Screening and treating pre-operative anaemia and suboptimal iron stores in elective colorectal surgery: a cost effectiveness analysis.

Our study investigated whether pre-operative screening and treatment for anaemia and suboptimal iron stores in a patient blood management clinic is cost effective. We used outcome data from a retrospective cohort study comparing colorectal surgery patients admitted pre- and post-implementation of a pre-operative screening programme. We applied propensity score weighting techniques with multivariable regression models to adjust for differences in baseline characteristics between groups. Episode-level hospitalisation costs were sourced from the health service clinical costing data system; the economic evaluation was conducted from a Western Australia Health System perspective. The primary outcome measure was the incremental cost per unit of red cell transfusion avoided. We compared 441 patients screened in the pre-operative anaemia programme with 239 patients not screened; of the patients screened, 180 (40.8%) received intravenous iron for anaemia and suboptimal iron stores. The estimated mean cost of screening and treating pre-operative anaemia was AU$332 (£183; US$231; €204) per screened patient. In the propensity score weighted analysis, screened patients were transfused 52% less red cell units when compared with those not screened (rate ratio = 0.48, 95%CI 0.36-0.63, p < 0.001). The mean difference in total screening, treatment and hospitalisation cost between groups was AU$3776 lower in the group screened (£2080; US$2629; €2325) (95%CI AU$1604-5947, p < 0.001). Screening elective patients pre-operatively for anaemia and suboptimal iron stores reduced the number of red cell units transfused. It also resulted in lower total costs than not screening patients, thus demonstrating cost effectiveness.

The Introduction of Laparoscopic Colorectal Surgery: Can It Improve Hospital Economics?

INTRODUCTION: Clinical benefits of laparoscopic surgery are well established, but evidence for financial benefits is limited. This study aimed to compare the financial impact of the introduction of laparoscopic colorectal surgery. METHODS: This study included patients who underwent colorectal surgery between January 2010 and 2015. We collected a range of financial data and divided the patients into 2 groups. Primary outcome was total cost defined by surgical-related costs. RESULTS: A total of 1,246 patients were included, of which 440 surgeries were performed laparoscopically. The total median cost of laparoscopy was higher compared to open surgery (EUR 4,665 vs. EUR 4,268, p = 0.001). Laparoscopy was associated with higher equipment costs (EUR 857 vs. EUR 232, p < 0.001), longer operating time (3.2 vs. 2.5 hours, p < 0.001), and more readmissions (10.9 vs. 8.5%, p < 0.001). However, after adjusting for heterogeneity, no difference was found in total cost. Surgical-related costs were counterbalanced by lower costs associated with shorter median hospital stay (6 vs. 9 days, p < 0.001), less morbidity (37.3 vs. 55.1%, p < 0.001), and less mortality (1.8 vs. 5.6%, p = 0.013) for laparoscopy. CONCLUSION: During the introduction of laparoscopy for colorectal surgery, no significant differences were found in total cost between laparoscopic and open colorectal surgery. However, favorable postoperative outcomes were achieved with laparoscopic surgery.

A Paradigm Shift in Physician Reimbursement: A Model to Align Reimbursement to Value in Laparoscopic Colorectal Surgery in the United States.

