Perioperative Costs Research Articles

The Financial Burden of Patient Comorbidities on Total Knee Arthroplasty Procedures: A Matched Cohort Analysis of Patients Who Have a High and Non-High Comorbidity Burden

IntroductionRecent literature has suggested a trend toward a higher comorbidity burden in patients undergoing total knee arthroplasty (TKA). However, there is a lack of data on the impact of increased comorbidities on the cost-effectiveness of TKA. The purpose of this study was to compare the financial implications and perioperative outcomes of patients who do and do not have a high comorbidity burden (HCB). MethodsWe retrospectively reviewed 10,647 patients who underwent an elective, unilateral TKA between 2012 and 2021 and had available financial data. Patients were stratified into HCB (Charlson Comorbidity Index [CCI] ≥ 5) and American Society of Anesthesiology [ASA] scores of 3 or 4) and non-HCB groups and were 1:1 propensity-matched based on baseline characteristics. Perioperative data, revenue, costs, and contribution margins (CM) of the inpatient episode were compared between groups. The 90-day readmissions and revisions were also compared. Of the 10,647 patients reviewed (1,186 HCB, 9,461 non-HCB), 1,536 patients were included in the matched analyses (768 per group). ResultsThe HCB patients had significantly greater total (P < 0.001) and direct (P < 0.001) costs, yet hospital revenue did not differ between cohorts (P = 0.638). This resulted in a significantly decreased CM for the HCB group (P = 0.009). The HCB cohort also had a significantly greater length of stay (P < 0.001) and 90-day readmissions (P = 0.005). ConclusionsIncreased inpatient costs for HCB patients undergoing TKA were not met with increased revenue to cover these costs, leading to a decreased CM. Furthermore, greater 90-day readmissions in the HCB cohort add to the already disproportionate financial burden of these patients. The capacity of hospitals to cover indirect expenses might be impacted, jeopardizing the accessibility of care for HCB patients who need TKA. Current reimbursement models should be modified to adequately consider the increased financial burden associated with HCB patients undergoing TKA.

Outcome of laparoscopic feeding jejunostomy, comparison of a pure laparoscopic technique with Witzel’s tunnel to open technique: a retrospective cohort study

IntroductionObstructive upper GI cancer commonly uses feeding jejunostomy as a standard procedure. Surgeons implemented laparoscopic feeding jejunostomy via minimally invasive surgery, employing a variety of techniques. This study assessed the perioperative results, safety, and costs associated with laparoscopic versus open jejunostomy surgeries. We used only Witzel’s tunnel and standard laparoscopic instruments.Patients and methodsWe collected data from all patients who underwent feeding jejunostomy between January 2016 and June 2018. We recorded pertinent data on baseline, surgical outcomes, postoperative results, complications, and costs. The study excluded patients with jejunostomy as a conversion or an addition.ResultWe divided the 74 patients into 2 groups: 30 underwent laparoscopy and 44 underwent open surgery. The mean operational times were 89.67 and 91.64 min and showed no statistically significant difference (p = 0.678). The mean morphine dosage was significantly lower in the laparoscopic group (3.3 vs. 7.19, p = < 0.001). Laparoscopic surgery lowered the median time of feeding initiation, feeding accomplished, and postoperative stay, although none of these reached statistical significance. There were significantly higher surgical expenses in the laparoscopic group (16,410 vs. 11,685 Thai Baht) (p < 0.001); however, median overall expenditures did not significantly differ (105,147 vs. 116,198 Thai Baht) (p = 0.387). Laparoscopic versus open surgery had similar incidences of postoperative complications (20% vs. 25%, p = 0.846). The feeding tube catheter location was infection-free in all patients in our study.ConclusionLaparoscopic jejunostomy feeding was safe, and postoperative morphine consumption was lower. Increasing operational costs did not have a significant impact on overall expenditures. Witzel’s tunnel may reduce jejunostomy site infections.

