Incremental Costs Of Complications Research Articles

PCN53 - Economic Impact of Laparoscopic Vs Open Low Anterior Resection for Rectal Cancer Surgery: A Budget Impact Analysis

Laparoscopic colorectal surgery has become a well-established treatment option for malignant colorectal disease. Despite the demonstrated clinical advantages, it remains underpenetrated; less than 50% of patients receive minimally invasive procedures. The study objective was to assess the economic and clinical impact of laparoscopy in comparison with an open procedure in low anterior resection (LAR) for rectal cancer surgery. A budget impact model was developed from a hospital perspective. Inpatient costs included device, operating room (OR), hospital stay (LOS) and treatment costs for major complications (anastomotic leak, surgical site infection (SSI) and bleeding). Peer-reviewed literature was leveraged to inform procedural costs for hourly OR cost and daily cost of LOS. Incremental costs of complications and frequencies of major complications were estimated from Ethicon’s internal data. Quantities of the devices used in both procedures were based on the literature as well as expert opinion, while unit costs of devices were based on average selling price in 2015 USD. Converted cases from laparoscopic to open (15%) were considered as part of model specifications. The cost estimate for converted cases was reported under laparoscopic surgery. Per procedure, the estimated cost saving of laparoscopy was $1,041 compared to open surgery. Although open surgery incurred lower device and OR costs, laparoscopic surgery demonstrated cost saving on hospital stay and treatment for complications, fully offsetting the upfront device costs of laparoscopic approach. Laparoscopic surgery was associated with reduction of major complication rates (costs): 30.6% ($783) less anastomotic leak, 30.1% ($1,140) less SSI, and 26.5% ($1,013) less bleeding. Despite longer (11.6%) operating times, laparoscopic surgery showed a 19.0% shorter LOS compared with open surgery. In LAR for rectal cancer surgery adoption of laparoscopic approach may help to reduce the cost of surgery for hospitals in addition to providing inherent clinical and patient benefits.

Complications and Health Care Costs Associated With Transvenous Cardiac Pacemakers in a Nationwide Assessment.

The aim of this study was to retrospectively characterize transvenous pacemaker (TVP) complications and associated health care costs in a large-scale U.S. patient cohort. TVP complications have previously been shown to affect more than 1 in 10 patients but may be underestimated. Pacemakers are widely implanted across community and urban hospitals by operators of varying specialization and experience. Truven Health MarketScan databases track U.S. health care claims and encounters of private or Medicare supplemental insurance. Patients implanted with de dual- and single-chamber TVPs between April 2010 and March 2014 and over 1 year of pre-implantation MarketScan enrollment were identified. International Classification of Diseases-Ninth Revision and Current Procedural Terminology codes were used to extract relevant comorbidities and complications. Incremental adjusted cost analysis was performed for acute complications, defined as those occurring within 30 days of implantation. Among 72,701 TVP implantations (mean age 75 ± 12 years, 55% men, 13% single chamber) with 1.5 ± 1.1 years of follow-up, acute complications (0 to 1 month) occurred in 7.7% of single- and 9.1% of dual-chamber TVPs and long-term complications (1 to 36 months) in 6.4% and 5.9% of single- and dual-chamber TVPs, respectively. The net 3-year event rates were approximately 15% and 16%. The incidence and incremental cost of complications are considerable. Most common acute complications include thoracic trauma (3.71%, $70,114), leads requiring revision (3.51%, $9,296), and infection (1.15%, $80,247). Long-term complications are attributed to leads (2.84%), infection (2.42%), and pocket (0.96%). Claims data suggest that TVP complications are more common than previously reported, affectingnearly 1 in 6 patients by 3 years and contributing to considerable incremental U.S. health care cost.