BACKGROUND: Despite common beliefs, underuse of laparoscopic colorectal surgery remains an issue. A paradigm shift to increase laparoscopy and align payment with effort is needed, with pressures to improve value. OBJECTIVE: The purpose of this study was to compare reimbursement across surgical approach and payer for common colorectal procedures and to propose a novel way to increase use in the United States. DATA SOURCES: Centers for Medicare & Medicaid Services (Medicare) reimbursement and commercial claims data from 2012 to 2015 were used. STUDY SELECTION: Reimbursement across payers was mapped for the 10 most common colorectal procedures using the open and laparoscopic approaches. MAIN OUTCOME MEASURES: The reimbursement difference across approaches by payer and potential value proposition from a cost-shifting model increasing reimbursement with corresponding increases in laparoscopic use was measured. RESULTS: For Medicare, reimbursement was lower laparoscopically than open for the majority. With commercial, laparoscopy was reimbursed less for 3 procedures. When laparoscopic reimbursement was higher, the amount was not substantial. Medicare payments were consistently lower than commercial, with corresponding lower reimbursement for laparoscopy. Increasing reimbursement by 10%, 20%, and 30% resulted in significant cost savings with laparoscopy. Savings were amplified with increasing use, with additional savings over baseline at all levels, except 30% reimbursement/10% increased use. LIMITATIONS: The study was limited by the use of claims data, which could have coding errors and confounding in the case mix across approaches. CONCLUSIONS: Reimbursement for laparoscopic colorectal surgery is comparatively lower than open. Reimbursement can be increased with significant overall cost savings, as the reimbursement/case is still less than total cost savings with laparoscopy compared with open cases. Incentivizing surgeons toward laparoscopy could drive use and improve outcomes, cost, and quality as we shift to value-based payment. See Video Abstract at http://links.lww.com/DCR/B290. CAMBIOS EN LOS PARADIGMAS DE REEMBOLSOS MÉDICOS: UN MODELO PARA ALINEAR EL REEMBOLSO AL VALOR REAL DE LA CIRUGÍA COLORRECTAL LAPAROSCÓPICA EN LOS ESTADOS UNIDOS: A pesar de las creencias comunes, la subutilización de la cirugía colorrectal laparoscópica sigue siendo un problema. Se necesita un cambio en los paradigmas para aumentar y alinear el rembolso de la laparoscopia aplicando mucho esfuerzo para obtener una mejoría en su valor real.Comparar los reembolsos del abordaje quirúrgico y los de la administración para procedimientos colorrectales comunes y proponer una nueva forma de aumentar su uso en los Estados Unidos.Reembolsos en los Centros de Servicios de Medicare y Medicaid (Medicare) y los datos de reclamos comerciales encontrados de 2012-2015.El reembolso administrativo se mapeó para los diez procedimientos colorrectales más comunes utilizando los enfoques abiertos y laparoscópicos.Diferencias de reembolso entre los enfoques por parte de la administración y la propuesta de valor real de un modelo de cambio de costos que aumentan el reembolso con los aumentos correspondientes si se utiliza la laparoscopía.Para Medicare, el reembolso fue menor para una mayoría por vía laparoscópica que abierta. Comercialmente, la laparoscopia se reembolsó menos por 3 procedimientos. Cuando el reembolso laparoscópico fue mayor, la cantidad no fue sustancial. Los pagos de Medicare fueron consistentemente más bajos que los pagos comerciales, con el correspondiente reembolso más bajo por laparoscopia. El aumento del reembolso en un 10%, 20% y 30% resultó en ahorros de costos significativos con la laparoscopía. Los ahorros se amplificaron con el aumento de la utilización, con ahorros adicionales sobre la línea de base en todos los niveles, excepto el 30% de reembolso / 10% de mayor uso.Uso de datos de reclamos, que podrían tener errores de codificación y confusión en la combinación de casos entre enfoques.El reembolso por la cirugía colorrectal laparoscópica es comparativamente más bajo que el abordaje abierto. El reembolso se puede aumentar con ahorros significativos en los costos generales, ya que el reembolso / caso es aún menor que el ahorro total en los costos de la laparoscopia en comparación con los casos abiertos. Incentivar a los cirujanos hacia la laparoscopía podría impulsar la utilización y mejorar los resultados, el costo y la calidad a medida que se pasa al pago basado en el valor real. Consulte Video Resumen en http://links.lww.com/DCR/B290. (Traducción-Dr Xavier Delgadillo).

The Impact of a Colorectal Care Bundle for Surgical Site Infections at an Academic Disproportionate Share Hospital With a Level I Trauma Center.

OBJECTIVES: Colorectal care bundles for surgical site infections (CRCB-SSIs) have been shown to reduce SSIs following elective colorectal surgery (CRS). There are limited data evaluating the effect of CRCB-SSI at Academic Disproportionate Share Hospitals (ADSH) with significant rates of urgent and emergent cases. METHODS: A CRCB-SSI was implemented in April 2016. We reviewed medical records of all patients undergoing colon resections between August 2015 and December 2017. Patients were divided into preimplementation and postimplementation groups. The primary endpoint was the SSI rate, and the secondary endpoint included types of SSI (superficial, deep, organ space). Univariable and multivariable analyses were performed. A subset analysis was performed in elective cases. RESULTS: We analyzed a total of 417 patients. Of these, 116 (28%) and 301 (72%) patients were in the preimplementation and postimplementation groups, respectively. The rate of SSI decreased from 30.1% to 15.9% in the postimplementation group (P = .0012); however, it was not statistically significant after adjusting for baseline differences (relative risk [RR] 0.65; 95% CI 0.41-1.02).The elective subset included 219 patients. The rate of SSI in this cohort decreased from 25% to 10.5% in the postimplementation group (P = .0012) and remained significant following multivariable analysis (RR 0.41, 95% CI 0.19- 0.88). There were no differences in the subtypes of SSI. DISCUSSION: While the CRCB-SSI was effective in decreasing the postoperative SSI rate for elective cases, its effect on the overall patient population was limited. CRCB-SSIs are not enough to bring SSI rates to accepted rates in high-risk patients such as those seen at ADSH.

