The cost-saving effect of centralized histological reviews with soft tissue and visceral sarcomas, GIST, and desmoid tumors: The experiences of the pathologists of the French Sarcoma Group.

OBJECTIVE: This study examined the types of discordance occurring in the diagnosis of soft tissue and visceral sarcomas, gastrointestinal stromal tumors (GIST), and desmoid tumors, as well as the economic impact of diagnostic discrepancies. METHODS: We carried out a retrospective, multicenter analysis using prospectively implemented databases performed on a cohort of patients within the French RRePS network in 2010. Diagnoses were deemed to be discordant based on the 2013 World Health Organization (WHO) classification. Predictive factors of discordant diagnoses were explored. A decision tree was used to assess the expected costs of two strategies of disease management: one based on revised diagnoses after centralized histological review (option 1), the other on diagnoses without centralized review (option 2). Both were defined based on the patient and the disease characteristics, according to national or international guidelines. The time horizon was 12 months and the perspective of the French National Health Insurance (NHI) was retained. Costs were expressed in Euros for 2013. Sensitivity analyses were performed using low and high scenarios that included ± 20% estimates for cost. RESULTS: A total of 2,425 patients were included. Three hundred forty-one patients (14%) had received discordant diagnoses. These discordances were determined to mainly be benign tumors diagnosed as sarcomas (n = 124), or non-sarcoma malignant tumors diagnosed as sarcomas (n = 77). The probability of discordance was higher for a final diagnosis of desmoid tumors when compared to liposarcomas (odds ratio = 5.1; 95%CI [2.6-10.4]). The expected costs per patient for the base-case analysis (low- and high-case scenarios) amounted to €8,791 (€7,033 and €10,549, respectively) for option 1 and €8,904 (€7,057 and €10,750, respectively) for option 2. CONCLUSIONS: Our findings highlight misdiagnoses of sarcomas, which were found to most often be confused with benign tumors. Centralized histological reviews are likely to provide cost-savings for the French NHI.

Postoperative Investigations Resulting in Cost Reduction in Oncological Patients Undergoing Major Abdominal and Pelvic Surgery.

AIM: Rising costs in health care are of progressively growing interest and a major factor affecting hospitalization costs is represented by postoperative complications. Complications of Major Abdominal Surgery (MAS) are associated with increased morbidity and mortality. This study estimates the costs of postoperative care associated with complications. Material and Methods: We performed a retrospective study on 254 patients admitted to the 1st General and Oncological Surgery Clinic of the Bucharest Oncology Institute who were submitted to MAS. The total hospitalization, complications and treatment costs were analysed. Results: For a patient undergoing MAS, the average costs for surgery without complications are 5,791.3 RON and reach an average of 20,806 RON after major complications. CONCLUSION: The results provide insight into the costs of hospitalization for oncology patients submitted to surgical interventions. Complications occur in 20.86% of patients undergoing MAS and account for 50% of total care costs. Establishing and implementing a protocol aimed at early diagnosis and treatment of specific complications could lead to a decrease in morbidity and mortality, as well as of the costs of hospitalization.

Suspected extracolonic neoplasms detected on CT colonography: literature review and possible outcomes.

RATIONALE AND OBJECTIVES: This study summarizes the literature on the detection of cancer among indeterminate extracolonic findings on computed tomographic (CT) colonography in five targeted organs. MATERIALS AND METHODS: We searched PubMed for English-language literature published between January 1, 1994, and December 31, 2010. We describe extracolonic findings in the kidney, lung, liver, pancreas, and ovary suspect for malignancy as they are associated with high mortality. For each organ, we calculated the median prevalence, positive predictive value (PPV), and false positive rate of malignancy and a pooled false-positive rate across studies. RESULTS: Of 91 publications initially identified, 24 were eligible for review. Indeterminate renal masses on CT colonography had 20.5% median PPV and low pooled false positive rate of 1.3% (95% confidence interval 0.6-2.0). In contrast, indeterminate masses of the lung, liver, pancreas, and ovary had low PPV (median values ranged from 0% to 3.8%). Indeterminate masses of the ovary resulted in the highest pooled false-positive rate of 2.2%. Results were similar in studies of both screening and nonscreening populations. We estimated the probability of false positive results through the detection of significant extracolonic findings as 46 per 1000 for men and 68 per 1000 for women. CONCLUSIONS: Indeterminate renal masses newly detected on CT colonography have an estimated one in five chance of malignancy and therefore warrant further follow-up to provide a definitive diagnosis. Conversely, indeterminate masses of the lung, liver, pancreas, and ovary are associated with high false positive rates and merit more conservative clinical follow-up.