Effect of preoperative Silodosin on facilitating access sheath placement in retrograde intrarenal surgery. A randomized controlled studys

ABSTRACT Introduction to evaluate the effect of preoperative Silodosin on ureteric dilatation to facilitate ureteral access sheath (UAS) placement and reduction of ureteral wall injury in retrograde intrarenal surgery (RIRS). Methods one hundred and twenty patients with renal or ureteric stones were randomly allocated into 2 equal groups. Group A represents patients who received a 7-day preoperative single dose Silodosin before RIRS while Group B represents patients who received a placebo for the same regimen. Our primary outcome was to assess the success rate of (UAS) placement. Our secondary outcomes were to evaluate the perioperative complication rate, stone-free rate, hospital stay, and cost analysis. Results In our study, Silodosin showed a higher success rate for (UAS) insertion compared to placebo with a statistically significant difference (p-value = 0.04). Spontaneous UAS insertion in the Silodosin group was 58.3%, which was increased with active ureteric dilatation to 98.3%. Preoperative Silodosin led to less postoperative pain and analgesics requirements without impacting postoperative hospital stay or stone-free rate. There was less ureteric injury incidence in the Silodosin group compared to placebo with a statistically significant difference (p-value = 0.002). Conclusion Preoperative Silodosin facilitates UAS insertion with a protective role against ureteric injury compared to placebo.

Preoperative Care Intensity and Cost for Renal Colic: Implications for Surgical Value-Based Reforms.

The aim of this study was to identify preoperative patient/facility factors associated with postoperative and total episode-related costs using renal colic as a model surgical condition to improve value-based payment models. Using state Healthcare Cost and Utilization Project data, we performed a retrospective cohort study examining perioperative costs for individuals presenting to an emergency department for renal colic and who ultimately underwent definitive surgical management. We estimated multivariable ordered and binary logistic regressions to examine the association between preoperative and operative cost quartiles on the probability of specific postoperative cost quartiles after accounting for hospital and individual factors. We also performed logistic regressions to identify patients who deviated from predicted perioperative cost pathways. Among 2736 individuals included in our analysis, episode-related costs ranged from $4536 (bottom quartile) to $26,662 (top quartile). Individuals in the highest preoperative cost quartile experienced an 11.7% higher probability of remaining in the highest postoperative cost quartile relative to those in the lowest preoperative cost quartile (95% CI, 0.0709-0.163; P < .001). Delays in surgery (95% CI, 0.0869-0.163; P < .001) and Medicaid vs private insurance (95% CI, 0.01-0.0728; P < .01) were associated with a 12.5% and 4.1% higher probability of being in the top quartile of preoperative costs, respectively. Treating facility experience with value-based payment models did not influence perioperative costs. Using renal colic as a model surgical condition, our novel findings suggest that preoperative costs are associated with both postoperative and total episode-related costs and should be accounted for when designing future value-based payment models.

Relationship between hospital surgical volume and the perioperative esophagectomy costs for esophageal cancer: a nationwide administrative claims database study.

Numerous studies have described positive relationships between hospital volume (HV) and clinical outcomes in highly complex procedures, including esophagectomies. Although the centralization of surgery has been considered a possible solution for improving clinical outcomes, the HV impact on perioperative healthcare costs is unknown. This study aimed to determine the relationship between HV and perioperative healthcare costs for patients undergoing esophagectomy for esophageal cancer. This retrospective, nationwide cohort study used Japanese Administrative Claims Database data. Data on esophagectomies performed nationwide in 2015 were extracted. The outcome measure was perioperative healthcare costs per person from the perspective of the insurer. The healthcare costs in outpatient or inpatient settings of any hospital and clinic where patients received treatment were summed up from the month the surgery was performed to 3months after. Linear regression analyses were conducted to assess the risk-adjusted effects of the HV category (1-4/5-9/10-14/15-) on perioperative costs. A total of 5232 patients underwent an esophagectomy at 584 hospitals. The overall perioperative cost was 20.834 billion Japanese yen (JPY). The median perioperative costs per person for each HV category (1-4/5-9/10-14/15-) were 3.728 (709 patients), 3.740 (658 patients), 3.760 (512 patients), and 3.760 (3253 patients) million JPY, respectively (P = 0.676). Multivariate analyses revealed that each HV category had no significant impact on perioperative costs. There were no significant differences in the perioperative costs between high- and low-volume centers. Esophageal cancer surgery centralization may be achievable without increasing healthcare costs.

