Postoperative Costs Research Articles

Robotic approach together with an enhanced recovery programme improve the perioperative outcomes for complex hepatectomy.

Robotic surgery has more advantages than traditional surgical approaches to complex liver resection; however, the robotic approach is invariably associated with increased cost. Enhanced recovery after surgery (ERAS) protocols are beneficial in conventional surgeries. The present study investigated the effects of robotic surgery combined with an ERAS protocol on perioperative outcomes and hospitalization costs of patients undergoing complex hepatectomy. Clinical data from consecutive robotic and open liver resections (RLR and OLR, respectively) performed in our unit in the pre-ERAS (January 2019-June 2020) and ERAS (July 2020-December 2021) periods were collected. Multivariate logistic regression analysis was performed to determine the impact of ERAS and surgical approaches-alone or in combination-on LOS and costs. A total of 171 consecutive complex liver resections were analyzed. ERAS patients had a shorter median LOS and decreased total hospitalization cost, without a significant difference in the complication rate compared with the pre-ERAS cohort. RLR patients had a shorter median LOS and decreased major complications, but with increased total hospitalization cost, compared with OLR patients. Comparing the four combinations of perioperative management and surgical approaches, ERAS + RLR had the shortest LOS and the fewest major complications, whereas pre-ERAS + RLR had the highest hospitalization costs. Multivariate analysis found that the robotic approach was protective against prolonged LOS, whereas the ERAS pathway was protective against high costs. The ERAS + RLR approach optimized postoperative complex liver resection outcomes and hospitalization costs compared with other combinations. The robotic approach combined with ERAS synergistically optimized outcome and overall cost compared with other strategies, and may be the best combination for optimizing perioperative outcomes for complex RLR.

Atrial Fibrillation after Descending Aorta Repair: Occurrence, Risk Factors, and Impact on Outcomes.

As risks of repairing the descending thoracic and thoracoabdominal aorta diminish, common complications that may prolong hospital stay, or actually increase risk, require attention. One such complication is postoperative atrial fibrillation (AF). Therefore, we characterized prevalence of, risk factors for, and effects of postoperative atrial fibrillation (PoAF) after descending and thoracoabdominal aorta repair. From January 2000 to January 2011, 696 patients underwent open descending or thoracoabdominal aorta repair at Cleveland Clinic. Operations approached via median sternotomy (n = 178) and patients treated preoperatively for arrhythmias (32 amiodarone, 9 paced) or in AF on preoperative electrocardiogram (n = 14) were excluded, leaving 463. Logistic regression analysis identified risk factors for PoAF. Temporal relation of PoAF with postoperative morbidities was determined, and outcomes following PoAF were compared between propensity-matched pairs. New-onset PoAF occurred in 101 patients (22%) at a median 68 hours of postincision. Risk factors included older age (p = 0.002) and history of remote AF (p = 0.0004) but not operative details, such as pericardiotomy for cardiac cannulation. Hypoperfusion and neurologic complications tended to precede PoAF, whereas sepsis, respiratory failure, and dialysis followed. Among 94 propensity-matched patient pairs, those developing PoAF were more likely to experience hypoperfusion (p = 0.006), respiratory failure (p = 0.009), dialysis (p = 0.04), paralysis (p < 0.0001), longer intensive care unit stay (median 7 vs. 5 d, p = 0.02), and longer postoperative hospital stay (median 15 vs. 13 d, p = 0.004). However, hospital death was similar (6/94 PoAF [6.4%] vs. 7/94 no PoAF [7.4%], p = 0.8). PoAF after descending thoracic aorta surgery is relatively common and a part of a constellation of other serious complications prolonging postoperative recovery. While PoAF was associated with adverse events, it did not impact postoperative cost and mortality. Descending thoracic aorta surgery is by itself comorbid enough, which is likely why PoAF does not have a more significant effect on postoperative recovery and cost.

MT43 Postoperative Hospital Costs after Anatomic and Reverse Total Shoulder Arthroplasty: A Retrospective, United States Hospital Billing Database Analysis

Total shoulder arthroplasty (TSA), while generally a successful procedure that improves shoulder function, can be associated with high post-operative resource utilization. Studies on hospital costs of post-operative care are sparse. The study objective was to estimate post-operative hospital costs after TSA and evaluate cost differences among patient characteristics.

Impact of the introduction of minimally invasive treatments of the thyroid (MITT) for benign thyroid nodules in an Italian hospital: a cost-minimization analysis.

