difference of 1.424 (p = 0.018) on a scale of 1-5 (increasing frequency), but not significantly from visit type 1 to 2 (p > 0.05). Pain severity improved from visit 0 to 2 by a difference of 1.512 (p = 0.004) on a scale of 1-5 (increasing severity), but improvement was not statistically significant from visit 0 to 1 or from visit 1 to 2. The SF-12 mental health aggregate score worsened from visit 1 to 2 by a score of -6.015 (p = 0.014) of 100, with no other statistically significant differences in between visit types 0 and 1 and visit 0 and 2. The SF-12 physical aggregate was not found to be correlated with the visit type. 

Conclusion: Our results indicate that lifestyle in geriatric patients improves after cholecystectomy. The most progress is observed in relation to abdominal pain frequency and severity, specifically between pre-operative and the first research follow-up, as well as between pre-operative and second research follow-up. However, the SF-12 indicated an overall decrease in mental health from pre-operative to second research follow-up.
 

92.07 Evaluating Trends in Management of Adults with Acute Appendicitis in Kentucky

Posted on January 31, 2019

L. A. Posey1, N. Bhutiani1, M. C. Bozeman1, B. G. Harbrecht1  1University of Louisville,Surgery,Louisville, KY, USA

Introduction: Recent changes in patterns of healthcare delivery of healthcare in Kentucky have stemmed from many elements, including Medicaid expansion and efforts focused on optimizing healthcare resource utilization.  This study assessed demographic, diagnosis, and management trends among patients in Kentucky who underwent operative management of acute appendicitis.

Methods:  Data from the Kentucky Cabinet Office of Health Policy was queried for all adult patients with who underwent operative intervention for acute appendicitis between 2008 and 2016.  Trends in demographics, use of abdominal imaging, and hospital setting in which procedures were performed (inpatient versus short hospital stay (outpatient or <24 hour admission)) were evaluated.  

Results: The annual number of patients undergoing operative intervention for acute appendicitis ranged from 4409 (2014) to 5043 (2010).   Overall, a greater proportion of patients underwent abdominal imaging as part of their diagnostic workup (39% 2008 to 76% in 2016,r=0.91,p<0.001), and an increasing proportion of patients listed as having a short hospital stay rather than full admission (41% in 2008 to 67% in 2016,r=0.99,p<0.001) after appendectomy (Figure). Insurance status did not change linearly over time.  Instead, beginning in 2014, the proportion of patients covered by Medicaid increased by approximately 150% (p=0.004), and the proportion of self-pay or uninsured patients decreased by over 60% (p<0.001), coinciding with Medicaid expansion.

Conclusion: Management of appendicitis has shifted toward including diagnostic imaging and earlier postoperative discharge over time in Kentucky.  These trends likely reflect changes in healthcare and hospital practice and may be independent of changes in the insurance landscape.

 

92.06 Enhanced Recovery After Surgery (ERAS) Reduces Post-Operative Length of Stay in Elderly Patients

Posted on January 31, 2019

S. J. Baker1,2, C. Rentas1,2, E. Malone1,2, J. Richman1,2, E. Dasinger1,2, C. Key1,2, D. Chu1,2, M. Morris1,2  1University Of Alabama at Birmingham,General Surgery,Birmingham, Alabama, USA 2Birmingham Veterans Affairs Medical Center,General Surgery,Birmingham, ALABAMA, USA

Introduction: ERAS has been shown to decrease post-operative length of stay (LOS). However, little research has been done specifically in the geriatric patient population. Given that certain components of a standard ERAS pathway may be avoided in the geriatric population (for example medications like ketorolac), it is unknown if this would decrease the overall efficacy of the pathway. Despite this, we hypothesized that LOS would decrease following ERAS implementation for our older adult patients.

Methods:  We conducted a cohort study between January 2012 and March 2018 for geriatric patients undergoing elective general surgery. All patients aged 65 and over who underwent an operation using the ERAS protocol between January 2016-March 2018 were identified as ERAS patients. CPT Codes identified pre-ERAS patients 65 and over who underwent similar operations from January 2012-January 2016. Demographic and procedural information was collected through Veterans Affairs Surgical Quality Improvement Program (VASQIP). Patients undergoing emergent surgery or who had an in-hospital mortality were excluded. Primary outcomes assessed included LOS and 30-day readmission rates. Patient demographics, surgery characteristics, and VASQIP defined complication rates were compared across groups (pre-ERAS vs ERAS) using Chi-square, Fisher’s exact, and Wilcoxon rank-sum tests. 