Perioperative outcomes using computer navigation in primary total shoulder arthroplasty

IntroductionThe utilization of computer navigation to improve glenoid component placement in primary total shoulder arthroplasty (TSA) is becoming increasingly prevalent. However, there is a paucity of literature examining the perioperative outcomes and cost of this technology compared to standard instrumentation. The purpose of this study was to compare the perioperative complications and healthcare utilization between computer navigation and standard instrumentation in primary TSA. MethodsThe Nationwide Readmissions Database was queried from 2016 to 2020 to identify patients who underwent elective primary TSA. Patients who underwent TSA with computer navigation (n = 752) were propensity score matched in a 1:3 proportion to patients who underwent TSA with standard instrumentation (n = 2256) for age, sex, smoking status, alcohol abuse, hypertension, diabetes mellitus, congestive heart failure, obesity, peripheral vascular disease, chronic kidney disease, chronic liver disease, and chronic lung disease. Bivariate statistical analyses were performed to compare preoperative demographic and comorbidity data, postoperative complications, and hospital utilization metrics between the 2 groups. Chi-square and student t-tests identified differences in categorical and continuous variables, respectively. ResultsPatients undergoing TSA with computer navigation exhibited lower rates of revision within 180 days (P < .001) and lower rates of certain postoperative medical and surgical complications, including acute renal failure (P = .006), urinary tract infection (P = .015), acute respiratory distress syndrome (P = .045), surgical site infection (P = .022), dislocation (P = .012), and prosthetic loosening (P = .032). Computer navigation patients had a higher cost of initial admission (P < .001) but were less likely to have extended hospital stays (P = .047), less likely to be discharged with home healthcare (P < .001), and more likely to be discharged routinely (P < .001). ConclusionTSA with computer navigation was associated with lower revision rates and reduced postoperative complications. Although greater initial costs were observed, decreased extended hospital stays and more routine discharges show promise for long-term cost efficiency. These findings underscore the advantages of computer navigation in TSA and should be considered by orthopedic surgeons when evaluating choice of instrumentation.

Relationship of Surgical Approach With Financial Toxicity in Patients With Resected Lung Cancer.

Minimally invasive surgery (MIS) reduces lengths of stay, complications, and potentially perioperative hospital costs. However, the impact of MIS on financial toxicity (FT), defined as the costs resulting from oncologic care and their negative effects on quality of life, in patients with lung cancer is unknown. Our objective was to investigate the association between surgical approach and FT in this population. A single-institution study was performed evaluating resected lung cancer patients (2016-2021). FT was assessed using the Comprehensive Score for Financial Toxicity (COST) questionnaire. The relationship between surgical approach (MIS vs. thoracotomy) and FT was evaluated using propensity score-matched (PSM) regression analysis. A sensitivity analysis involving the entire cohort was also performed using an inverse probability-weighted generalized linear model. As reported previously, of 1477 patients surveyed, 463 responded (31.3%) with FT reported in 196 patients (42.3%). Resection was performed by thoracotomy in 53.3% (n = 247), and by MIS in the remainder (n = 216, 46.7%; video-assisted thoracoscopic surgery [VATS] = 115; robotic-assisted = 101). There was no difference in FT in patients who underwent VATS and robotic-assisted surgery (p = 0.515). In the PSM analysis, MIS was not associated with FT (odds ratio [OR]: 0.980, 95% confidence interval [CI]: 0.628-1.533, p = 0.929). Similar results were found on sensitivity analysis (OR: 1.488, CI: 0.931-2.378, p = 0.096). Compared to MIS, thoracotomy was not associated with FT in patients with resected lung cancer. Though there are several benefits from MIS, it does not appear to be a meaningful strategy to alleviate FT in this population.

SP1.2 - Laparoscopic versus Robotic ventral hernia repair: a systematic review and meta-analysis comparing the perioperative outcomes randomised controlled trials

Abstract Objective The objective of this meta-analysis is to compare the perioperative surgical outcomes and cost-effectiveness of robotic incisional/ventral hernia repair (RIVHR) versus laparoscopic incisional/ventral hernia repair (LIVHR). Methods Randomised control trials (RCTs) reporting perioperative outcomes and costs in patients undergoing RIVHR versus LIVHR were selected from medical electronic databases and meta-analysis was conducted under the guidelines of the Cochrane Collaboration using statistical software RevMan version 5. Results Four RCTs on 337 patients reporting perioperative outcomes and cost comparison were included. In the random effect model analysis, the duration of operation [standardized mean difference (SMD) -48.07, 95%, CI (-78.06, -18.07), z = 3.14, p = 0.002] was shorter and cost was lower [SMD 0.82, 95%, CI (-1.48, -0.16), z = 2.45, p = 0.01] in the LIVHR group but with significant statistical heterogeneity. However, the variables of hernia recurrence [risk ratio (RR) 2.29, 95%, CI (0.73, 7.12), z = 1.43, p = 0.15] and surgical site complications [RR 0.85, 95%, CI (0.48, 1.50), z = 0.55, p = 0.58] were statistically similar in both groups without any statistical heterogeneity among the included studies. Conclusion The RIVHR does not offer any superiority over LIVHR in all perioperative variables and it is not cost effective. Due to the paucity of the RCTs, a major multi-centre RCT is needed to validate these findings.