Prevalence of thyroid nodules is high in the adult population, approaching 60% in women and older people. Most thyroid nodules are benign and asymptomatic. However, a not negligible part of them causes compressive symptoms and/or cosmetic concerns and need to be treated. In the last two decades, minimally-invasive treatments of the thyroid (MITT) have been proposed in routine clinical practice as a reliable cost-effective alternative to surgery in patients with symptomatic benign thyroid nodules (SBTNs). To perform a cost-minimization analysis comparing direct, indirect and intangible costs of radiofrequency (RFA) and laser thermal ablation (LTA) with traditional surgery in patients with SBTNs. Data of patients treated by MITT for SBTNs from October 1st 2019 to September 30th 2022 in a single Italian tertiary Center were analyzed. Costs were compared to those of traditional surgery reported in the 2022 Associazione Medici Endocrinologi Guidelines on the Management of SBTNs. In the study lapse, 157 MITT of SBTNs were performed in 148 patients, 114 females and 34 males (mean age: 59 yrs; median age: 57 yrs). Before MITT, the mean thyroid nodule volume was 19 ml; 1 year after MITT, volume reduction rate >50% and symptom relief were achieved in 89% and 93% of patients, respectively. No major complications occurred. Adding up pre-operative, operative and post-operative costs, total direct costs per single procedure are the following: 1361.43 € for LTA when using one optic fiber; 1761.43 € for LTA when using two optic fibers; 1968.53 € for RFA; 3338.39 € for hemithyroidectomy plus isthmectomy; 4034.99 € for total thyroidectomy. Surgery was impactful on direct-i.e., preoperative, operative and postoperative-costs, due to longer operating room occupation time and hospital stay. Overall, a total saving for the Italian National Health Service of 285,377.15 € has been obtained treating the 148 patients by MITT instead of surgery. Likewise, MITT was advantageous also for indirect costs-i.e., those related to "loss of productivity" caused by time off work due to hospital stay and recovery time-, for both the self-employed workers and the Government, the latter saving 53,838.50 € overall. Finally, intangible costs, related to patients' quality of life-e.g., residual surgical scar, stress related to general anesthesia, convalescence, and life-long intake of L-Thyroxine replacement therapy-were all in favor of MITT. This real-life cost-minimization analysis demonstrates that LTA and RFA are safe and cost-effective procedures for the treatment of SBTNs. In our 3 years experience, adding the savings of 285,377.15 € for direct costs to those of 53.838,50 € for indirect costs, in total 339,215.65 € were saved. The saving concern patients, the National Health System and the Government.

Euthyroidectomy under local versus general anesthesia in health camp settings in Uganda: a protocol for randomized prospective equivalence single-blind controlled trial

BackgroundEndemic goiter is highly prevalent in Uganda at 60.2%, contributing to the high surgical burden. While compelling evidence suggest that in selected cases, thyroidectomy under local anesthesia (LA) is associated with fewer post-operative complications, low costs, and short hospital stays, local anesthesia is not considered a priority technique for thyroidectomy in resource-constrained settings such as Uganda, despite having fewer general anesthesia (GA) and critical care providers. The objective of this trial is to compare euthyroidectomy under local versus general anesthesia among patients with grade 1–2 uncomplicated euthyroid goiter in Uganda.MethodsThis prospective equivalence randomized, single-blind controlled trial protocol will be conducted among eligible participants with grade 1–2 uncomplicated euthyroid goiters. The recruitment processes will start in October 2022 and end in April 2023. Consenting participants with an indication for thyroidectomy will be randomized into two arms of 29 participants in each arm during the Bulamu Health Care Organization surgical camps in Uganda.DiscussionThe primary outcome of this trial protocol is to compare the early post-operative complications of euthyroidectomy done under LA versus GA. The outcome variables include post-operative pain based on visual analogue scale, nausea, vomiting, hematoma formation, and transient voice changes determined at an interval of 6, 12, and 24 h and at 30 days.In addition, we shall compare the surgical site infection rates, procedure costs, hospital stay, and patients’ level of satisfaction based on a 5-point Likert scale and their willingness to undergo a similar surgery using the same anesthetic technique between the two groups. We hypothesize that euthyroidectomy under LA could potentially offer similar benefits as GA, reduce costs related to procedure, complications, and hospital stay while at the same time mitigating the unmet need for surgery attributable to shortage of general anesthesia providers and critical care facilities in low-income settings.Trial registrationPan African Clinical Trial Registry PACTR202208635457430. Registered on 11th August 2022. All items from the WHO trial registration data set are within the protocol. Version number and date: version 3, 15/03/2023.

Rural-urban differences in characteristics, postoperative outcomes, and costs for patients undergoing knee arthroplasty: a national retrospective propensity score matched cohort study.