Results: Our entire cohort included 257 patients (177 pre-ERAS vs. 80 ERAS). The median age was 68 (IQR: 66-72), 94% were male (n=242), and 70% were Caucasian. There was no significant difference between the groups in age, race, or pre-operative functional status, and both groups underwent similar procedures (pre-ERAS vs ERAS; Age: 68 vs 69, p=0.36; Race (Caucasian): 73% vs 63%, p=0.55; Functional Status (Independent): 93% vs 86%, p=0.5). The ERAS patients had a significantly shorter median LOS at 5 days compared to the pre-ERAS group at 7 days (p<0.001). There was no difference in 30-day readmission rates (pre-ERAS 14% vs ERAS 15%, p=0.85) or overall complication rates (pre-ERAS 22% vs ERAS 24%, p=0.40). 

Conclusion: Older adult patients benefit from ERAS implementation within the VA hospital. Further research needs to be focused on which ERAS elements may be safely eliminated in older adults while maintaining the length of stay and readmission benefits. 

 

92.05 Hospital 30-day Mortality Rates are Influenced by Social Determinants Of Health

Posted on January 31, 2019

D. Kindell1, S. Markowiak1, F. C. Brunicardi1, M. Nazzal1  1The University of Toledo College of Medicine,Department Of Surgery,Toledo, OH, USA

Introduction:  In FY2014 Medicare began modifying payments to hospitals based on hospital heart failure (HF), acute myocardial infarction (AMI), and pneumonia (PNA) 30-day mortality rates through the Value-Based Purchasing (VBP) Program.  To date, approximately 1.86 billion dollars in Medicare funding has been allocated to hospitals based on these scores.  The purpose of this study was to determine whether these mortality rates were influenced by social determinants of health (SDOH).

Methods:  Data were gathered from Centers for Medicare and Medicaid Services (CMS) and US Census Bureau archives. We created a database pairing individual hospital mortality outcome performance scores (30-day HF, AMI, PNA) to corresponding census measures at the county level. Pearson’s Correlation Coefficient (Pearson r) was used to test 133 SDOH against mortality outcomes. Student’s t-test was used to compare the top and bottom quartile of performers across each mortality outcome. The United States Department of Agriculture criteria were used to classify urban vs rural counties.

Results: In total, 2955 hospitals across 977 counties were analyzed. Greater rural setting for hospitals was correlated with worse 30-day mortality rates in heart failure (r= – .144), pneumonia (r= – .136), AMI (r= -.082, p <0.001). The top correlations associated with improved mortality rates were improved PNA mortality rates in communities with more college graduates (r=0.170, p<0001), better heart failure rates in communities with more immigrants (r=0.206, p<0.001), and better pneumonia performance rates in communities with more white-collar jobs (r=0.170, p<0.001).  Predominantly Caucasian communities were correlated with worse HF outcome (r=-0.176, p<0.001), whereas lower income was correlated with worse PNA performance (r=-0.160, p<0.001).  Although there were many significant correlations (p<0.001) between community characteristics and hospital AMI mortality, none were strong.

Conclusion: Of the SDOH analyzed, 79% demonstrated statistical significance within the AMI mortality outcome, 88% in the heart failure mortality outcome and 87.3% in the pneumonia mortality outcome. The weaker strength of correlations between SDOH and AMI mortality rates may be due to the decades old efforts by the American Heart Association to increase rural and poor hospital access to fast percutaneous coronary revascularization. Due to the disparities in SDOH between urban and rural hospitals, mortality outcomes will shift CMS incentive payments away from hospitals in disadvantaged communities.