Industry Payments in Colon and Rectal Surgery: A Cross-Sectional Analysis of Open Payments Data.

BACKGROUND: The Physician Payments Sunshine Act of 2010 mandated publication of all financial relationships between companies and physicians on the Centers for Medicare and Medicaid Services' Open Payments Data to elucidate potential conflicts of interest. This study seeks to illuminate the financial relationships that the pharmaceutical, medical device, biologics, and medical supply industries maintained with colon and rectal surgeons across the United States from 2014 to 2018. MATERIALS AND METHODS: We extracted and analyzed all colon and rectal surgeon data from the Open Payments Data for 2014-2018 using Microsoft Excel 2018 and JMP PRO 13.2.0 (SAS Institute). We calculated descriptive statistics and displayed prominent trends in the data. RESULTS: From 2014 to 2018, totals of $26,841,274 in general payments and $7,492,822 in research payments were made to 1935 and 150 colorectal surgeons, respectively. Intuitive Surgical, Inc paid the most money in general payments every year, ranging from 39.0% to 58.8% of the total payment amount. Intuitive Surgical, Inc's product, da Vinci Surgical System, had the greatest number of payments, totaling 21,191 general payments. The year with the highest amount paid for research was 2017, in which a total of $2,810,558 was paid to colorectal surgeons. CONCLUSIONS: Companies across industries paid millions of dollars to colorectal surgeons from 2014 to 2018. However, further research is required to determine the causal effects of these surgeons' financial relationships with the industry on research, prescription, and technology adoption practices.

Differential Index-Hospitalization Cost Center Impact of Enhanced Recovery After Surgery Program Implementation.