[Visceral and thoracic surgical interventions in patients over 80 years old. Evaluation of cost coverage]. / Viszeral- und thoraxchirurgische Eingriffe bei über 80-Jährigen : Bewertung der Kostendeckung.

Due to the higher incidence of malignant tumours with increasing age, cancer is the second most common cause of death among those aged over 65 years old. Consequently, demographic changes in Germany have resulted in a rising demand for oncological operations in elderly patients which is more cost-intensive. Objective of the present study in the setting of a university surgical department is whether oncological operations on patients over 80 years old is cost-effective in the era of diagnosis-related groups. The revenue and expenditure of 116 cases of patients over 80 years old documented for the years 2005-2007 were collated and evaluated. The calculated average proceeds were compared with cases of patients under 80 years old.The average return was -1493.50 EUR/case for over 80-year olds and was not cost-effective. The presence or absence of complications had a significant impact on proceeds, because the mean return/case without complications was profitable (1297.30 EUR). Medical care of patients over 80 years old was on average cost-effective and generated a profit. Oncological operations in patients under 80 years old were not sufficiently remunerated by the current DRG system. Therefore, there is an economical risk associated with oncological operations in elderly patients.

Staging laparoscopy in the management of intra-abdominal malignancies.

BACKGROUND: Laparoscopy in the evaluation of intra-abdominal malignancies has become a debated issue. Proponents have claimed that it increases resectability rates, whereas opponents suggest that many patients require laparotomy regardless of the laparoscopic findings. The purpose of this study was to compare outcomes in patients undergoing staging laparoscopy versus those who were managed by initial exploratory laparotomy. METHODS: The medical records of all patients during an 18-month period who underwent surgical evaluation for upper gastrointestinal or hepatobiliary malignancies were reviewed. Forty-eight patients underwent staging laparoscopy (SL) initially; 80 patients underwent initial exploratory laparotomy (EL). Data obtained included type of cancer, laparoscopic findings, laparoscopic determination of resectability, laparoscopic procedures, open determination of resectability, open procedures, and length of stay (LOS). Statistical analysis was done by using Fisher exact test or the Mann-Whitney U test. RESULTS: The malignancies of 75% of patients were deemed resectable by SL. Of these, 77.8% were resected. This compares to 56.3% resectability rate in the EL group (P = .025). SL findings in patients with unresectable malignancies were carcinomatosis (75%), liver metastasis (33.3%), and direct invasion (16.7%). In the 8 false-negative SLs, 75% were unresectable as a result of vascular invasion and 25% for other reasons. Findings in the EL group whose malignancies were unresectable were carcinomatosis (34.3%), direct invasion (22.6%), liver metastasis (42.9%), and vascular invasion only (17.1%). Therefore 82.9% of patients in the EL group could have been determined to have unresectable malignancy by SL. In the EL group 22.5% of the laparotomies were nontherapeutic, whereas 4.2% of patients in the SL group underwent nontherapeutic laparotomy. Average LOS for unresectable patients in the SL group was 0.5 days, with 75% discharged the same day of operation. This compares to 10.9 days in the EL group (P < .00001) and 7.6 days in the nontherapeutic EL group (P < .00001). CONCLUSIONS: SL increases the resectability rate, decreases the nontherapeutic laparotomy rate, and decreases LOS in patients with unresectable disease. SL is poor at detecting unresectability as a result of vascular invasion only, but this accounts for less than one-fifth of patients. Laparoscopic sonography and palliation may further decrease the need for EL.

Percutaneous abdominal biopsy: cost-identification analysis.