IMPACT OF COMPLICATION COST ASSUMPTIONS ON THE REAL-WORLD COST-EFFECTIVENESS OF TRANSCATHETER AORTIC VALVE REPLACEMENT IN THE UNITED STATES

BACKGROUND: Prior studies have supported the cost-effectiveness of transcatheter aortic valve replacement (TAVR) for patients considered to be high-risk for conventional surgical aortic valve replacement (SAVR). However, the extent to which these results are sensitive to the frequency and cost of specific procedural complications remains unknown and data have recently emerged suggesting that TAVR complications may be considerably more costly than previously assumed. METHODS: Using a Markov decision-analytic model based on a meta-analysis of real-world outcomes for 13,408 TAVR and 2,046 SAVR patients, we examined the impact of alternative assumptions with respect to the cost of complications based on three different sources: HCUP databases (base case); the CoreValve US pivotal extreme risk study; and the PARTNER I trial. All analyses we performed from the perspective of the US healthcare system with a lifetime time horizon. In the base case analysis, complication costs were assumed to be the same whether a patient underwent TAVR or SAVR. RESULTS: In the primary analysis, TF TAVR was economically dominant compared with SAVR, resulting in cost savings of $3,191/patient and a gain of 0.57 QALYs. Under base case assumptions there was an 81.3% likelihood that the TF TAVR incremental cost-effectiveness ratio (ICER) was <$50,000/QALY. This probability was 82.2% under cost assumptions derived from the CoreValve US Pivotal trial and 80.8% using Partner I cost data. The likelihood an ICER <$50,000/QALY with alternative access (AA) TAVR was considerably lower (26%), but there was similarly little impact of alternate complications cost-structures. However, sensitivity analyses revealed that the different cost-structures were indeed important considerations when the cost of specific complications following TAVR and SAVR were assumed to differ. This was particularly true for AA TAVR, which was projected to be an economically dominated strategy if the cost of specific complications after SAVR were 30% lower than the cost of the same complications after TAVR, but the optimal choice only when SAVR complication costs were assumed to be 2 or more times the cost following TAVR. The exact economic projection was heavily influenced by the complication cost-structure assumed (interaction). CONCLUSION: Assuming differential complication costs between TAVR and SAVR had an important impact on the probability that AA-TAVR would be economically attractive compared with SAVR. Studies are therefore needed to determine the extent to which the incremental costs of complications differ between TAVR and SAVR. 221 TAVI FOR VERY SMALL PATIENTS

PO239 COST-EFFECTIVENESS ANALYSIS OF MEDICAL INTERVENTION IN PATIENTS WITH EARLY DETECTION OF DIABETIC NEUROPATHY IN A TERTIARY CARE HOSPITAL IN BANGLADESH