BACKGROUND: Most hospitals in the United States are reimbursed for colectomy via a bundled payment based on the diagnosis-related group assigned. Enhanced recovery after surgery programs have been shown to improve the value of colorectal surgery, but little is known about the granular financial tradeoffs required at individual hospitals. OBJECTIVE: The purpose of this study is to analyze the index-hospitalization impact on specific cost centers associated with enhanced recovery after surgery implementation for diagnosis-related groups commonly assigned to patients undergoing colon resections. DESIGN: We performed a single-institution retrospective, nonrandomized, preintervention (2013-2014) and postintervention (2015-2017) analysis of hospital costs. SETTING: This study was conducted at an academic medical center. PATIENTS: A total of 1297 patients with diagnosis-related group 330 (colectomy with complications/comorbidities) and 331 (colectomy without complications/comorbidities) were selected. MAIN OUTCOME MEASURES: The primary outcome was total index-hospitalization cost. Secondary outcomes included specific cost center expenses. RESULTS: Total median cost for diagnosis-related group 330 in the pre-enhanced recovery after surgery group was $24,111 ($19,285-$28,658) compared to $21,896 ($17,477-$29,179) in the enhanced recovery after surgery group, p = 0.01. Total median cost for diagnosis-related group 331 in the pre-enhanced recovery after surgery group was $19,268 ($17,286-$21,858) compared to $18,444 ($15,506-$22,847) in the enhanced recovery after surgery group, p = 0.22. When assessing cost changes after enhanced recovery after surgery implementation for diagnosis-related group 330, operating room costs increased (p = 0.90), nursing costs decreased (p = 0.02), anesthesia costs increased (p = 0.20), and pharmacy costs increased (p = 0.08). For diagnosis-related group 331, operating room costs increased (p = 0.001), nursing costs decreased (p < 0.001), anesthesia costs increased (p = 0.03), and pharmacy costs increased (p = 0.001). LIMITATIONS: This is a single-center study with a pre- and postintervention design. CONCLUSIONS: The returns on investment at the hospital level for enhanced recovery after surgery implementations in colorectal surgery result largely from cost savings associated with decreased nursing expenses. These savings likely offset increased spending on operating room supplies, anesthesia, and medications. See Video Abstract at http://links.lww.com/DCR/B204. IMPACTO DE LA IMPLEMENTACIÓN DEL PROTOCOLO DE RECUPERACIÓN MEJORADA DESPUÉS DE CIRUGÍA EN EL COSTO DE LA HOSPITALIZACIÓN ÍNDICE EN CENTROS ESPECÍFICOS: La mayoría de los hospitales en los Estados Unidos son reembolsados por la colectomía a través de un paquete de pago basado en el grupo de diagnóstico asignado. Se ha demostrado que los programas de recuperación después de la cirugía mejoran el valor de la cirugía colorrectal, pero se sabe poco sobre las compensaciones financieras granulares que se requieren en los hospitales individuales.El objetivo de este estudio es analizar el impacto del índice de hospitalización en centros de costos específicos asociados con la implementación de RMDC para grupos relacionados con el diagnóstico comúnmente asignados a pacientes que se someten a resecciones de colon.Realizamos un análisis retrospectivo, no aleatorio, previo (2013-2014) y posterior a la intervención (2015-2017) de los costos hospitalarios de una sola institución.Centro médico académico.Un total de 1. 297 pacientes con diagnóstico relacionado con el grupo 330 (colectomía con complicaciones/comorbilidades) y 331 (colectomía sin complicaciones/comorbilidades).El resultado primario fue el índice total de costos de hospitalización. Los resultados secundarios incluyeron gastos específicos del centro de costos.El costo medio total para el grupo relacionado con el diagnóstico de 330 en el grupo de recuperación pre-mejorada después de la cirugía fue de $24,111 ($19,285- $28,658) en comparación con $21,896 ($17,477- $29,179) en el grupo de recuperación mejorada después de la cirugía, p = 0.01. El costo medio total para DRG 331 en el grupo de recuperación pre-mejorada después de la cirugía fue de $19,268 ($17,286- $21,858) en comparación con $18,444 ($15,506-$22,847) en el grupo de recuperación mejorada después de la cirugía, p = 0.22. Al evaluar los cambios en los costos después de una recuperación mejorada después de la implementación de la cirugía para el grupo 330 relacionado con el diagnóstico, los costos de la sala de operaciones aumentaron (p = 0.90), los costos de enfermería disminuyeron (p = 0.02) los costos de anestesia aumentaron (p = 0.20) y los costos de farmacia aumentaron (p = 0.08). Para el grupo 331 relacionado con el diagnóstico, los costos de la sala de operaciones aumentaron (p = 0.001), los costos de enfermería disminuyeron (p < 0.001) los costos de anestesia aumentaron (p = 0.03) y los costos de farmacia aumentaron (p = 0.001).Este es un estudio de un solo centro con un diseño previo y posterior a la intervención.El retorno de la inversión a nivel hospitalario para una recuperación mejorada después de la implementación de la cirugía en la cirugía colorrectal se debe en gran parte al ahorro de costos asociado con la disminución de los gastos de enfermería. Es probable que estos ahorros compensen el aumento de los gastos en suministros de quirófano, anestesia y medicamentos. Consulte Video Resumen en http://links.lww.com/DCR/B204. (Traducción-Dr. Gonzalo Hagerman).

Early feeding in colorectal surgery patients: safe and cost effective.

PURPOSE: Enhanced recovery after surgery (ERAS) pathways has demonstrated improved outcomes in colorectal surgery. An important component of ERAS is early oral intake. The aim of this study is to determine the impact of early oral intake in patients following colorectal surgery. METHODS: A retrospective analysis of patients who underwent colectomy and proctectomy at an academic institution from January 2015 to November 2018 was performed. Postoperative outcomes were compared between patients who had postoperative day 0 (POD 0) oral intake and those who did not. RESULTS: A total of 436 ERAS patients had oral intake timing documented. The majority of patients were women (241, 55.3%) and white (313, 71.8%). The mean age was 57 ± 15.09. Patients who had early intake were found to have lower 30-day overall morbidity and length of stay (p < 0.05), and no difference in serious adverse events. Additionally, hospital costs were lower in the POD 0 feeding group for all patients (p < 0.05). CONCLUSION: We have demonstrated that early oral feeding in an established ERAS pathway is associated with improved clinical outcomes as well as decreased total hospital costs. Early postoperative feeding is safe in colorectal patients and should be prioritized to decrease complications and healthcare costs.

Clinical and economic burden of colorectal and bariatric anastomotic leaks.

