Cost Of Surgical Care Research Articles

The Impact of the Novel Coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Pandemic on Case Fatality Rates and Cost of Surgical Care in Brazil.

Background The coronavirus disease 2019 (COVID-19) pandemic provoked disruptions in healthcare delivery. Following the recommendations of major surgical societies and surgical departments globally, most surgeries were widely canceled or postponed, causing significant disruptions to healthcare delivery worldwide, including in Brazil. Brazil's public healthcare system - Sistema Único de Saúde (SUS) was particularly affected, with a substantial decline in elective procedures, especially during the pandemic's early stages. The impact of the pandemic on surgical services in Brazil has not been adequately studied since most studies only cover the early phases of the pandemic. Thus, this study aims to analyze the case fatality rates and costs, associated with the different surgical procedure subgroups performed during the pre-pandemic, pandemic, recovery, and post-pandemic periods in all five regions of Brazil. Methods A retrospective cross-sectional design was used to examine surgical cases from 2019 to 2022. Data was divided into four time periods, named as the pre-pandemic (March-December 2019), pandemic (March-December 2020), recovery (March-December 2021), and post-pandemic (March-December 2022), and was analyzed for the cost of surgical procedures in the aforementioned four periods. In addition, the case fatality rates and rate ratios in the four periods stratified according to region were calculated. Results The cost of surgical procedures decreased during the pandemic and recovery period compared with pre-pandemic for all procedures except thoracic surgery where it was higher in the recovery period than pre-pandemic. No statistically significant change in cost was observed in surgeries of the central and peripheral nervous system, circulatory system, obstetric, and oncology. Case fatality rates increased among all five regions of Brazil in pandemic and recovery periods compared to pre-pandemic and post-pandemic periods. Case fatality rates increased during the pandemic and/or recovery as compared to pre-pandemic in all procedures except visual apparatus and obstetric surgeries were not affected by the pandemic in terms of case fatality rates. Conclusion The COVID-19 pandemic had a significant impact on surgical care costs and case fatality rates for surgery in Brazil. There was a decreasing trend in the costs of procedures during the pandemic, followed by a gradual recovery to baseline values, except for thoracic surgery. Case fatality rates rose initially and then declined, ultimately reaching baseline levels. The pandemic posed significant challenges to the healthcare system, affecting medical services, including surgical care.

Economic Impact of COVID-19 on a Free-Standing Pediatric Ambulatory Center.

Operating safely throughout the coronavirus disease 2019 (COVID-19) pandemic has required surgical centers to adapt and raise their level of readiness. Intuitively, additional expenses related to such adaptation may have resulted in an increase in the cost of surgical care. However, little is known about the magnitude of such an increase, and no study has evaluated the temporal variation in the costs of care throughout the pandemic. The aim of the current study was to evaluate the impact of COVID-19 on the cost of surgical and anesthetic care in a free-standing, pediatric ambulatory care center. We performed a retrospective review of the electronic medical record (EMR) and financial data for pediatric ambulatory settings between 2019 and 2020 (April - August) from our tertiary care children's hospital. The primary outcomes were the inflation-adjusted surgical cost for elective tonsillectomy, adenoidectomy, and tympanostomy tubes (BTI) placement procedures in children less than 18 years of age. These data were obtained from financial databases and aggregated into categories including anesthesia services, operating room services, recovery room services, and supply and medical devices. Costs per case to provide care were significantly higher following the COVID-19 pandemic in 2020 compared to 2019 across all services: anesthesia ($1,268 versus $1,143; cost ratio (CR): 1.11, 95% confidence interval (CI): 1.08 - 1.14, P-value < 0.001), operating room ($1,221 vs. $1,255; CR: 1.03, 95% CI: 1.02 - 1.04, P-value < 0.001), recovery room ($659 vs. $751; CR: 1.14, 95% CI: 1.10 - 1.18, P-value < 0.001), and supply ($150 vs. $271; CR: 1.81, 95% CI: 1.26 - 2.6, P-value = 0.001). There was an overall increase in healthcare service costs in 2020, with significant fluctuations in the early and mid-year months. Our study identified specific economic impacts of COVID-19 on free-standing pediatric ambulatory centers, thereby highlighting the need for innovative practices with cost containment for sustainability of such specialized centers when dealing with future pandemics related to COVID-19 or other viral pathogens.