The rural-urban disparities in postoperative complications and costs among patients undergoing knee arthroplasty (KA) have not been thoroughly explored. This study aimed to determine whether such differences exist in this patient population. The study was conducted using data from the national Hospital Quality Monitoring System of China. Hospitalized patients undergoing KA from 2013 to 2019 were enrolled. Patient and hospital characteristics were compared between rural and urban patients, and differences in postoperative complications, readmissions, and hospitalization costs were analyzed using propensity score matching. Of the 146,877 KA cases analyzed, 71.4% (104,920) were urban patients and 28.6% (41,957) were rural patients. Rural patients tended to be younger (64.4±7.7y vs. 68.0±8.0y; P<0.001) and had fewer comorbidities. In the matched cohort of 36,482 participants per group, rural patients were found to be more likely to experience deep vein thrombosis (OR: 1.31, 95% CI: 1.17-1.46; P<0.001) and require RBC transfusion (OR: 1.38, 95% CI: 1.31-1.46; P<0.001). However, they had a lower incidence of readmission within 30 days (OR: 0.65, 95% CI: 0.59-0.72; P<0.001) and readmission within 90 days (OR: 0.61, 95% CI: 0.57-0.66; P<0.001) than their urban counterparts. In addition, rural patients incurred lower hospitalization costs than urban patients (57,396.2 Chinese Yuan [CNY] vs. 60,844.3 CNY; P<0.001). Rural KA patients had different clinical characteristics compared with urban patients. While they had a higher likelihood of deep vein thrombosis and RBC transfusion following KA than urban patients, they had fewer readmissions and lower hospitalization costs. Targeted clinical management strategies are needed for rural patients.

Titanium Versus Autologous Bone-Based Cranioplasty: A Systematic Review and Meta-Analysis.

At present, there is no gold standard when looking at reconstructive evidence for cranioplasty with the use of autologous bone as well as other synthetic materials. Titanium has been considered recently as a good option due to its unique properties such as strength and biocompatibility. Numerous studies have previously compared titanium with autologous bone for cranioplasty yet no meta-analysis has been performed within the literature to provide guidelines for craniofacial surgeons. A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of electronic information was conducted to identify all comparative studies of autologous bone vs. titanium implants in cranioplasty following a craniectomy. The primary outcomes were measured as re-operation rates and cosmesis, the secondary outcome measures included the incidence of complications, for example, bone resorption and infection. Five studies were selected, enrolling 323 cases. A high reoperation rate (p > 0.007) was seen in autologous cranioplasty using bone due to the significantly high resorption rate reported in this group. Cosmetic outcomes demonstrated no significant difference between the two groups examined. Finally, costs and infection rates (p > 0.18) were found to be comparable. Overall, titanium implants used in cranioplasty offer lower re-operation rates in comparison to autologous bone grafts whilst there was no major increase in adverse outcomes such as postoperative cost or rates.

A comparison of coblation and modified monopolar tonsillectomy in adults

ObjectiveTo compare the intraoperative records and postoperative clinical outcomes of adults who underwent coblation and modified monopolar tonsillectomy tonsillectomies.Materials and methodsAdult patients with tonsillectomy were randomly divided into the coblation and modified monopolar tonsillectomy groups. The estimated blood loss, postoperative pain score, operation time, post-tonsillectomy hemorrhage (PTH), and cost of disposable equipment were compared.ResultsPain intensity in the coblation and monopolar groups was similar on postoperative days 3 and 7. However, the mean maximum pain score in the monopolar group was significantly higher compared to the coblation group on postoperative days 1 (P < 0.01) and 2 (P < 0.05).Secondary PTH occurred in 7.1% (23/326) of patients in the coblation group and 2.8% (9/327) of patients in the monopolar group (P < 0.05).ConclusionAlthough pain was significantly increased on postoperative days 1 and 2 in the modified monopolar tonsillectomy group, the operation time, secondary PTH, and medical costs were significantly decreased compared to the coblation technique group.

Multimodal analgesia did not improve post-operative pain scores, reduce opioid consumption or reduce length of stay following hip arthroscopy.