BACKGROUND: Anastomotic leaks cause a significant clinical and economic burden on patients undergoing bariatric and colorectal surgeries. Current literature shows a wide variation in incidence of anastomotic leaks and a significant gap in associated economic metrics. This analysis utilized claims data to quantify the full episode-of-care cost burden of leaks following colorectal and bariatric surgeries. METHODS: Medicare Fee-for-Service and commercial claims data from a large U.S.-based health plan were queried for cost and utilization of members that underwent bariatric and colorectal surgical procedures between January 1, 2013 and August 31, 2015. Outcomes were collected for members with anastomotic leaks versus those without leaks during the initial hospital stay (index) and within 30 days of the procedure. These outcomes included leak frequency, payer reimbursement, and length of stay (LOS). RESULTS: The colorectal Medicare analysis identified 239,350 patients undergoing colorectal surgery. For patients with a leak compared to those without, index admission costs were $30,670 greater ($48,982 vs. $18,312; p < 0.0001) and the index LOS was 12 days longer (19 vs. 7 days; p < 0.0001). This finding was similar for the bariatric patients (n = 62,292) where cost was $30,885 higher ($43,918 vs. $13,033; p < 0.0001) and LOS was 15 days longer (17 vs. 2 days; p < 0.0001). Furthermore, readmissions and associated costs were also substantially higher for those with an index leak. The commercial analysis of both the bariatric and colorectal populations trended similarly to the Medicare population in regards to all outcomes measured. CONCLUSION: Patients experiencing anastomotic leaks during and after bariatric and colorectal surgery have significantly higher costs and longer LOS both at the initial stay and within 30 days of the procedure. It is important that providers and hospitals understand the economic consequences of these procedures and implement technologies and techniques to prevent/reduce anastomotic leaks.

A National study on the adoption of laparoscopic colorectal surgery in the elderly population: current state and value proposition.

BACKGROUND: The economic and clinical benefits of laparoscopic colorectal surgery are proven, yet may be underutilized in appropriate cases, especially in the elderly. Since the elderly constitute the greatest colorectal surgical volume, our goal was to identify trends in utilization and impact of laparoscopy in this cohort. METHODS: A national review of elective inpatient colorectal resections from the Premier Inpatient Database between 2010 and 2015 was performed. Patients were included if elderly (≥ 65 years), then grouped into open or laparoscopic procedures. The main outcome measures were trends in utilization by approach and total costs for the episode of care, length of stay (LOS), readmission, and complications by approach in the elderly. Multivariable regression models controlled for differences across platforms, adjusting for patient demographic, comorbidities and hospital characteristics. RESULTS: In 70,655 elderly patients evaluated, laparoscopic adoption remained lower than open throughout the study period. Rates increased until 2013, then declined, with increasing rates of open surgery. Laparoscopy was associated with significantly lower mean total costs ($4012 less/case), complications and readmissions (36% and 33% less, respectively), and shorter LOS (2.6 less days) than open cases (all p < 0.0001). When complications occurred, they were less severe and the readmission episodes were less costly with laparoscopy than open colorectal surgery. CONCLUSION: The adoption of laparoscopy in the elderly has lagged behind open surgery and even declined in recent years despite being associated with improved clinical outcomes and reduced cost. With this tremendous value proposition to increase use of laparoscopic surgery in the elderly, further work needs to evaluate root causes of the disparity.

Robotic colorectal surgery in Australia: a cohort study examining clinical outcomes and cost.

Objective The aim of this study was to compare robotic versus laparoscopic colorectal operations for clinical outcomes, safety and cost. Methods A retrospective cohort study was performed of 213 elective colorectal operations (59 robotic, 154 laparoscopic), matched by surgeon and operation type. Results No differences in age, body mass index, median American Society of Anesthesiologists score or presence of cancer were observed between the laparoscopic or robotic surgery groups. However, patients undergoing robotic colorectal surgery were more frequently male (P = 0.004) with earlier T stage tumours (P = 0.02) if cancer present. Procedures took longer in cases of robotic surgery (302 vs 130 min; P < 0.001), and patients in this group were more frequently admitted to intensive care units (P < 0.001). Overall length of stay was longer (7 vs 5 days; P = 0.03) and consumable cost was A$2728 higher per patient in the robotic surgery group. Conclusion Robotic colorectal surgery appears to be safe compared with current laparoscopic techniques, albeit with longer procedure times and overall length of stay, more frequent intensive care admissions and higher consumables cost. What is known about the topic? Robotic surgery is an emerging alternative to traditional laparoscopic approaches in colorectal surgery. International trials suggest the two techniques are equivalent in safety. What does this paper add? This is an original cohort study examining clinical outcomes in Australian colorectal robotic surgery. The data suggest it may be safe, but this paper demonstrates key issues in the implementation and audit of novel surgical technologies in relatively low-volume centres. What are implications for practitioners? In our study, patients undergoing robotic colorectal surgery at a single centre in Australia had equivalent measured clinical outcomes to those undergoing laparoscopic surgery. However, practitioners may counsel patients that robotic procedures are typically longer and more expensive, with a longer overall hospital admission and a higher likelihood of intensive care admission.