Key drivers of 90-day costs in primary total elbow arthroplasty

BackgroundA comprehensive understanding of both surgical care costs and the factors influencing these costs is critical to make progress toward value-based care in orthopedics. Therefore, the purpose of this study was to assess 90-day health system costs in primary total elbow arthroplasty (TEA), the proportion of contribution from each cost group to total hospital cost, and to determine key drivers of 90-day costs in primary TEA. MethodsConsecutive patients who underwent primary TEA between 2014 and 2021 at a tertiary care academic medical center were included. An institutional accounting database was queried to determine direct costs to the health system attributed to TEA. All costs within 90 days of the surgical encounter were included for analysis to reflect the global postoperative period. Descriptive statistics were used to summarize patient and surgical characteristics, as well as cost data. Subcategories were determined to assess the key cost groups that contribute to total hospital fees for the entire cohort, and subanalysis was performed to evaluate only readmitted patients. Furthermore, a linear regression analysis was used to determine key drivers of 90-day costs in the setting of primary TEA. ResultsThirty-five patients who underwent primary TEA were identified from 2014 to 2021; 28 patients with 90-day cost data were included in this study. The mean surgical encounter cost was $18,075 (+/− $9772) and mean 90-day cost was $19,875 (+/− $9885). The largest proportion of health system costs in primary TEA was surgical implants (48%), followed by operating room fees (18%), surgical supplies (9%), and anesthesia (7%). Among readmitted patients, the most significant share of health system costs was attributed to surgical implants (30%) followed by operating room fees (22%). However, hospital fees (19%) experienced a substantial increase. In assessing the key drivers of 90-day health system costs, length of stay (B = 1304.30, 95% confidence interval [CI] 674.54 to 1934.05; P < .001), readmission (B = 16,148.55, 95% CI 7055.01 to 25,240.08; P = .001∗), and Charlson comorbidity index (B = 2247.43, 95% CI 68.64 to 4426.22; P = .044) were statistically significant predictors of increased 90-day costs. ConclusionImplant costs comprise nearly half of total 90-day costs in primary TEA, with operating room costs making the second largest contribution. Additionally, length of stay, readmission, and patient comorbidity burden were significantly associated with increased 90-day costs.

Team Approach: Improving Orthopaedic Operating Room Efficiency.

The cost of surgical care accounts for almost one-third of all health care spending in the United States. Within health care spending, the operating room (OR) is one of the largest health care costs during a perioperative episode of care. Efficiency in the OR has been associated with increased productivity, safety, and quality of care. However, multiple sources of delays can contribute to inefficiency, and improving efficiency in the OR requires a systematic approach to identify and address each issue. We report on the case of a process improvement initiative implemented in a large academic institution to improve OR efficiency in outpatient orthopaedic cases, and we discuss the lessons learned through this program. Optimizing workflow in the OR requires a multidisciplinary team approach consisting of clinician leaders with common goals and open discussion regarding the needs of each team member, including circulating nurses, surgical nurses/technologists, and anesthesiologists. Our experience highlights the importance of practical, clinician-driven changes that are supported by administrative engagement, resources for staffing and equipment, and institutional flexibility, which are required to implement systemic changes to address and improve efficiency in the OR.

Trends and Economic Implications of Disparities in Postoperative Pneumonia.

Postoperative pneumonia is the third most common surgical complication and can seriously impair surgical rehabilitation and lead to related morbidity and mortality. We evaluated the temporal trends in racial and ethnic disparities in postoperative pneumonia and quantified the economic burden resulting from these inequalities in the United States. This population-based study includes 195 028 children (weighted to 964 679) admitted for elective surgery across 5340 US hospitals reporting to the Nationwide Inpatient Sample between 2010 and 2018. We estimated the risk-adjusted incidence of postoperative pneumonia, comparing racial and ethnic groups. We also quantified the inflation-adjusted hospital costs attributable to racial and ethnic disparities in postoperative pneumonia. The risk-adjusted rates of pneumonia declined across all racial and ethnic categories, with Black children having the lowest annual rate of decline (Black: 0.03 percentage points, Hispanic: 0.05 percentage points, white: 0.05 percentage points). The risk-adjusted rates of pneumonia trended consistently higher for Black and Hispanic children, relative to white children, throughout the study period (Black versus white: relative risk, 1.31 (95% confidence interval, 1.14-1.51), P<.01; Hispanic versus white: relative risk, 1.16 (95% confidence interval, 1.02-1.32), P = .02). These disparities did not narrow significantly over time. During the study period, the excess hospitalization cost attributable to racial and ethnic disparities in postoperative pneumonia was $24 533 458 for Black children and $26 200 783 for Hispanic children (total, $50 734 241). Against the backdrop of decreasing postoperative pneumonia, Black and Hispanic children continue to experience higher rates compared with white children. These persistent disparities in postoperative pneumonia were associated with considerable excess cost of surgical care.