To determine whether different regimens of multimodal analgesia will reduce postoperative pain scores, opioid consumption, costs and hospital length-of-stay following hip arthroscopy. From 2018 to 2021, 132 patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) were included in this prospective, single-center randomized controlled trial. Patients were randomized into four treatment groups: (1) Group 1-Control: opioid medication (oxycodone-acetaminophen 5mg/325mg, 1-2 tabs q6H as needed), Heterotopic ossification prophylaxis-Naprosyn 500mg twice daily × 3weeks); (2) Group 2-Control + postoperative sleeping aid (Zopiclone 7.5mg nightly × 7days); (3) Group 3-Control + preoperative and postoperative Gabapentin (600mg orally, 1h preoperatively; 600mg postoperatively, 8h following pre-op dose); (4) Group 4-Control + pre-medicate with Celecoxib (400mg orally, 1h preoperatively) The primary outcome was pain measured with a visual analog scale, monitored daily for the first week and every other day for 6weeks. Secondary outcomes included opioid consumption, healthcare resource use, and hospital length of stay. Patient characteristics were similar between groups. There were no statistically significant differences in pain scores between groups at any timepoint after adjusting for intra-operative traction time, intra-operative opioid administration and preoperative pain scores (p > 0.05). There were also no significant differences in the number of days that opioids were taken (n.s.) and the average daily morphine milligram equivalents consumed (n.s.). Similarly, there were no statistically significant differences in length of stay in the experimental groups, compared with the control group (n.s.). Finally, there were no differences in cost between groups (n.s.). The routine use of Zopiclone, Celecoxib and Gabapentin did not improve postoperative pain control or reduce length-of-stay following hip arthroscopy. Therefore, these medications are not recommended for routine postoperative pain control following hip arthroscopy. l.

Comparison of Postoperative Outcomes, Costs, and Readmission Between Total and Subtotal Cholecystectomy.

An increasing body of literature supports subtotal cholecystectomy (STC) in the management of patients with difficult gallbladder anatomy; however, large-scale studies examining outcomes of total cholecystectomy and STC are lacking. All adults undergoing total cholecystectomy or STC were tabulated from the 2016-2019 Nationwide Readmissions Database. Entropy balancing was performed to adjust for patient differences based on extent of resection. Subsequent multivariable regression models were used to assess the association of STC with major adverse events, postoperative length of stay (pLOS), hospitalization costs, and 30-day non-elective readmission rates. Of an estimated 854357 patients, 7089 (.8%) underwent STC. Compared to total, STC patients were significantly older, less commonly female, and had a higher Elixhauser Index (all P < .001). Both cohorts had similar rates of postoperative ERCP (1.7% vs 1.5%, P = .33); however, the STC cohort had significantly higher utilization of subsequent drainage procedures (1.8% vs .5%, P < .001). After entropy balancing and multivariable risk-adjustment, STC was not associated with greater odds of MAE (AOR 1.11, 95% CI .99-1.23, P = .06). Notably, relative to total, STC was associated with longer pLOS (β .14, 95% CI .11-.17, P < .001) and greater hospitalization costs (β + $1,900, 95% CI 1300-2,500, P < .001). However, the extent of resection was not associated with the likelihood of 30-day non-elective readmission (AOR 1.01, 95% CI .91-1.13, P = .86). Our findings suggest that STC is a viable, yet resource intensive, option in the management of complex cholecystitis.

Retrospective evaluation of the impact of hypoxemia during thoracic surgery in dogs on outcome: a multicenter analysis of 94 cases

ObjectiveTo investigate the statistical association of severe intraoperative hypoxemia in thoracic surgery with mortality, postoperative hospitalization times and cost of care. Study designRetrospective study. AnimalsDogs that underwent thoracic surgery in three veterinary hospitals between October 1, 2018 and October 1, 2020. MethodsAnesthesia and hospitalization records from 112 dogs were reviewed and 94 cases met inclusion criteria. Recorded data included signalment, disease etiology, pulmonary or extrapulmonary nature of disease, surgical procedure performed, episodes of severe intraoperative hypoxemia defined as a pulse oximetry reading (SpO2) <90% of 5 minutes or longer duration, survival to discharge, time from extubation to hospital discharge and total invoice cost for clinical visit. Dogs were divided into two groups, those that experienced severe hypoxemia (group A) and those in which SpO2 reading <90% was not observed throughout the procedure (group B). ResultsGroup A had a greater risk of mortality (odds ratio 10.6, 95% confidence interval 1.9–106.7; p = 0.002), prolonged hospitalization (median 62 hours versus 46 hours; p = 0.035) and more expensive cost of care (median US$10,287 versus $8506; p = 0.056) than group B. No significant difference was found for the type of surgical procedure or pulmonary versus extrapulmonary nature of disease. Conclusions and clinical relevanceSevere intraoperative hypoxemia was statistically associated with an increased risk of mortality and longer postoperative hospitalization times. Although not achieving statistical significance, there was a trend toward increased costs to the client for animals with intraoperative hypoxemia.