A propensity score matched cost analysis of robotic versus open hepatectomy

IntroductionCost-effectiveness of Robotic-assisted hepatectomy compared to the open approach is scrutinized. We compared the costs of robotic versus open hepatectomy at a large cancer center. MethodsPatients undergoing hepatectomy (1/2019-2/2022) were collected from a prospectively maintained database and 1:1 propensity score matched for 61 robotic and 61 open hepatectomy patients by complexity, tumor diagnosis, and age >65. Financial data was collected and converted to a ratio of service cost to average OR cost. Short-term and economic outcomes were compared. ResultsMedian length of stay (2 vs. 3 days), major complication rates (0% vs. 8.2%), and 90-day readmission rates (3.3% vs. 11.5%) were lower for robotic hepatectomy (all p < 0.05). Total 90-day perioperative costs were lower by 19.5% for the robotic cohort (mean 6.89 vs 8.56; p < 0.01). Intraoperative costs were higher in the robotic cohort (mean 2.75 vs. 2.44; p < 0.01). Cost reduction drivers during postoperative care were supplies (mean 0.26 vs. 0.75), laboratory (mean 0.27 vs. 0.49), regular surgery unit (mean 0.19 vs. 0.32), recovery room (mean 0.26 vs. 0.29) and pharmacy cost (median 0.21 vs. 0.32; all p < 0.05). ConclusionHospital costs of robotic hepatectomy were lower than those of open hepatectomy due to significantly reduced postoperative costs.

Perioperative complications and cost of posterior decompression with fusion in thoracic spine for ossification of the posterior longitudinal ligament and ossification of the ligamentum flavum -a comparative study using a national inpatient database

BackgroundAlthough posterior decompression with fusion (PDF) are effective for treating thoracic myelopathy, surgical treatment has a high risk of various complications. There is currently no information available on the perioperative complications in thoracic ossification of the longitudinal ligament (T-OPLL) and thoracic ossification of the ligamentum flavum (T-OLF). We evaluate the perioperative complication rate and cost between T-OPLL and T-OLF for patients underwent PDF.MethodsPatients undergoing PDF for T-OPLL and T-OLF from 2012 to 2018 were detected in Japanese nationwide inpatient database. One-to-one propensity score matching between T-OPLL and T-OLF was performed based on patient characteristics and preoperative comorbidities. We examined systemic and local complication rate, reoperation rate, length of hospital stays, costs, discharge destination, and mortality after matching.ResultsIn a total of 2,660 patients, 828 pairs of T-OPLL and T-OLF patients were included after matching. The incidence of systemic complications did not differ significantly between the T-OPLL and OLF groups. However, local complications were more frequently occurred in T-OPLL than in T-OLF groups (11.4% vs. 7.7% P = 0.012). Transfusion rates was also significantly higher in the T-OPLL group (14.1% vs. 9.4%, P = 0.003). T-OPLL group had longer hospital stay (42.2 days vs. 36.2 days, P = 0.004) and higher medical costs (USD 32,805 vs. USD 25,134, P < 0.001). In both T-OPLL and T-OLF, the occurrence of perioperative complications led to longer hospital stay and higher medical costs. While fewer patients in T-OPLL were discharged home (51.6% vs. 65.1%, P < 0.001), patients were transferred to other hospitals more frequently (47.5% vs. 33.5%, P = 0.001).ConclusionThis research identified the perioperative complications of T-OPLL and T-OLF in PDF using a large national database, which revealed that the incidence of local complications was higher in the T-OPLL patients. Perioperative complications resulted in longer hospital stays and higher medical costs.

Perioperative capacity and contextual challenges in teaching hospitals of southern Ethiopia: explanatory sequential mixed-methods research