The economic burden resulting from Diabetic Nephropathy (DN) consumes a major portion of resources allocated for health-care services. Cost-effectiveness of various interventions on DN and its complications have relatively been well explored in developed countries, but these are almost absent in developing countries. The present study was undertaken to assess the cost-effectiveness of medical intervention in patients with DN. Two hundred patients with DN, with at least 1 yr of follow-up, were purposively selected from BIRDEM (tertiary diabetes care hospital) of Bangladesh. Of them 100 were late in detection (Serum Creatinine 4.0 mmom/l, Late detected DN or Late detected diabetic nephropathy) and 100 were detected early (Serum Creatinine <4.0 mmom/l, early detected DN or early detected diabetic nephropathy). The degree and extent of complications like cardiopathy, peripheral neuropathy, retinopathy and vasculopathy, treatment outcome, clinical effectiveness of interventions and direct, indirect and incremental cost of complications were calculated. Comparison was made between the groups. Cost included drugs, hospitalizations, diagnostics and visits. A total of 200 patients were considered for an average of 365 days, amounting to 651 person years of observation in total. The mean SD fasting serum glucose of the groups was 9.36 0.40 mmol/l and 4.78 0.38 mmol/l, total cholesterol was 206.50 42.60 and 104.20 35.50 mg/dl, HbA1c was 9.80 0.50% and 5.70 0.38%, TG was 163.76 99.46 and 155.67 94.84 mg/dl and serum creatinine was 0.89 0.03 and 4.90 1.17 mmol/l in Late detected diabetic nephropathy and early detected diabetic nephropathy respectively. About 19% patients in Late detected diabetic nephropathy and 36% in early detected diabetic nephropathy were free of diabetic complications other than DN. In Late detected diabetic nephropathy, 32% had one complication, 29% had two and 20% had more than two complications. On the other hand, in early detected diabetic nephropathy the corresponding values were 48%, 10% and 6% respectively. The most frequent complication was cardiopathy, which affected 33% patients in Late detected diabetic nephropathy and 27% in early detected diabetic nephropathy, followed by peripheral neuropathy 21% and 18%, retinopathy 17% and 13%, and vasculopathy 10% and 6% respectively. The average annual cost of care was US$ 27,954 (direct US$ 16,983 and indirect US$ 10,971), with an average US$ 140 per patient. Among the average annual cost Late detected diabetic nephropathy consumed US$ 19,837 (US$ 198 per patient) and early detected diabetic nephropathy US$ 8117 (US$ 81 per patient). 48% (US$ 13,473) of costs were attributable to drugs for both groups of which US$ 10,817 (80%) was for Late detected diabetic nephropathy and US$ 2656 (20%) for early detected diabetic nephropathy, 31% (US$ 8739) to hospitalizations of which US$ 5211 (60%) for Late detected diabetic nephropathy and 3528 (40%) for early detected diabetic nephropathy. In case of diagnostics and visits the corresponding values were US$ 2136 (60%) and 1419 (40%) and US$ 1673 (76%) and 514 (24%) for Late detected diabetic nephropathy and early detected diabetic nephropathy respectively. The annual medical costs increased with the number of complications from US$ 1320–2296 and to 3989 in Late detected diabetic nephropathy with one, two and more than two complications (other than DN) which is increasing at a rapid rate and US$ 917–1556 and to 2372 in early detected diabetic nephropathy respectively, increasing at a diminishing marginal rate. The regression equation showed that medical cost is significantly related to complications tested in both univariate (P < 0.0001) and multiple linear regression analyses (R 2 =0 .52;F = 82.3, P < 0.0001). Proper management with regular screening substantially reduces the expenditure related to care of patients with Diabetic Nephropathy and related complications even in a developing country. Strategies aimed at preventing Diabetic Nephropathy and early detection of the onset of nephropathy complication will reduce medical costs in a substantial way.

Incremental cost of complications in colectomy: a warranty guided approach to surgical quality improvement

BackgroundWe assessed the warranty cost for colectomy at a single institution, as defined by the additional cost of treating complications distributed across all patients treated. MethodsAll segmental colectomies from July 8 to June 12 were reviewed for 0, 1, 2, and ≥3 complications. Warranty cost is defined as follows: ([mean additional cost of the case with complication(s) – mean base case cost] × number of episodes)/total population. ResultsThousand four hundred twenty-two colectomies were analyzed. The lowest cost case was a laparoscopic resection with 0 complications ($7,739 ± 4,150). Warranty costs were less for laparoscopic versus open colectomy (0 - $0, 1 - $128, 2 - $66, ≥3 - $248 vs 0 - $1,036, 1 - $501, 2 - $520, ≥3 - $1,971). This was true for costs associated with readmission ($303 vs $1,519). Emergency status and elderly status also impacted warranty costs. ConclusionsThe data demonstrate that warranty costs were highest with open colectomy, emergency cases, and the elderly. These data can be used to measure both quality and cost impact of mitigation strategies.

Cost-effectiveness analysis of immune-modulating nutritional support for gastrointestinal cancer patients