Comparison between Mesh Hernioplasty and Nylon Darn Repair in Inguinal Hernia Surgery; A Randomized Controlled Trail

Background: One of the procedures that is conducted the most frequently worldwide is inguinal hernia surgery. Several methods have been developed over time, but Lichtenstein has long dominated all others. This is said to lead to a less painful procedure and less suture tearing out, which lowers the likelihood of recurrence. Because to the paucity and high cost of commercial prosthetic mesh, conventional Bassini operations are still carried out at hospitals with minimal resources in developing nations. Because sutured material for darning repair is readily available, has a little amount of reactivity, and has acceptable recurrence rates, we compared it to Lichtenstein in this study. Inguinal hernia recurrence rates following non-mesh surgery range from 0.1 to 1%. Aim: This study is set out to compare darning with Lichtenstein technique of inguinal hernia repair in terms of frequency of post-operative complications, recovery and cost. Study Design: Prospective Randomized Control Trial Place and Duration of Study: This study was done in department of General surgery at Central Park Teaching Hospital, Lahore during a period of 4 months that span from October 2021 till January 2022. Methodology: Using a continuous simple random selection, 100 male patients between the ages of 20 and 80 who had been clinically diagnosed with an uncomplicated direct or indirect inguinal hernia were divided into two groups using a lottery system. This prospective randomised control trial included Group A, who underwent Darn Repair, and Group B, which underwent Open Mesh/Lichtenstein repair on the elective list (RCT). With follow-up at one week, six weeks, and one year, the primary end point compared the operating time, post-operative pain, analgesic requirement in the first 24 hours, length of hospital stay, time until return to work, surgical site infection, and hernia recurrence between patients who had Darning Repair (group A) and patients who had LMH (group B). Results: In group A, the average operation time and hospital stay following surgery were less. Early postoperative complication rates and the period before returning to work were comparable in both groups. The required length of analgesia was identical as were the pain scores at 24, 48, and 72 hours. Return to regular activity took an average of 5 weeks for each group, which was also comparable. During the 1-year assessment, the recurrence rates in the two groups were similar, at 4% after mesh repair and 4% following darn repair. Practical Implication: This will help in early and prompt management and repair of hernia even at smaller setups as nylon repair is as good as polypropylene mesh repair. Conclusion: Open inguinal hernia repair with a nylon darn was equal to polypropylene mesh with respect to early assessments of postoperative outcome and recurrence at 1 year. When compared to the Lichtenstein approach in individuals with inguinal hernias, the darn repair technique is straightforward, secure, affordable, and has a similar risk of recurrence. Keywords: Inguinal hernia, Lichtenstein Mesh Repair, Open Darn repair, recurrence rate.

A-25 | Impact of Household Income on Post-PCI Outcomes of Acute Coronary Syndrome Patients With SARS-CoV-2 Infection, a Population-Based Analysis in the USA, 2020

Income is a key social determinant of health, and the gap in access to care has been exacerbated by the pandemic. We aim to study the impact of income on post-PCI outcomes in SARS-CoV-2 patients hospitalized with ACS. NIS 2020 was analyzed to study the impact of income on post-PCI outcomes in SARS-CoV-2 patients hospitalized with ACS. Low income Quartile (LIQ) and highest income groups (HIQ) were compared, to look at comorbidities and in hospital outcomes (mortality, stroke, AKI, discharge status, hospital stay, and cost). Multivariable regression analyses were adjusted for relevant confounders. Among the population of interest, 68.2% are from the LIQ group and 31.8% are from the HIQ group with median age of 62 years. The HIQ group is predominantly males, whites and are from NE. The LIQ cohort had a higher prevalence of HTN (78.5% vs 73.5% p=0.018) and DM (53% vs 42.7%, p=0.001) whereas the HIQ group had a significantly higher prevalence of smoking (23.9% vs 18.7% p=0.01), PVD (9.4% vs 5.2% p 0.001), and cancer (4.3% vs 2.0 p=0.05). All-cause of in-hospital mortality (23.5% vs 17.9% p=0.007), and AKI (34.7% vs 25.6% p=0.001) are statistically higher in the LIQ group. Postoperative stroke, hospital stay and cost are comparable between both groups. When adjusted for confounders, the odds were not significant for any of the primary outcomes [Table 1]. Though LIQ group had higher prevalence of HTN, DM, post-PCI mortality and AKI rates, this association was not significant when adjusted for confounders. Social determinants of health should be explored further to effectively predict long-term cardiovascular outcomes in COVID-19 patients.

A cost analysis of robotic vs. video-assisted thoracic surgery: The impact of the learning curve and the COVID-19 pandemic.