 

92.04 Race, Gender, and Language Concordance in the Care of Surgical Patients: A Systematic Review

Posted on January 31, 2019

C. Zhao2, P. Dowzicky1,2, L. Colbert-Mack1, S. Roberts1,2, R. R. Kelz1,2  1Hospital Of The University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA 2Hospital Of The University Of Pennsylvania,Center For Surgery And Health Economics,Philadelphia, PA, USA

Introduction: A recent summit on surgical disparities established the importance of the patient-provider relationship as a target to address surgical disparities. However, there is no consensus on whether patient-provider race, gender, and language concordance provides benefits to surgical patients. In this systematic review, we report the association between patient-provider concordance and patient preferences and outcomes in Surgery.

Methods: We performed a systematic review of the literature with defined search terms using Medline and PubMed to identify studies related to patient-provider concordance in surgical patients. We included studies published in English in the United States between 1998 and July, 2018. The number of studies associated with each outcome is reported below. Using the Oxford Centre for Evidence-Based Medicine guidelines, four members of a multi-disciplinary team assigned a level of evidence (1Best – 5Worst) to each study.

Results: Out of 253 titles screened, sixteen studies met inclusion criteria. Six discussed race-concordance, eleven discussed gender-concordance, and three discussed language-concordance. (Some examined multiple concordance types.) The studies included 12,614 patients (Mean 788; Range 18-4,157). The studies were performed in several specialties: surgical oncology (n=6) including two in plastic surgery, obstetrics and gynecology (n=3), cardiothoracic surgery (n=2), and other (n=5). Outcomes examined included patient preferences (n=6), patient adherence to physician recommendations (n=3), quality of care (n=5), effectiveness of communication (n=2) and decision-making regarding the patients’ willingness to undergo an elective operation (n=1). Five studies were rated as having level 4 evidence, with the remaining 11 studies rated as having level 3 evidence. In two out of six relevant studies, patients preferred providers with a similar background. Patients infrequently expressed a preference for provider concordance (n=2/6). Race, gender, and language-concordance had no effect on adherence to provider recommendations (n=3/3). No effect of race concordance on the quality of care was seen (n=2/3). Gender concordance was associated with improved quality of care (n=2/3). There were mixed effects of concordance on the effectiveness of communication (n=2). Patients treated by gender concordant physicians were more likely to undergo elective breast reconstruction (n=1).

Conclusions: Overall the number of studies examining patient-provider concordance and patient outcomes was small and the level of evidence modest. Most patients prioritize culturally, technically, and clinically competent providers over race, gender, and language concordance. Interventions to ameliorate surgical disparities should focus on giving physicians the training to provide an accommodating demeanor when working with vulnerable patients.

92.03 Exploring the surgical needs of the incarcerated population

Posted on January 31, 2019

C. Hutchinson1, M. K. Bryant1, S. Scarlet1, R. Maine1, E. B. Dreesen1  1University of North Carolina at Chapel Hill,Surgery,Chapel Hill, NC, USA

Introduction:  There are over two million incarcerated people in America. Incarceration is strongly tied to poor health outcomes and contributes to health disparities. Medical and mental illness are more common among the incarcerated than the general population. The need for primary, psychiatry, and infectious disease care in this population has been well described. However, little is known regarding the surgical needs of incarcerated people. In this study, we characterized surgical care provided to incarcerated people at a large academic medical center in North Carolina.

Methods:  We conducted a retrospective case series. All incarcerated patients who received surgical care between April 4, 2014 and March 31, 2018 were identified in billing records based on payer. Basic demographic information (age, sex, correctional facility), primary diagnosis, surgical division, operation(s) performed, length of stay (LOS), charges, and amounts paid were obtained.