Immune-modulating nutritional formula containing arginine, omega-3 fatty acids and nucleotides has been demonstrated to decrease complications and length of stay in surgical patients. This study aims at assessing the impact of immune-modulating formula on hospital costs in gastrointestinal cancer surgical patients in Switzerland. Based on a previously published meta-analysis, the relative risks of overall and infectious complications with immune-modulating versus standard nutrition formula were computed. Swiss hospital costs of patients undergoing gastrointestinal cancer surgery were retrieved. A method was developed to compute the patients' severity level, not taking into account the complications from the surgery. Incremental costs of complications were computed for both treatment groups, and sensitivity analyses were carried out. Relative risk of complications with pre-, peri- and post-operative use of immune-modulating formula was 0.69 (95%CI 0.58-0.83), 0.62 (95%CI 0.53-0.73) and 0.73 (95%CI 0.35-0.96) respectively. The estimated average contribution of complications to the cost of stay was CHF 14,949 (€10,901) per patient (95%CI 10,712-19,186), independently of case's severity. Based on this cost, immune-modulating nutritional support decreased costs of hospital stay by CHF 1638 to CHF 2488 per patient (€1195-€1814). Net hospital savings were present for baseline complications rates as low as 5%. Immune-modulating nutritional solution is a cost-saving intervention in gastrointestinal cancer patients. The additional cost of immune-modulating formula are more than offset by savings associated with decreased treatment of complications.

193 The Incremental Cost of Complications after Left Ventricular Assist Device Placement

193 The Incremental Cost of Complications after Left Ventricular Assist Device Placement

Cost-effectiveness analysis of medical intervention in patients with early detected of Diabetic Nephropathy in a tertiary care hospital in Bangladesh

The economic burden resulting from Diabetic Nephropathy (DN) consumes a major portion of resources allocated for health-care services. Cost-effectiveness of various interventions on DN and its complications have relatively been well explored in developed countries, but these are almost absent in developing countries. The present study was undertaken to assess the cost-effectiveness of medical intervention in patients with DN. Two hundred patients with DN, with at least 1 yr of follow-up, were purposively selected from BIRDEM (tertiary diabetes care hospital) of Bangladesh. Of them 100 were late in detection (Serum Creatinine ≥4.0 mmom/l, Late detected DN or Late detected diabetic nephropathy) and 100 were detected early (Serum Creatinine <4.0 mmom/l, early detected DN or early detected diabetic nephropathy). The degree and extent of complications like cardiopathy, peripheral neuropathy, retinopathy and vasculopathy, treatment outcome, clinical effectiveness of interventions and direct, indirect and incremental cost of complications were calculated. Comparison was made between the groups. Cost included drugs, hospitalizations, diagnostics and visits. A total of 200 patients were considered for an average of 365 days, amounting to 651 person years of observation in total. The mean ± SD fasting serum glucose of the groups was 9.36 ± 0.40 mmol/l and 4.78 ± 0.38 mmol/l, total cholesterol was 206.50 ± 42.60 and 104.20 ± 35.50 mg/dl, HbA1c was 9.80 ± 0.50% and 5.70 ± 0.38%, TG was 163.76 ± 99.46 and 155.67 ± 94.84 mg/dl and serum creatinine was 0.89 ± 0.03 and 4.90 ± 1.17 mmol/l in Late detected diabetic nephropathy and early detected diabetic nephropathy respectively. About 19% patients in Late detected diabetic nephropathy and 36% in early detected diabetic nephropathy were free of diabetic complications other than DN. In Late detected diabetic nephropathy, 32% had one complication, 29% had two and 20% had more than two complications. On the other hand, in early detected diabetic nephropathy the corresponding values were 48%, 10% and 6% respectively. The most frequent complication was cardiopathy, which affected 33% patients in Late detected diabetic nephropathy and 27% in early detected diabetic nephropathy, followed by peripheral neuropathy 21% and 18%, retinopathy 17% and 13%, and vasculopathy 10% and 6% respectively. The average annual cost of care was US$ 27,954 (direct US$ 16,983 and indirect US$ 10,971), with an average US$ 140 per patient. Among the average annual cost Late detected diabetic nephropathy consumed US$ 19,837 (US$ 198 per patient) and early detected diabetic nephropathy US$ 8117 (US$ 81 per patient). 48% (US$ 13,473) of costs were attributable to drugs for both groups of which US$ 10,817 (80%) was for Late detected diabetic nephropathy and US$ 2656 (20%) for early detected diabetic nephropathy, 31% (US$ 8739) to hospitalizations of which US$ 5211 (60%) for Late detected diabetic nephropathy and 3528 (40%) for early detected diabetic nephropathy. In case of diagnostics and visits the corresponding values were US$ 2136 (60%) and 1419 (40%) and US$ 1673 (76%) and 514 (24%) for Late detected diabetic nephropathy and early detected diabetic nephropathy respectively. The annual medical costs increased with the number of complications from US$ 1320–2296 and to 3989 in Late detected diabetic nephropathy with one, two and more than two complications (other than DN) which is increasing at a rapid rate and US$ 917–1556 and to 2372 in early detected diabetic nephropathy respectively, increasing at a diminishing marginal rate. The regression equation showed that medical cost is significantly related to complications tested in both univariate ( P < 0.0001) and multiple linear regression analyses ( R 2 = 0.52; F = 82.3, P < 0.0001). Proper management with regular screening substantially reduces the expenditure related to care of patients with Diabetic Nephropathy and related complications even in a developing country. Strategies aimed at preventing Diabetic Nephropathy and early detection of the onset of nephropathy complication will reduce medical costs in a substantial way.