Robot-assisted thoracoscopic surgery (RATS) is an alternative to video-assessed thoracoscopic surgery (VATS) for the treatment of lung cancer but concern exists regarding the high associated costs. The COVID-19 pandemic added further financial pressure to healthcare systems. This study investigated the impact of the learning curve on the cost-effectiveness of RATS lung resection and the financial impact of the COVID-19 pandemic on a RATS program. Patients undergoing RATS lung resection between January 2017 and December 2020 were prospectively followed. A matched cohort of VATS cases were analyzed in parallel. The first 100 and most recent 100 RATS cases performed at our institution were compared to assess the learning curve. Cases performed before and after March 2020 were compared to assess the impact of the COVID-19 pandemic. A comprehensive cost analysis of multiple theatre and postoperative data points was performed using Stata statistics package (v14.2). 365 RATS cases were included. Median cost per procedure was £7,167 and theatre cost accounted for 70%. Major contributing factors to overall cost were operative time and postoperative length of stay. Cost per case was £640 less after passing the learning curve (p < 0.001) largely due to reduced operative time. Comparison of a post-learning curve RATS subgroup matched to 101 VATS cases revealed no significant difference in theatre costs between the two techniques. Overall cost of RATS lung resections performed before and during the COVID-19 pandemic were not significantly different. However, theatre costs were significantly cheaper (£620/case; p < 0.001) and postoperative costs were significantly more expensive (£1,221/case; p = 0.018) during the pandemic. Passing the learning curve is associated with a significant reduction in the theatre costs associated with RATS lung resection and is comparable with the cost of VATS. This study may underestimate the true cost benefit of passing the learning curve due to the effect of the COVID-19 pandemic on theatre costs. The COVID-19 pandemic made RATS lung resection more expensive due to prolonged hospital stay and increased readmission rate. The present study offers some evidence that the initial increased costs associated with RATS lung resection may be gradually offset as a program progresses.

The costs of surgical site infection after abdominal surgery in middle-income countries: Key resource use In Wound Infection (KIWI) study

Surgical site infection (SSI) is the most common complication of abdominal surgery, with substantial costs to patients and health systems. Heterogeneity in costing methods in existing SSI studies makes multi-country comparison challenging. The objective of the study was to assess the costs of SSI across middle-income countries. Centres from a randomised controlled trial assessing interventions to reduce SSI (FALCON, ClinicalTrials.gov, NCT03700749NCT) were sampled from two upper-middle (India, Mexico) and two lower-middle (Ghana, Nigeria) income countries. The Key resource use In Wound Infection (KIWI) study collected data on postoperative resource use and costs from consecutive patients undergoing abdominal surgery with an incision >5cm (including caesarean section) that were recruited to FALCON between April and October 2020. The overall costs faced by patients with and without SSI were compared by operative field contamination (clean-contaminated versus contaminated-dirty), country and timing (inpatient versus outpatient). 335 patients were included in KIWI; SSI occurred in 7% of clean-contaminated cases and 27% of contaminated-dirty cases. Overall, SSI was associated with an increase in postoperative healthcare costs by 75.3% (€412 international euros) after clean-contaminated surgery and 66.6% (€331) after contaminated-dirty surgery. The highest and lowest cost increases was in India for clean-contaminated cases (€517) and contaminated-dirty cases (€223), respectively. Overall, inpatient costs accounted for 96.4% of the total healthcare costs after clean-contaminated surgery and 92.5% after contaminated-dirty surgery. SSI was associated with substantial additional postoperative costs across a range of settings. Investment in health technologies to reduce SSI may mitigate the financial burden to patients and low-resource health systems.

Scheduled Postoperative Ketorolac Does Not Decrease Opiate Use following Free Flap Breast Reconstruction.

In the setting of the opioid crisis, managing postoperative pain without the exclusive use of opiates has become a topic of interest. Many hospitals have begun implementing enhanced recovery after surgery protocols to decrease postoperative complications, hospital costs, and opiate utilization. Ketorolac has been added to many of these protocols, but few studies have examined its effects independently. A retrospective chart review was performed on all patients that received autologous breast reconstruction from October 2020 to June 2022 at an academic institution. We identified patients who did and did not receive postoperative ketorolac. Use of ketorolac was based upon surgeon preference. The two groups were compared in basic demographics, reconstruction characteristics, length of stay, complications, reoperations, and morphine milligram equivalents (MMEs). One-hundred ten patients were included for the analysis, with 55 receiving scheduled postoperative ketorolac and 55 who did not receive ketorolac. There were seven incidences of postoperative complications in each group (12.7%, p = 1.00). The total mean postoperative MMEs were 344.7 for the nonketorolac group and 336.5 for the ketorolac group (p = 0.81). No variable was found to be independently associated with postoperative opiate use. Ketorolac was not found to contribute significantly to any postoperative complication. In this study, the use of ketorolac did not significantly reduce opiate use in a cohort of 110 patients. Surgeons should consider whether the use of ketorolac alone is the best option to reduce postoperative opiate use following free flap breast reconstruction.

