Bundled Payments for Appendectomy: a Model of Financial Implications to Institutions.

BACKGROUND: Bundled payments are increasingly becoming common in surgery, yet little is known regarding their potential impact on reimbursements for patients presenting with acute appendicitis. This study examines the financial impact of bundled payments for acute appendicitis. METHODS: This was a retrospective review of all open or laparoscopic appendectomies between July 2014 and June 2017. Patients that were not candidates for surgery were not included in this review. RESULTS: Of the total 741 patients, 42.1% were diagnosed with complicated acute appendicitis. The median length of stay was 1 day (range, 0 to 21 days). The median hospital cost was $4183 (range, $2075 to $71,023). The 90-day readmission rate was 3.2%, with a mean cost of $5025 per readmission (range, $1595 to $10,795). Length of stay, hospital costs, and 90-day readmissions were significantly higher for complicated versus uncomplicated acute appendicitis. In our current fee-for-service model, hospital reimbursements resulted in margins of - 4.0% to 24.6% depending on the severity of disease. If we assume that bundled payments do not reimburse for readmissions, we estimate that our hospital would incur losses of - 5.7% for patients with acute appendicitis with localized peritonitis and - 20.2% for patients with acute appendicitis with generalized peritonitis. CONCLUSIONS: As bundled payments become more common, hospitals may incur significant losses for acute appendicitis under a model that does not reflect the heterogeneous nature of patients requiring appendectomies. These losses can range up to - 20.2% for complicated cases. Improving clinical outcomes by reducing readmissions may mitigate some of these anticipated losses.

New anatomic repair of midline abdominal wall incisions extending to suprapubic region.

This article describes a new technique to close infraumbilical midline abdominal wall incisions extending to the suprapubic region. This repair is technically easy to perform, saves time, reduces the risk of bowel and bladder injury and takes into consideration the anatomical landmarks of the peritoneum, the rectus sheath and the arcuate line. Abdominal wall closure with this repair is especially useful in obese patients. Furthermore, with this repair the pelvic cavity is lined with smooth peritoneum, which may reduce postoperative adhesions in the pelvis. Technically easy to perform and saves time Very useful technique for obese patients Reduced risk of bowel and bladder injury Anatomical in nature Potentially minimizes postoperative adhesions.

Role of the physician versus the patient in the detection of recurrent disease following treatment for head and neck cancer.

OBJECTIVES/HYPOTHESIS: Objective evidence supporting current National Comprehensive Cancer Network guidelines regarding surveillance of patients treated for head and neck cancer is presently lacking. The study examines the relative role of current surveillance methods on disease detection in this patient population. STUDY DESIGN: Prospective nonrandomized study. METHODS: Clinical information was prospectively collected in a standardized format during 3645 encounters with patients with head and neck cancer over an 18-month period. Data pertaining to visit history, symptom history, patient findings, physician findings, and disease status for each encounter were reviewed. RESULTS: Of 3645 visits, disease recurrence or new primary tumor was documented in 180 encounters (5%). Salvage therapy was thought to be feasible in at least 65% of cases. Of these 180 recurrences or new primaries, there were 142 patients (79%) who had identified new symptoms or physical findings, or both, before the physician's examination. Most commonly reported was the presence of a neck mass (38%), progressive pain (27%), or other visible lesion or ulcer (14%). Patients with recurrence represented nearly 40% of all patients reporting new symptoms or findings (142 of 367). Conversely, recurrence was rare in the absence of reported symptoms or findings (1.2%). Surprisingly, despite patients reporting new symptoms or findings, physician evaluation most commonly occurred at the patient's routine surveillance visit rather than an earlier time point (104 of 142 [73%]). CONCLUSION: Self-diagnosis of recurrent or new primary disease is extremely common by virtue of symptoms or findings noted by patients before interaction with the clinician. However, presence of symptoms or findings did not motivate the patients to seek earlier medical attention. In the absence of such symptoms, physician diagnosis of recurrence is uncommon. Given the significant social and economic impact involved in surveillance of patients with head and neck cancer, further prospective study to optimize the method and frequency of this type of clinical activity is warranted and planned.