Cost of Surgical Care at Public Sector District Hospitals in India: Implications for Universal Health Coverage and Publicly Financed Health Insurance Schemes.

BackgroundIn low- and middle-income countries (LMICs), provisioning for surgical care is a public health priority. Ayushman Bharat Pradhan Mantri-Jan Aarogya Yojana (AB PM-JAY) is India’s largest national insurance scheme providing free surgical and medical care. In this paper, we present the costs of surgical health benefit packages (HBPs) for secondary care in public district hospitals.MethodsThe costs were estimated using mixed (top-down and bottom-up) micro-costing methods. In phase II of the Costing of Health Services in India (CHSI) study, data were collected from a sample of 27 district hospitals from nine states of India. The district hospitals were selected using stratified random sampling based on the district’s composite development score. We estimated unit costs for individual services—outpatient (OP) visit, per bed-day in inpatient (IP) and intensive care unit (ICU) stays, and surgical procedures. Together, this was used to estimate the cost of 250 AB PM-JAY HBPs.ResultsAt the current level of utilization, the mean cost per OP consultation varied from US$4.10 to US$2.60 among different surgical specialities. The mean unit cost per IP bed-day ranged from US$13.40 to US$35.60. For the ICU, the mean unit cost per bed-day was US$74. Further, the unit cost of HBPs varied from US$564 for bone tumour excision to US$49 for lid tear repair.ConclusionsData on the cost of delivering surgical care at the level of district hospitals is of critical value for evidence-based policymaking, price-setting for surgical care and planning to strengthen the availability of high quality and cost-effective surgical care in district hospitals.Supplementary InformationThe online version contains supplementary material available at 10.1007/s41669-022-00342-6.

Impact of out-of-pocket expenses for surgical care on households in rural Haiti: a mixed-methods study

ObjectivesThis study aimed to report household catastrophic spending on surgery and the experiences of patients and families seeking surgical care in rural Haiti.DesignThe study used an explanatory, sequential mixed-methods approach....

Time-Driven Activity-Based Costing in Breast Cancer Care Delivery.

Accurate measurement of healthcare costs is required to assess and improve the value of oncology care. We aimed to determine the cost of breast cancer care provision across collaborating health care organizations. We used time-driven activity-based costing (TDABC) to calculate the complete cost of breast cancer care-initial treatment planning, chemotherapy, radiation therapy, surgical resection and reconstruction, and ancillary services (e.g., psychosocial oncology, physical therapy)-across multiple hospital sites. Data were collected between December 2019 and February 2020. TDABC steps involved (1) developing process maps for care delivery pathways; (2) determine capacity cost rates for staff, medical equipment, and hospital space; (3) measure the time required for each process step, both manually through clinic observation and using data from the Real-Time Location System (RTLS); and (4) calculate the total cost of care delivery. Surgical care costs ranged from $1431 for a lumpectomy to $12,129 for a mastectomy with prepectoral implant reconstruction. Radiation therapy was costed at $1224 for initial simulation and patient education, and $200 for each additional treatment. Base costs for chemotherapy delivery were $382 per visit, with additional costs driven by chemotherapy agent(s) administered. Personnel expenses were the greatest contributor to the cost of surgical care, except in mastectomy with implant reconstruction, where device costs equated to up to 60% of the cost of surgery. The cost of complete breast cancer care depended on (1) treatment protocols; (2) patient choice of reconstruction; and (3) the need for ancillary services (e.g., physical therapy). Understanding the actual costs and cost drivers of breast cancer care delivery may better inform resource utilization to lower the cost and improve thequality of care.

Estimating the Cost of Surgical Care Purchased in the Community by the Veterans Health Administration.