Effect of Perioperative Oral Vitamin C Supplementation on In-Hospital Postoperative Medication Costs for Cardiac Surgery Patients: A Prospective, Single-Centre, Randomised Clinical Trial.

Due to its antioxidant properties, vitamin C might be a promising and effective strategy for preventing postoperative atrial fibrillation (POAF) after cardiac surgery. This study was aimed at evaluating whether vitamin C supplementation is effective in reducing the cost of in-hospital postoperative medication used for patients undergoing coronary artery bypass (CABG) or valve surgery (±CABG). The primary goal of this study was to evaluate the impact of perioperative vitamin C supplementation in patients undergoing cardiac surgery on in-hospital postoperative medication costs, while secondary endpoints were the effects on length of stay (LOS) in both the intensive care unit (ICU) and the hospital, and the incidence of POAF. From November 2018 to January 2021, 253 patients planned for CABG or valve surgery (±CABG) in AZ Maria Middelares, Ghent, Belgium, and who met the inclusion criteria (≥18 years of age, all having cardiac sinus rhythm, and who provided written informed consent) were randomised into a placebo group or vitamin C group. The medication was administered orally (1g twice daily), starting from 5 days preoperatively until 10 days postoperatively. The medication used, LOS in the hospital/ICU, and development of clinically relevant POAF in the ICU were registered. Mean medication costs were €264.6±98.1 for patients in the vitamin C group and €294.9±267.3 for patients in the placebo group. When stratifying according to the type of surgery (CABG or valve surgery [±CABG]), these costs did not significantly differ. There was no significant difference in LOS or the incidence of clinically relevant POAF. Our data did not identify any short-term financial impact on postoperative medication costs after oral perioperative vitamin C supplementation (1g twice daily) for patients undergoing a CABG procedure or valve surgery (±CABG). No effect was found on the LOS or the incidence of clinically relevant POAF. Potential effects in the longer term, after intravenous administration of vitamin C or in other types of (cardiac) surgery, are still to be investigated. NCT03592680.

Thunderbeat®: a new step forward in transoral surgery—systematic review of literature and our experience

IntroductionMinimally invasive surgery is today the main challenge of ENT surgeons who aim to achieve oncological radicality with less aesthetic and functional impact. This is the basis for the widespread transoral surgical techniques, as the Thunderbeat®.ObjectiveTo date, the use of Thunderbeat® in transoral surgery is still little known and widespread. So, this study analyzes, with a systematic review, current literature about the transoral use of Thunderbeat® and shows our case studies.MethodsThe research was carried out on Pubmed, Scopus, Web of Science and Cochrane databases using specific keywords. Then, a retrospective study was carried out on 10 patients who underwent transoral surgery by Thunderbeat® in our ENT Clinic. Both in our cases and in the systematic review the following parameters have been evaluated: treated anatomical site and subsite, histological diagnosis, type of surgery, duration of nasogastric tube and hospitalization, post-operative complications, tracheostomy, resection margin status.ResultsThe review included 3 articles that described transoral use of Thunderbeat® for a total of 31 patients suffering from oropharyngeal, hypopharyngeal and/or laryngeal carcinoma. Nasogastric tube was removed after 21.5 days on average, temporary tracheostomy was performed in 6 patients. The main complications were: bleeding (12.90%) and pharyngocutaneous fistula (29.03%). Thunderbeat® shaft was 35 cm long and 5 mm large. Our case studies included 5 males and 5 females, mean age 64.4 ± 10.28, with oropharyngeal or supraglottic carcinoma, parapharyngeal pleomorphic adenoma and cavernous hemangioma of the tongue base. Temporary tracheostomy was performed in 8 patients. Free resection margins were achieved in all cases (100%). No peri-operative complications occurred. Nasogastric tube was removed after 5.3 ± 2 days on average. All patients were discharged without tracheal tube and NGT after 18.2 ± 4.72 days on average.ConclusionThis study demonstrated that Thunderbeat® has several advantages over other transoral surgical approaches, such as CO2 laser and robotic surgery, in terms of best combination of oncological and functional success, less post-operative complications and costs. So, it could represent a step forward in transoral surgery.