Results: A total of 1,725 incarcerated patients were cared for during the study period. Mean patient age was 46.5 years (SD 13.6, range 16-88). The majority of patients were men (n=1265, 73%). Location of incarceration was available for 81% of patients. Seventy-one correctional facilities across North Carolina (40%) were represented. A total 8,568 charges and 1,553 procedures were identified. The average number of charges per patient was 5.0 (SD 9.8, range 1-211). Every division in the Department of Surgery cared for an incarcerated person during the study period, including Pediatric Surgery. The division most likely to care for incarcerated patients was Vascular Surgery (n=2268 charges, 30%), followed by Gastrointestinal Surgery (n= 1636 charges, 22%), and Surgical Oncology (n=1293 charges, 17%). Emergency room visits represented 11.6% of the charges (n=992), and 620 patients (35.9%) had at least one ER visit. The division that billed for the most operative/procedural charges was Vascular Surgery (n=458, 29%), followed by GI Surgery (n= 319, 21%), and Surgical Oncology (n=222, 14%). A wide range of operative procedures were performed across the Department with the top five procedures billed representing only 11.7% of the total number of procedures. Of these, the most common procedure performed was wound debridement (n=64, 4%), followed by vascular access procedures (n=33, 2%), lysis of adhesions (n=29, 1.9%) and robotic surgery (n=29, 1.9%). The sum total of charges filed was $4,035,981.73. The amount paid by the Department of Corrections (DOC) was $2,594,533.51 (64% of the total charges filed). 

Conclusion: Incarcerated patients sought care for a wide variety of operations and procedures.  Incarcerated patients presented to our hospital from correctional facilities across the state. Elective procedures related to chronic conditions were more common than emergent procedures.  The procedures performed were reflective of the aging prison population. The DOC offers comparable reimbursement rates at > 60% of charges billed. 

 

92.02 Clinical Outcomes and Readmissions for Cholecystitis in an Elderly Cohort: Cholecystectomy vs Cholecystostomy

Posted on January 31, 2019

Y. Sanaiha1, Y. Juo1, R. Jaman1, S. Rudasill2, H. Khoury2, H. Xing2, A. L. Mardock2, P. Benharash2  1University Of California – Los Angeles,General Surgery,Los Angeles, CA, USA 2University Of California – Los Angeles,Division Of Cardiac Surgery,Los Angeles, CA, USA

Introduction: Gallstone disease is highly prevalent amongst the aging population. Acute cholecystitis is most often managed with cholecystectomy, but clinical instability and advanced age have been cited as indications for gallbladder decompression with percutaneous cholecystostomy. The aim of the present study was to evaluate the mortality, morbidity, readmissions and resource utilization associated with management of cholecystitis in this high risk population

Methods: This was a retrospective cohort study using the Nationwide Readmissions Database (NRD), one of the largest, all-payer discharge databases, representing nearly 57% of all US hospitalizations through survey-weighted estimates. All non-elective admissions for cholecystitis in adults ≥70 years who underwent either percutaneous cholecystostomy (PC), laparoscopic (LC) or open cholecystectomy (OC) from 2010-2015 were identified.  Significant predictors of in-hospital mortality, composite comorbidity including neurologic, cardiovascular, renal and infectious complications, unplanned early (30-days from discharge), and intermediate readmissions (30-90 days from discharge) were analyzed using logistic regression models. Linear regression models were utilized to identify incremental costs and length of stay with each treatment modality.

Results:Of the estimated 416,902 patients over the age of 70 years who were admitted non-electively for management of cholecystitis, 9.7% underwent PC, 13.5% OC, and 76.1% LC. Patients who underwent PC were older (81.2 vs 79.0 vs 78.7 years, P<0.001) with a higher proportion of patients with an Elixhauser comorbidity score ≥ 4 (53.6 vs 38.2 vs 34.1%, P<0.001). The unadjusted index mortality rate was lowest for LC (Figure 1A). Composite complication, early, and intermediate readmission rate were higher in the PC cohort (Figure 1A). In this elderly cohort, OC and LC had significantly lower odds of mortality, composite morbidity, early, and intermediate readmission compared to PC (Figure 1B). Of all patients who received PC at index hospitalization and were readmitted within 30 days, 8.7% underwent interval LC and 3.7% OC. Compared to LC, PC was associated with significantly increased risk-adjusted costs ($3,318, P<0.0001) and length of stay (2.8 days, P<0.001). 

Conclusion:As expected, patients undergoing cholecystostomy had higher rates of mortality, complications, and readmissions, which is a reflection of baseline comorbidity prohibitive of surgical intervention. Further study of mechanisms of readmission reduction and post-discharge care for patients undergoing PC may help decrease the total resource utilization for this high-risk population, especially as OC in this high-risk population is being supplanted by PC. 

 

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.

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