Background. Veterans’ access to Veterans Affairs (VA)-purchased community care expanded due to large increases in funding provided in the 2014 Veterans Choice Act. Objectives. To compare costs between VA-delivered care and VA payments for purchased care for two commonly performed surgeries: total knee arthroplasties (TKAs) and cataract surgeries. Research Design. Descriptive statistics and regressions examining costs in VA-delivered and VA-purchased care (fiscal year [FY] 2018 [October 2017 to September 2018]). Subjects. A total of 13,718 TKAs, of which 6,293 (46%) were performed in VA. A total of 91,659 cataract surgeries, of which 65,799 (72%) were performed in VA. Measures. Costs of VA-delivered care based on activity-based cost estimates; costs of VA-purchased care based on approved and paid claims. Results. Ninety-eight percent of VA-delivered TKAs occurred in inpatient hospitals, with an average cost of $28,969 (SD $10,778). The majority (86%) of VA-purchased TKAs were also performed at inpatient hospitals, with an average payment of $13,339 (SD $23,698). VA-delivered cataract surgeries were performed at hospitals as outpatient procedures, with an average cost of $4,301 (SD $2,835). VA-purchased cataract surgeries performed at hospitals averaged $1,585 (SD $629); those performed at ambulatory surgical centers cost an average of $1,346 (SD $463). We also found significantly higher Nosos risk scores for patients who used VA-delivered versus VA-purchased care. Conclusions. Costs of VA-delivered care were higher than payments for VA-purchased care, but this partly reflects legislative caps limiting VA payments to community providers to Medicare amounts. Higher patient risk scores in the VA could indicate that community providers are reluctant to accept high-risk patients because of Medicare reimbursements, or that VA providers prefer to keep the more complex patients in VA.

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

Identifying provider variation in surgical costs could control rising healthcare expenditure and deliver cost-effective care. While these efforts have mostly focused on complex and expensive operations, provider-level variation in costs of thyroidectomy has not been well examined. We retrospectively evaluated 921 consecutive total thyroidectomies performed by 14 surgeons at our institution between September 2011 and July 2016. Data were extracted from the Change Healthcare Performance Analytics Program. Mean patient age was 47.4 ± 0.5 y, 81% were females, 64.7% were Caucasians, and 18.8% were outpatients. The number of thyroidectomies performed by the 14 surgeons ranged from 4 to 597 (mean=66). The mean costs per provider varied widely from $4,293 to $15,529 (P < 0.001). The mean length of stay was 1d ± .03 with wide variation among providers (0-6 d). Providers whose hospital cost exceeded the institutional mean demonstrated significantly higher anesthesia fees and lab costs (P < 0.001). We found substantial variation in hospital cost among providers for thyroidectomy despite practicing in the same academic institution, with some surgeons spending 3x more for the same operation. Implementing institutional standards of practice could reduce variation and the costs of surgical care.

The societal cost and economic impact of surgical care on patients\u2019 households in rural Uganda; a mixed method study

BackgroundThe epidemiology and cost of surgical care delivery in low-and middle-income countries (LMICs) is poorly understood. This study characterizes the cost of surgical care, rate of catastrophic medical expenditure and medical impoverishment, and impact of surgical hospitalization on patients’ households at Soroti Regional Referral Hospital (SRRH), Uganda.MethodsWe prospectively collected demographic, clinical, and cost data from all surgical inpatients and caregivers at SRRH between February 2018 and January 2019. We conducted and thematically analyzed qualitative interviews to discern the impact of hospitalization on patients’ households. We employed the chi-square, t-test, ANOVA, and Bonferroni tests and built regression models to identify predictors of societal cost of surgical care. Out of pocket spending (OOPS) and catastrophic expenses were determined.ResultsWe encountered 546 patients, mostly male (62%) peasant farmers (42%), at a median age of 22 years; and 615 caregivers, typically married (87%), female (69%), at a median age of 35 years. Femur fractures (20.4%), soft tissue infections (12.3%), and non-femur fractures (11.9%) were commonest. The total societal cost of surgical care was USD 147,378 with femur fractures (USD 47,879), intestinal obstruction (USD 18,737) and non-femur fractures (USD 10,212) as the leading contributors. Procedures (40%) and supplies (12%) were the largest components of societal cost. About 29% of patients suffered catastrophic expenses and 31% were medically impoverished.ConclusionDespite free care, surgical conditions cause catastrophic expenses and impoverishment in Uganda. Femur fracture is the most expensive surgical condition due to prolonged hospitalization associated with traction immobilization and lack of treatment modalities with shorter hospitalization.