BackgroundPrevious Ethiopian literature on surgical capacity and challenges has focused on quantitative investigations, lacking contextual understanding. This explanatory sequential mixed-methods research (MMR) aimed to assess perioperative capacity and contextual challenges at three teaching hospitals in southern Ethiopia.MethodsA quantitative survey assessed workforce, infrastructure, service delivery, financing, and information systems. The survey findings were explained by qualitative semi-structured interviews of twenty perioperative providers. Descriptive statistics were integrated with qualitative thematic analysis findings using the narrative waving approach. Key findings from both datasets were linked using a joint display table.ResultsThe survey revealed shortages in the specialist workforce (with a ratio of 0.58 per 100,000 population), surgical volume (at 115 surgeries per 100,000 population), equipment, supplies, financing, and perioperative data tracking. Hospitals’ radiology services and blood products were only available 25–50% of the time, while anesthetic agents and essential laboratory services were often available 51–75% of the time. Perioperative management protocols were used rarely (1–25% of the time). Over 90% of patients lack health insurance coverage. Qualitative data also revealed scarcity of perioperative resources and equipment; unaffordable perioperative costs, lack of health insurance coverage, and unforeseen expenses; poor patient safety culture and communication barriers across the perioperative continuum of care; workforce shortages, job dissatisfaction, and concerns of competence; and weak national governance, and sociopolitical turmoil, and global market volatility exacerbating local challenges. These challenges are linked to risks in quality of care and patient safety, according to clinicians.ConclusionThe study identifies deficiencies in the health system and sociopolitical landscape affecting safe surgery conduct. It highlights the need for comprehensive health system strengthening to expand workforce, upgrade facilities, improve safety culture, resilience, and leadership to ensure timely access to essential surgery. Exploring external factors, such as the impact of national governance and sociopolitical stability on reform efforts is also essential.

Contemporary utilization of three-column osteotomy techniques in a prospective complex spinal deformity multicenter database: implications on full-body alignment and perioperative course.

Research has focused on the increased correction from a three-column osteotomy (3CO) during adult spinal deformity (ASD) surgery. However, an in-depth analysis on the performance of a 3CO in a cohort of complex spinal deformity cases has not been described. This is a retrospective study on a prospectively enrolled, complex ASD database. This study aimed to determine if three-column osteotomies demonstrate superior benefit in correction of complex sagittal deformity at the cost of increased perioperative complications. Surgical complex adult spinal deformity patients were included and grouped into thoracolumbar 3COs compared to those who did not have a 3CO (No 3CO) (remaining cohort). Rigid deformity was defined as ΔLL less than 33% from standing to supine. Severe deformity was defined as global (SVA > 70mm) or C7-PL > 70mm, or lumbopelvic (PI-LL > 30°). Means comparison tests assessed correction by 3CO grade/location. Multivariate analysis controlling for baseline deformity evaluated outcomes up to six weeks compared to No 3CO. 648 patients were included (Mean age 61 ± 14.6years, BMI 27.55 ± 5.8kg/m2, levels fused: 12.6 ± 3.8). 126 underwent 3CO, a 20% higher usage than historical cohorts. 3COs were older, frail, and more likely to undergo revision (OR 5.2, 95% CI [2.6-10.6]; p < .001). 3COs were more likely to present with both severe global/lumbopelvic deformity (OR 4), 62.4% being rigid. 3COs had greater use of secondary rods (OR 4st) and incurred 4 times greater risk for: massive blood loss (> 3500mL), longer LOS, SICU admission, perioperative wound and spine-related complications, and neurologic complications when performed below L3. 3COs had similar HRQL benefit, but higher perioperative opioid use. Mean segmental correction increased by grade (G3-21; G4-24; G5-27) and was 4 × greater than low-grade osteotomies, especially below L3 (OR 12). 3COs achieved 2 × greater spinopelvic correction. Higher grades properly distributed lordosis 50% of the time except L5. Pelvic compensation and non-response were relieved more often with increasing grade, with greater correction in all lower extremity parameters (p < .01). Due to the increased rate of complications, 3COs trended toward higher perioperative cost ($42,806 vs. $40,046, p = .086). Three-column osteotomy usage in contemporary complex spinal deformities is generally limited to more disabled individuals undergoing the most severe sagittal and coronal realignment procedures. While there is an increased perioperative cost and prolongation of length of stay with usage, these techniques represent the most powerful realignment techniques available with a dramatic impact on normalization at operative levels and reciprocal changes.

Effect of IWATE laparoscopic difficulty score on postoperative outcomes and costs for robotic hepatectomy: Are complex resections more expensive?