Incremental Costs of Post–Liver Transplantation Complications

Complications after liver transplantation are common and expensive. The incremental costs of adult posttransplantation liver transplantation complications and who pays for these complications (center or payor) is unknown. We reviewed the medical and financial records (first 90 postoperative days) of all adult liver transplant recipients at our center between July 1, 2002, and October 30, 2005 (N = 214). The association of donor, recipient, and financial data points (total costs, reimbursements, and profits) was assessed using standard univariable analyses. The incremental costs of complications were determined with multiple linear regression models to control for the costs inherent to donor and recipient characteristics. Univariate analyses demonstrated that both total hospital costs and reimbursements were substantially increased in patients with several different complications. Multiple linear regression analysis, controlling for recipient (age, gender, race, and laboratory Model for End-Stage Liver Disease [MELD]) and donor factors (donor risk index), noted that increased hospital costs and hospital reimbursements were independently associated with laboratory MELD (incremental costs of $3,368 and $2,787, respectively, per MELD point) and pneumonia ($83,718 and $68,214, respectively). A negative profit margin for the medical center was independently associated with peritonitis ($21,760). Commercial insurance was associated with no changes in total costs when compared with public insurer, but it was associated with decreased reimbursement and profit. The incremental costs of complications in liver transplantation are high for both the medical center and payor, but medical center profits are not affected substantially. The payor bears the financial burden for post-liver transplantation complications.

The economics of treatment for infants with respiratory distress syndrome.

To define clinical outcomes and prevailing patterns of care for the initial hospitalization of infants at greatest risk for respiratory distress syndrome (RDS); to estimate direct medical care costs associated with the initial hospitalization; and to introduce and demonstrate a simulation technique for the economic evaluation of health care technologies. Clinical outcomes and usual-care algorithms were determined for infants with RDS in three birthweight categories (500-1,000g; >1,000-1,500g; and >1,500g) using literature- and expert-panel-based data. The experts were practitioners from major U.S. hospitals who were directly involved in the clinical care of such infants. Using the framework derived from the usual care patterns and outcomes, the authors developed an itemized "micro-costing" economic model to simulate the costs associated with the initial hospitalization of a hypothetical RDS patient. The model is computerized and dynamic; unit costs, frequencies, number of days, probabilities and population multipliers are all variable and can be modified on the basis of new information or local conditions. Aggregated unit costs are used to estimate the expected medical costs of treatment per patient. Expected costs of initial hospitalization per uncomplicated surviving infant with RDS were estimated to be $101,867 for 500-1,000g infants; $64,524 for >1,000-1,500g infants; and $27,224 for >1,500g infants. Incremental costs of complications among survivors were estimated to be $22,155 (500-1,000g); $11,041 (>1,000-1,500g); and $2,448 (>1,500 g). Expected costs of initial hospitalization per case (including non-survivors) were $100,603; $72,353; and $28,756, respectively. An itemized model such as the one developed here serves as a benchmark for the economic assessment of treatment costs and utilization. Moreover, it offers a powerful tool for the prospective evaluation of new technologies or procedures designed to reduce the incidence of, severity of, and/or total hospital resource use ascribed to RDS.