What is the financial burden to patients of accessing surgical care in Sierra Leone? A cross-sectional survey of catastrophic and impoverishing expenditure

ObjectivesTo measure the financial burden associated with accessing surgical care in Sierra Leone.DesignA cross-sectional survey conducted with patients at the time of discharge from tertiary-level care. This captured demographics, yearly...

Risk assessment of postoperative pneumonia among children undergoing otolaryngologic surgery: Derivation and validation of a preoperative risk profiling

BackgroundPostoperative pneumonia is a serious complication because it may be associated with morbidity, mortality and substantially increased cost of surgical care. Risk of postoperative pneumonia varies across surgical specialties, although its incidence and risk factors in pediatric otolaryngology have not been comprehensively elucidated. ObjectiveTo identify factors associated with postoperative pneumonia and determine whether a subset of children with a disproportionate risk of pneumonia can be identified. MethodsUsing the National Surgical Quality Improvement- Pediatric (NSQIP-P) database, we first selected children (N = 17,776; age under 18 years) who underwent inpatient pediatric otolaryngology procedures between 2012 and 2017. Using a random subset of 80% of the study population (derivation cohort), we next developed a multivariable logistic regression model to identify independent risk factors for postoperative pneumonia. We then divided children into risk groups and evaluated whether the Pareto principle applied to distribution of postoperative pneumonia across the risk groups. ResultsAmong the 12,443 children in the derivation cohort, 177 (1.4%) developed postoperative pneumonia. A multivariable risk model identified patients who developed postoperative pneumonia with good accuracy in both the derivation and validation cohorts. Stratification of patients into five mutually exclusive risk groups showed that 71% of postoperative pneumonia occurred in the highest risk group representing 20% the study cohort. Children who developed postoperative pneumonia were 18 times more likely to require an extended hospital length of stay (OR: 18.6; 95%CI: 12.3–28.2), and 7 times more likely to die compared to children without pneumonia (OR: 7.40, 95%CI: 3.53–15.48). ConclusionsWe identified key preoperative risk factors for postoperative pneumonia in children undergoing otolaryngology surgery. A small proportion (20%) of high-risk patients accounted for a large proportion (71%) of postoperative pneumonia indicating an underlying Pareto distribution and underscoring the need for targeted interventions for this “vital few”. Postoperative pneumonia in pediatric otolaryngology surgical inpatients was associated with longer hospital stay and a higher risk of mortality. Clinical trial number and registryNot applicable.

Importance of Routine Laboratory Investigations Before Elective Surgery.

BACKGROUND AND AIMS: Certain routine pre-operative laboratory investigations are performed in all patients before elective surgeries. We conducted this study to assess the value of routine pre-operative tests in the ASA (American Society of Anesthesiologists) Grade I and II adults undergoing elective surgery and their influence in the conduct of anaesthesia together with the costs incurred on unwarranted tests. METHODS: A total of 1271 patients posted for elective surgery under anaesthesia were recruited. Each patient attended the Pre-Anaesthetic Checkup Clinic and underwent clinical evaluation and investigations according to institutional policy. Demographic data and other characteristics were recorded, along with the results of laboratory test, any peri-operative intervention done as a result of abnormality and the cost incurred on tests. RESULTS: Majority of the patients belonged to ASA status I (74%) and underwent moderately invasive surgery (78%). The total number of routine investigations performed was 8015. Of these, 351 (4.37%) tests had abnormal results. Amongst these 333 (4.15%) abnormalities were suspected clinically and peri-operative intervention was only performed in 0.43% of patients. Anemia was the most common abnormal finding. Abnormal blood glucose was detected in 6 patients who were not clinically suspected. Abnormal electrocardiograph (ECG) was found in 54 patients. However, the intervention was required only in 13 patients. No intervention was required because of abnormal findings of the chest X-Ray. In total cost of investigations, only 6.9% was contributed by abnormal investigations and the rest was spent on the normal tests. CONCLUSION: The incidence of tests with abnormal results was very low in our study, and less than 1% of the patients with abnormal tests required changes in their peri-anaesthetic management. No major complications were seen in any patient with normal or abnormal test results. Most of the expenses (93%) were related to the normal test, which did not contribute to the perioperative management, safety and outcome of the patient. Thus, pre-operative investigations should be judiciously advised to avoid inconvenience, surgical delays and escalation of the costs of surgical care.