The IWATE criteria, a four-level classification system for laparoscopic hepatectomy, measures technical complexity but lacks studies on its impact on outcomes and costs, especially in robotic surgeries. This study evaluated the effects of technical complexity on perioperative outcomes and costs in robotic hepatectomy. Since 2013, we prospectively followed 500 patients who underwent robotic hepatectomy. Patients were classified into four levels of IWATE scores; (low [0-3], intermediate [4-6], advanced [7-9], and expert [10-12]) determined by tumor characteristics, liver function and resection extent. Perioperative variables were analyzed with significance accepted at a p-value ≤.05. Among 500 patients, 337 (67%) underwent advanced to expert-level operations. Median operative duration was 213 min (range: 16-817 min; mean ± SD: 240 ± 116.1 min; p < .001) and estimated blood loss (EBL) was 95 mL (range: 0-3500 mL; mean ± SD:142 ± 171.1 mL; p < .001). Both operative duration and EBL showed positive correlations with increasing IWATE scores. Median length of stay (LOS) of 3 days (range: 0-34; mean ± SD:4 ± 3.0 days; p < .001) significantly correlated with IWATE score. Total cost of $25 388 (range: $84-354 407; mean ± SD: 29752 ± 20106.8; p < .001) also significantly correlated with operative complexity, however hospital reimbursement did not. No correlation was found between IWATE score and postoperative complications or mortality. Clinical variables such as operative duration, EBL, and LOS correlate with IWATE difficulty scores in robotic hepatectomy. Financial metrics such as costs but not reimbursement received by the hospital correlate with IWATE scores.

Analysis of Costs Associated With Increased Length of Stay After Total Joint Arthroplasty at a Single Private Practice.

As the demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA) increases, so does the financial burden of these services. Despite efforts to optimize spending and bundled care payments, THA and TKA costs still need to be assessed. Our study explores the relationship between perioperative costs and length of stay (LOS) for THA and TKA. A total of 614 patients undergoing THA or TKA at a single private practice with LOS from zero to 3 days were identified. All patients were insured by private or Medicare Advantage insurance from a single provider. Primary outcomes included total costs and their relationship with LOS, classified into surgeon reimbursement, facility costs, and anesthesia costs. Secondary outcomes included readmission rates and discharge disposition. Analyses involved Student t-test, analysis of variance, and chi-square tests. Longer LOS was associated with increased total, facility, and anesthesia costs. Costs for THA patients were stable except for reduced surgeon reimbursement with longer LOS. Patients undergoing TKA experienced an increase in facility costs with longer LOS. Total facility and anesthesia costs increased with LOS for Medicare Advantage patients, but surgeon reimbursement remained stable. Privately insured patients experienced higher total and facility costs but stable surgeon reimbursement and anesthesia costs regardless of LOS. Our study shows an increase in total cost with longer LOS, especially pronounced in privately insured patients. A notable reduction was observed in the surgeon reimbursement for Medicare Advantage patients with extended LOS. These findings underscore the need for efficient surgical practices and postoperative care strategies to optimize hospital stays and control costs.

Randomized Controlled Trial of Awake Transnasal Laser-Assisted Surgery for Benign Laryngeal Lesions.

To compare functional and cost-effectiveness of awake transnasal laser assisted-surgery versus microlaryngeal surgery for benign laryngeal lesions. This was a prospective non-inferiority randomized controlled trial conducted from May 2021 to December 2022 at two tertiary referral hospitals in Hong Kong. Patients were block-randomized to receive either awake transnasal laser-assisted surgery or microlaryngeal surgery, with post-operative follow-up in a multidisciplinary voice clinic for 1-year. Primary outcome was Voice Handicap Index (VHI-30). Secondary outcomes included operation time, complications, length of stay, peri-operative discomfort, recurrence, and medical costs. Sixty-one patients were randomized to either awake transnasal laser-assisted surgery (n = 30) and microlaryngeal surgery (n = 31). Both groups had comparable demographics and laryngeal pathologies. Both groups showed significant improvement of VHI-30 score over time and had comparable post-operative VHI-30. Awake transnasal laser-assisted surgery group had a significantly shorter length of stay (0.5 vs. 1 day) and less throat discomfort (2 vs. 4) compared to microlaryngeal surgery group. Intraoperative complications were more common in microlaryngeal surgery group (14.3% vs. 0%). Otherwise, both groups had similar operative time and recurrence rate. Cost-analysis showed a significantly lower hospital cost for awake transnasal laser-assisted surgery (USD 3090) compared to microlaryngeal surgery group (USD 5120). Awake transnasal laser-assisted surgery was safe, functionally non-inferior, as measured by VHI-30, to microlaryngeal surgery in managing benign laryngeal lesions, while superior to microlaryngeal surgery in peri-operative discomfort and medical costs. 2 Laryngoscope, 134:3732-3740, 2024.