PURPOSE: To determine the difference in cost to providers of percutaneous abdominal biopsy as the first strategy versus surgical biopsy. MATERIALS AND METHODS: Cost of tissue diagnosis determination with percutaneous biopsy as the first strategy in 439 patients with an abdominal mass was estimated. Costs included direct hospital costs and professional costs of initial and repeat biopsy, follow-up imaging and clinic visits, surgical biopsy (when needed), and treatment of complications. The sum of these costs was compared with the estimated cost had the same patients undergone surgical biopsy instead, with no complications or need for follow-up or repeat biopsy. RESULTS: The total estimated cost of percutaneous biopsy as the first strategy ($543,245) was less than the cost had surgical biopsy been used alone ($1,919,867). The average per patient direct hospital cost of percutaneous biopsy ($800) was lower than that of surgical biopsy ($3,419). The average per patient professional cost of percutaneous biopsy ($438) was also lower than that of surgical biopsy ($955). Savings averaged $3,136 per patient, or $1,376,622 for the study period. CONCLUSION: Substantial health care cost savings may result by using a diagnostic algorithm in which percutaneous biopsy is the first strategy for establishment of a diagnosis in patients suspected of having abdominal malignancy.

[Prolonged intensive care stay after abdominal surgery interventions with special reference to quality of life, occupational rehabilitation and economics]. / Untersuchungen zu prolongierten Intensivverläufen nach abdominalchirurgischen Eingriffen unter besonderer Berücksichtigung von Lebensqualität, beruflicher Rehabilitation und Okonomie.

Owing to increasing limitations on resources in health care, there is an urgent need to investigate effectiveness and efficiency of medical procedures. Therefore, we retrospectively studied the courses of 62 surgical patients who required at least 30 days of intensive care regarding mortality, long-term prognosis and quality of life. Additionally, a cost analysis was made using quality-adjusted life years (QALYs). The hospital mortality was 40.3%. The overall median survival time of discharged patients (n = 37) was 3.7 years and the calculated 3-year survival was 56.4%. The most frequent causes of death were septic complications or multiple organ failure in hospitalized patients and tumor relapses in discharged patients. In most of the surviving patients quality of life (median Gastrointestinal Quality of Life Index: 104 points) was good. About 20% of the discharged patients were able to return to work. Although extended intensive care therapy is extremely expensive (DM 68,250 per QALY), these costs are comparable with other accepted procedures in medicine (i.e. hemodialysis). Therefore, economical aspects should not be a generalized reason for withdrawing or withholding intensive care therapy.

[The efficacy dilemma]. / Das Effizienz-Dilemma.

Effectivity and efficiency of medical treatment have conflicting aims which result in a conflict of interests between a patient, interested in maximal effectively and the society, interested in maximal efficiency. The physician cannot solve this conflict because he is primarily obliged to the interests of the individual patient. If rationing is unavoidable in modern health care services, there must be an open discussion in order to reach a broad consensus within the society.

[Abdominal ultrasound as a screening method]. / Abdominelle Sonographie als Screening-Methode.

Abdominal ultrasound is increasingly used as part of the initial patient evaluation, without a specific indication. However, such an indiscriminate use of abdominal ultrasound is still controversial. The review of available literature on the value of abdominal ultrasound in clinical screening suggests the following conclusions: 1) The primary screening examination of asymptomatic persons leads to clinically relevant findings in less than 0.5% of cases. However, approximately 50% of the persons examined have abnormal findings without clinical relevance. This high frequency of abnormal findings may cause high costs due to unnecessary follow-up examinations. 2) A sonographic screening of asymptomatic persons may, however, be useful for specific indications in preselected individuals. This has been demonstrated for the detection of abdominal aortic aneurysm in the age group over 65 years. 3) Routine abdominal ultrasound in patients with a known internal disease appears to be useful even in the absence of a specific indication. This 'secondary screening' yields unexpected findings which turn out to be relevant for therapeutic decisions or for the final diagnosis in 6-25% of the cases. Routine abdominal ultrasound of all patients with internal disease may thus be a valuable extension of the initial patient evaluation.