Single-institution Cost Comparison: Single-port Versus Multiport Robotic Prostatectomy

BackgroundIn the era of efficient value-based health care, each surgical innovation should be proven to be cost-effective for the patient and the hospital administration. ObjectiveTo compare the costs associated with robot-assisted prostatectomy using a single-port (SP) or multiport (MP) robotic platform. Design, setting, and participantsCosts for surgical care for consecutive patients with localized prostate cancer treated from November 2018 to November 2019 were itemized and evaluated. InterventionPatients were treated using either the SP (n = 78) or MP (n = 97) platform. Outcome measurements and statistical analysisDemographics, perioperative data, and costs for surgical care of patients in both groups were analyzed. Results and limitationThe mean cost for prostatectomy was comparable between SP ($13 512 ± $1615) and MP ($13 284 ± $1360; p = 0.32). The main cost differences between the groups were the cost of hospitalization, which was lower in the SP group (p < 0.001), offset by the cost of disposables in the operating room, which was higher in the SP group (p < 0.001). The mean length of stay was significantly shorter in the SP group (9.84 ± 11.3 vs 35.5 ± 29.1 h; p < 0.001) and the proportion of patients discharged home on the day of surgery was higher in the SP group (70% vs 5%; p < 0.001). The main limitation of this study is its retrospective design. ConclusionsOverall, the costs for SP and MP prostatectomy are comparable. The higher SP cost for consumable surgical materials is offset by the lower cost associated with hospitalization, which was largely due to a shorter hospital stay after SP surgery. Patient summaryIn this report, we found that implementation of the new single-port robotic platform for radical prostatectomy was not associated with higher surgical care costs compared to conventional multiport surgery.

A Comprehensive Estimation of the Costs of 30-Day Postoperative Complications Using Actual Costs from Multiple, Diverse Hospitals

The cost of surgical care is largely measured by charges or payments, both of which are inadequate. Actual cost data from the hospital's perspective are required to accurately quantify the financial return on investment of engaging in quality improvement. The objective of this study was to define the cost of individual, 30-day postoperative complications using robust cost data from a diverse group of hospitals. Using clinical data derived from the American College of Surgeons National Surgical Quality Improvement Program, this retrospective study assessed postoperative complications for patients who underwent surgery at one of four hospitals in 2016. Actual direct and indirect 30-day costs were obtained, and the adjusted cost per complication was determined. From the 6,387 patients identified, the three complications associated with the highest independent adjusted cost per event were prolonged ventilation ($48,168; 95% confidence interval [CI]: $21,861-$74,476), unplanned intubation ($26,718; 95% CI: $15,374-$38,062), and renal failure ($18,528; CI: $17,076-$19,981). The three complications associated with the lowest independent adjusted cost per event were urinary tract infection (-$372; 95% CI: -$1,336-$592), superficial surgical site infection ($2,473; 95% CI: -$256-$5,201) and venous thromboembolism ($7,909; 95% CI: -$17,903-$33,721). After colectomy, the adjusted independent cost of anastomotic leak was $10,195 (95% CI: $5,941-$14,449), while the cost of postoperative ileus was $10,205 (95% CI: $6,259-$14,149). The actual hospital costs of complications were estimated using cost data from four diverse hospitals. These data can be used by hospitals to estimate the financial benefit of reducing surgical complications.

Impact of Gastrointestinal Surgical Site Wound Complications on Long-term Healthcare Utilization