Inpatient Hospital Costs, Emergency Department Visits, and Readmissions for Revision Hip and Knee Arthroplasty

BackgroundRevision total hip arthroplasty (THA) and total knee arthroplasty (TKA) tremendously burden hospital resources. This study evaluated factors influencing perioperative costs, including emergency department (ED) visits, readmissions, and total costs-of-care within 90 days following revision surgery. MethodsA retrospective analysis of 772 revision TKAs and THAs performed on 630 subjects at a single center between January 2007 and December 2019 was conducted. Cost data were available from January 2015 to December 2019 for 277 patients. Factors examined included comorbidities, demographic information, preoperative Anesthesia Society of Anesthesiologists score, implant selection, and operative indication using mixed-effects linear regression models. ResultsAmong 772 revisions (425 THAs and 347 TKAs), 213 patients required an ED visit, and 90 required hospital readmission within 90 days. There were 22.6% of patients who underwent a second procedure after their initial revision. Liver disease was a significant predictor of ED readmission for THA patients (multivariable odds ratio [OR]: 3.473, P = .001), while aseptic loosening, osteolysis, or instability significantly reduced the odds of readmission for TKA patients (OR: 0.368, P = .014). In terms of ED visits, liver disease increased the odds for THA patients (OR: 1.845, P = .100), and aseptic loosening, osteolysis, or instability decreased the odds for TKA patients (OR: 0.223, P < .001). Increased age was associated with increased costs in both THA and TKA patients, with significant cost factors including congestive heart failure for TKA patients (OR: $7,308.17, P = .004) and kidney disease for THA patients. Revision surgeries took longer than primary ones, with TKA averaging 3.0 hours (1.6 times longer) and THA 2.8 hours (1.5 times longer). ConclusionsLiver disease increases ED readmission risk in revision THA, while aseptic loosening, osteolysis, or instability decreases it in revision TKA. Increased age and congestive heart failure are associated with increased costs. These findings inform postoperative care and resource allocation in revision arthroplasty. Level of EvidenceEconomic and Decision Analysis, Level IV.

Postoperative Global Period Cost Reduction Using 3 Successive Risk-Stratified Pancreatectomy Clinical Pathways.

We hypothesized that iterative revisions of our original 2016 risk-stratified pancreatectomy clinical pathways would be associated with decreased 90-day perioperative costs. From a single-institution retrospective cohort study of consecutive patients with 3 iterations: "version 1" (V1) (October 2016 to January 2019), V2 (February 2019 to October 2020), and V3 (November 2020 to February 2022), institutional data were aggregated using revenue codes and adjusted to constant 2022-dollar value. Grand total perioperative costs (primary endpoint) were the sum of pancreatectomy, inpatient care, readmission, and 90-day global outpatient care. Proprietary hospital-based costs were converted to ratios using the mean cost of all hospital operations as the denominator. Of 814 patients, pathway V1 included 363, V2 229, and V3 222 patients. Accordion Grade 3+ complications decreased with each iteration (V1: 28.4%, V2: 22.7%, and V3: 15.3%). Median length of stay decreased (V1: 6 days, interquartile range [IQR] 5 to 8; V2: 5 [IQR 4 to 6]; and V3: 5 [IQR 4 to 6]) without an increase in readmissions. Ninety-day global perioperative costs decreased by 32% (V1 cost ratio 12.6, V2 10.9, and V3 8.6). Reduction of the index hospitalization cost was associated with the greatest savings (-31%: 9.4, 8.3, and 6.5). Outpatient care costs decreased consistently (1.58, 1.41, and 1.04). When combining readmission and all outpatient costs, total "postdischarge" costs decreased (3.17, 2.59, and 2.13). Component costs of the index hospitalization that were associated with the greatest savings were room or board costs (-55%: 1.74, 1.14, and 0.79) and pharmacy costs (-61%: 2.20, 1.61, and 0.87; all p < 0.001). Three iterative risk-stratified pancreatectomy clinical pathway refinements were associated with a 32% global period cost savings, driven by reduced index hospitalization costs. This successful learning health system model could be externally validated at other institutions performing abdominal cancer surgery.

Cost Analysis for Robotic and Open Gastrectomy.