MP39-19 VISUALIZING EPISODE-SPECIFIC COSTS FOR RENAL COLIC: A MODEL FOR BUNDLE PAYMENT REFORM

You have accessJournal of UrologyCME1 Apr 2023MP39-19 VISUALIZING EPISODE-SPECIFIC COSTS FOR RENAL COLIC: A MODEL FOR BUNDLE PAYMENT REFORM Loren Oh, Charles Scales, Marisa Domino, and David Friedlander Loren OhLoren Oh More articles by this author , Charles ScalesCharles Scales More articles by this author , Marisa DominoMarisa Domino More articles by this author , and David FriedlanderDavid Friedlander More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003277.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Bundled payments are value-based reimbursement models that link payments to providers for episodes of care related to inpatient admissions for certain conditions. What remains a limitation of episode-based payments, however, is their inability to account for health care expenditures that may accrue prior to the inciting inpatient admission. Renal colic is uniquely suited to evaluate the association between pre- and post-operative events. Renal colic episodes often begin in the emergency department and may require both inpatient and ambulatory care prior to definitive surgery. Therefore, limiting bundles to inpatient admissions associated with surgery may miss important upstream events that influence post-operative outcomes. The objective of this study is to better understand how pre-operative costs may relate to operative and post-operative costs for a renal colic episode. METHODS: Using 2018 data from the Healthcare Cost and Utilization Project, we identified individuals in Maryland and Florida who had a renal colic diagnosis, a subsequent definitive surgical episode after diagnosis, and a post-surgical health care encounter within 90 days of surgery. We then limited our sample to individuals who had information about pre-operative, operative, and post-operative costs. We categorized individuals into quartiles based on incurred costs during the pre-operative, operative, and post-operative periods. We then plotted the number of individuals in each quartile across the care time horizon using a Sankey diagram to visualize costs throughout a renal colic episode. RESULTS: A total of 1,525 individuals in Florida and Maryland underwent definitive surgery for renal colic during the study period. When looking at the movement of individuals between pre-operative and operative quartiles, 207 of 381 individuals (54.3%) with the lowest pre-operative costs remained in either the 1st or 2nd quartile of operative costs. Meanwhile, 219 out of 381 individuals (57.3%) in the highest quartile had operative costs in the upper half. Similar results are seen when looking at movement of individuals between operative and post-operative quartiles. Most of the individuals in the lowest quartile of operative costs remained in the lowest quartile of post-operative costs while individuals in the highest quartile of operative costs remained in the top two quartiles of post-operative costs. CONCLUSIONS: Our findings suggest that pre-operative spending influences post-operative expenditures for an episode of renal colic, and accounting for this relationship may help inform future iterations of surgical payment bundles. Source of Funding: American Urological Association Research Scholars Grant © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e543 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Loren Oh More articles by this author Charles Scales More articles by this author Marisa Domino More articles by this author David Friedlander More articles by this author Expand All Advertisement PDF downloadLoading ...

Simplified total arch reconstruction with a stented graft for extended aortic arch dilation.

Reconstruction of the aortic arch and its three supra-aortic vessels remains a great surgical challenge with postoperative complications. We present a simplified total arch reconstruction with a modified stent graft (s-TAR) and compared its operative outcomes with conventional total arch replacement (c-TAR). This retrospective analysis of prospectively collected data from all consecutive patients who had ascending aortic aneurysm with extended aortic arch dilation and underwent simultaneous ascending aorta replacement and aortic arch reconstruction with the s-TAR or c-TAR between 2018 and 2021. The indication for intervention was maximum diameter of ascending aorta >55 mm and aortic arch in zone II >35 mm. A total of 84 patients were analyzed: 43 in the s-TAR group and 41 in the c-TAR group. No inter-group differences were found for sex, age, comorbidities, or EuroSCORE II results. All patients were successfully treated with s-TAR or c-TAR, and none died intraoperatively. Cardiopulmonary bypass, selective cerebral perfusion, and lower-body circulatory arrest time were significantly shorter in the s-TAR group, which also had a lower incidence of prolonged ventilation and transient neurologic dysfunction. No patient in either group experienced permanent neurologic dysfunction. The incidence of recurrent laryngeal nerve injury and paraplegia was markedly increased in the c-TAR group; however, no such events were observed in the s-TAR group. Both perioperative blood loss and the incidence of reoperation for bleeding were significantly lower in the s-TAR group. The in-hospital mortality rate was 0% in the s-TAR group and 4.9% in the c-TAR group. The s-TAR group had significantly shorter intensive care unit (ICU) stay and lower total hospitalization costs. The s-TAR technique is a safe and effective alternative for total arch reconstruction with shorter operation time, lower rate of postoperative complications and lower total hospitalization costs compared with c-TAR.