ImportanceWound complication following gastrointestinal surgery substantially impacts the quality and costs of surgical care. The impact of wound complication on subsequent long-term healthcare utilization has not been fully studied. ObjectiveWe assessed the impact of surgical wound complication on inpatient and outpatient healthcare utilization in the 2 years after gastrointestinal (GI) surgery. DesignAn observational retrospective cohort study was conducted on Veterans Affairs health system patients who underwent an inpatient GI surgical procedure, were assessed by the Veterans Affairs Surgical Quality Improvement Program (VASQIP), and were discharged alive from Veterans Affairs (VA) hospitals between October 1, 2007 and September 30, 2014. SettingPopulation-based ParticipantsA total of 64,351 patients underwent a GI surgical procedure in the VA system between 2007 and 2014. The cohort was 93.5% male, with a median age of 63.0 years (interquartile range (IQR) 57.0–70.0). A total of 7880 patients (12.2%) had at least one reported wound complication, 5460 of which had their postoperative wound complication classified by a VASQIP nurse. ExposureVASQIP-assessed or ICD-9-coded wound complication in the 30 days after surgery Main Outcome MeasurementsInpatient visits, total inpatient days, outpatient visits, and emergency department visits, and operative interventions up to 2 years after discharge from index admission ResultsPatients with a postoperative wound complication had greater inpatient healthcare utilization compared with no-wound complication for up to 2 years after surgery: inpatient admissions (mean number 3.5 vs. 2.8; P < .001), inpatient bed days (mean 41.0 vs. 25.0; P < .001). Patients with a postoperative wound complication also had greater 2-year outpatient utilization than the no-wound complication cohort: outpatient visits (mean number 92.7 vs. 75.9; P < .001) and emergency department visits (mean 3.5 vs. 2.7; P < .001). The same relationship held for wound-related parameters; inpatient admissions (2.2 vs. 0.4; P < .001); inpatient bed days (21.4 vs. 3.7; P < .001); and outpatient visits (56.2 vs. 9.7; P < .001). A greater proportion of patients in the wound complication cohort had an operative intervention for all time intervals examined (P < .001). ConclusionsSurgical wound complications impact healthcare utilization patterns for up to 2 years after the index procedure including hospital readmissions and operative interventions; efforts to reduce postoperative wound complications will have substantial effects on patient outcomes and healthcare expenditures well beyond the 30-day postoperative period.

‘A small cemetery’: death and dying in the contemporary British operating theatre

Surgeon Henry Marsh begins his autobiography, Do No Harm, with a quotation from the French practitioner René Leriche, “Every surgeon carries within himself a small cemetery, where from time to...

Operative Time and Cost Vary by Surgeon: An Analysis of Supracondylar Humerus Fractures in Children.

Operative time is a critical driver of cost in orthopedics and an important target for improving value in health care. This study used an archetypal pediatric orthopedic procedure to identify surgeon-dependent variability in operative time. The authors reviewed patients 12 years or younger treated with closed reduction and percutaneous pinning for extension-type supracondylar humerus fractures. Variability in operative time across surgeons was assessed. Surgeon experience at the time of the procedure and case volume (quarterly) were evaluated to explain variations in operative time. A total of 1472 patients were reviewed (57% Gartland type II and 43% type III fractures). Procedures were performed by 12 fellowship-trained pediatric orthopedists with 2 weeks to 32.8 years of experience. For individual surgeons, the mean operative time ranged from 20.4 to 33.7 minutes for type II fractures and from 31.0 to 46.8 minutes for type III fractures. There was significant variation across surgeons in mean operative time and cost (P<.001). Analysis showed no significant effect of surgeon experience or quarterly case volume. Surgeons' mean operative time for type II fractures was strongly positively correlated with their mean operative time for type III fractures (r2=0.74). Mean operative time and cost for supracondylar humerus fracture closed reduction and percutaneous pinning vary significantly between surgeons, but this variation is not explained by experience or volume. Surgeons who required more time for type II fractures were also slower for type III fractures. Because of the high per minute cost of the operating room, surgeon variability significantly impacts cost. Identification and modification of sources of variation in surgeon behavior will allow for reduction in the cost of surgical care. [Orthopedics. 2019; 42(3):e317-e321.].

Wide variation in cost of surgical care for parathyroidectomy: is there a need for standardization of practice?

BackgroundIdentifying hospital and provider variation in surgical cost is a potent method for controlling rising healthcare expenditure and delivering cost-effective care. The purpose of this study was to examine the variation of hospital cost by providers for parathyroidectomy in a single academic institution. MethodsWe retrospectively evaluated 894 consecutive parathyroidectomies under 8 surgeons in our institution between September 2011 and July 2016. Total duration of stay and cost were evaluated using nonparametric tests. Categorical variables were evaluated with χ2. ResultsThe median total hospital cost for parathyroidectomy was $4,863.28 (interquartile range: 4,196–5,764), but the median costs per provider varied widely from $4,522.30 to $12,072.87. The median duration of stay was 0 days (IQR: 0–1) and demonstrated a wide variation among providers. Longer duration of practice was associated with lower cost. Despite the variation, only 2% was readmitted after discharge with no patient mortality. ConclusionWe found substantial variation in hospital cost among providers for parathyroidectomy despite practicing in the same academic institution, with some surgeons spending 4 time more for the same operation. Implementing institutional standards of practice could be a method to decrease variation and costs of surgical care.