To determine the magnitude of the perioperative costs associated with robotic gastrectomy (RG). A robotic surgery platform has a high implementation cost and requires maintenance costs; however, whether the overall cost of RG, including all perioperative costs, is higher than conventional open gastrectomy (OG) remains unknown. Patients who underwent a major gastrectomy during February 2018 through December 2021 were retrospectively identified. We calculated the perioperative costs of RG and OG and compared them overall as well as in different phases, including intraoperative costs and 30-day postsurgery inpatient and outpatient costs. We investigated factors potentially associated with high cost and estimated the likelihood of RG to reduce overall cost under a Bayesian framework. All cost data were converted to ratios to the average cost of all operations performed at our center in year FY2021. We identified 119 patients who underwent gastrectomy. The incidence of postoperative complications (Clavien-Dindo >IIIa; RG, 10% vs OG, 13%) did not significantly differ between approaches. The median length of stay was 3 days shorter for RG versus OG (4 vs 7 days, P < 0.001). Intraoperative cost ratios were significantly higher for RG (RG, 2.6 vs OG, 1.7; P < 0.001). However, postoperative hospitalization cost ratios were significantly lower for RG (RG, 2.8 vs OG, 3.9; P < 0.001). Total perioperative cost ratios were similar between groups (RG, 6.1 vs OG, 6.4; P = 0.534). The multiple Bayesian generalized linear analysis showed RG had 76.5% posterior probability of overall perioperative cost reduction (adjusted risk ratio of 0.95; 95% credible interval, 0.85-1.07). Despite increased intraoperative costs, total perioperative costs in the RG group were similar to those in the OG group because of reduced postoperative hospitalization costs.

The cost-utility of intraoperative tranexamic acid in adult spinal deformity patients undergoing long posterior spinal fusion.

This study aims to evaluate the cost-utility of intraoperative tranexamic acid (TXA) in adult spinal deformity (ASD) patients undergoing long posterior (≥ 5 vertebral levels) spinal fusion. A decision-analysis model was built for a hypothetical 60-year-old adult patient with spinal deformity undergoing long posterior spinal fusion. A comprehensive review of the literature was performed to obtain event probabilities, costs and health utilities at each node. Health utilities were utilized to calculate Quality-Adjusted Life Years (QALYs). A base-case analysis was carried out to obtain the incremental cost and effectiveness of intraoperative TXA. Probabilistic sensitivity analysis was performed to evaluate uncertainty in our model and obtain mean incremental costs, effectiveness, and net monetary benefits. One-way sensitivity analyses were also performed to identify the variables with the most impact on our model. Use of intraoperative TXA was the favored strategy in 88% of the iterations. The mean incremental utility ratio for using intraoperative TXA demonstrated higher benefit and lower cost while being lower than the willingness-to-pay threshold set at $50,000 per quality adjusted life years. Use of intraoperative TXA was associated with a mean incremental net monetary benefit (INMB) of $3743 (95% CI 3492-3995). One-way sensitivity analysis reported cost of blood transfusions due to post-operative anemia to be a major driver of cost-utility analysis. Use of intraoperative TXAs is a cost-effective strategy to reduce overall perioperative costs related to post-operative blood transfusions. Administration of intraoperative TXA should be considered for long fusions in ASD population when not explicitly contra-indicated due to patient factors.

The Financial Burden of Patient Comorbidities on Total Hip Arthroplasties—A Matched Cohort Analysis of High Comorbidity Burden and Non–High Comorbidity Burden Patients

BackgroundThe impact of increased patient comorbidities on the cost-effectiveness of total hip arthroplasty (THAs) is lacking. This study aimed to compare revenue, costs, and short-term (90 days) surgical outcomes between patients who have and do not have a high comorbidity burden (HCB). MethodsWe retrospectively reviewed 14,949 patients who underwent an elective, unilateral THA between 2012 and 2021. Patients were stratified into HCB (Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiology scores of 3 or 4) and non-HCB groups, and were further 1:1 propensity matched based on baseline characteristics. Perioperative data, revenue, costs, and contribution margins (CMs) of the inpatient episode were compared between groups. Also, 90-day readmissions and revisions were compared between groups. Of the 11,717 patients who had available financial data (n = 1,017 HCB, n = 10,700 non-HCB), 1,914 patients were included in the final matched analyses (957 per group). ResultsTotal (P < .001) and direct (P < .001) costs were significantly higher for HCB patients. Comparable revenue between cohorts (P = .083) resulted in a significantly decreased CM in the HCB patient group (P < .001). The HCB patients were less likely to be discharged home (P < .001) and had significantly higher 90-day readmission rates (P = .049). ConclusionsIncreased THA costs for HCB patients were not matched by increased revenue, resulting in decreased CM. Higher rates of nonhome discharge and readmissions in the HCB population add to the additional financial burden. Adjustments to the current reimbursement models should better account for the increased financial burden of HCB patients undergoing THA and ensure access to care for all patient populations. Level of evidenceIII.