Costs-benefits of robot-assisted colorectal surgery: a different perspective.

The costs of robot-assisted surgery (RAS) still represent a critical issue. Kulaylat et al. reported a propensity-matched study to compare the outcomes of colorectal surgery between a robotic and a laparoscopic group, concluding that RAS was burdened by higher costs. However, authors did not mention what da Vinci system, Si or Xi, they used and this could be crucial, as recently data published by our group on rectal resections showed that the use of the da Vinci Xi and the surgeon's increased experience could improve the results and significantly reduce the costs of RAS.

Interventions and Innovation to Prevent Surgical Site Infection in Colorectal Surgery: A Cost-Effectiveness Analysis.

BACKGROUND: Surgical site infection (SSI), particularly in colorectal surgery, continues to cause substantial morbidity and cost. Both process- and product-based interventions have been proposed and implemented. No cost-effectiveness analysis of such interventions has been published. MATERIALS AND METHODS: This study used a decision-analytic model to evaluate the cost-effectiveness of strategies for the prevention of SSI. Costs, utilities, and transition probabilities were obtained from literature review. We used a lifetime time horizon, captured with explicit event modeling for a year plus quantification of enduring health outcomes. We represented costs in 2017 US dollars and health effects in Quality-Adjusted Life Years (QALYs). Deterministic and probabilistic sensitivity analyses were performed. RESULTS: Both process- and device-based strategies were dominant-clinically superior and also less expensive-compared with no intervention. Two types of double-ring wound protection barrier devices with greater anticontamination functionality were found to be both clinically superior and cost-saving compared with bundled process measures and simpler single-ring devices. Gains in QALYs were 230 per 1000 patients, and cost savings were 2.2 million dollars per 1000 patients, driven primarily by the high cost of SSI. CONCLUSIONS: We found process-based interventions and wound protection devices to be superior to no intervention in the prevention of SSI. Double ring devices offered a distinct advantage over simpler devices, with small reductions in SSI risk leading to substantial cost savings. Further innovation in device-based wound protection devices may offer increased prevention of SSI at acceptable cost-effectiveness levels.

An economic evaluation of perioperative enteral nutrition in patients undergoing colorectal surgery (SANICS II study).

AIMS: The objective of this (trial based) economic evaluation was to assess, from a societal perspective, the cost-effectiveness of perioperative enteral nutrition compared with standard care in patients undergoing colorectal surgery. MATERIALS AND METHODS: Alongside the SANICS II randomized controlled trial, global quality-of-life, utilities (measured by EQ-5D-5L), healthcare costs, production losses, and patient and family costs were assessed at baseline, 3 months, and 6 months. Incremental cost-effectiveness ratios (ICERs) (i.e. cost per increased global quality-of-life score or quality-adjusted life year [QALY] gained) and cost effectiveness acceptability curves were visualized. RESULTS: In total, 265 patients were included in the original trial (n = 132 in the perioperative enteral nutrition group and n = 133 in the standard care group). At 6 months, global quality-of-life (83 vs 83, p = .357) did not differ significantly between the groups. The mean total societal costs for the intervention and standard care groups were €14,673 and €11,974, respectively, but did not reach statistical significance (p = .109). The intervention resulted in an ICER of -€6,276 per point increase in the global quality of life score. The gain in QALY was marginal (0.003), with an additional cost of €2,941, and the ICUR (Incremental cost utility ratio) was estimated at €980,333. LIMITATIONS: The cost elements for all the participating centers reflect the reference prices from the Netherlands. Patient-reported questionnaires may have resulted in recall bias. Sample size was limited by exclusion of patients who did not complete questionnaires for at least at two time points. A power analysis based on costs and health-related quality-of-life (HRQoL) was not performed. The economic impact could not be analyzed at 1 month post-operatively where the effects could potentially be higher. CONCLUSIONS: This study suggests that perioperative nutrition is not beneficial for the patients in terms of quality-of-life and is not cost-effective.

Insurance status does not affect short-term outcomes after oncological colorectal surgery in Europe, but influences the use of minimally invasive techniques: a propensity score-matched analysis.

BACKGROUND AND PURPOSE: Controversy exists whether surgical treatment is influenced by insurance status. American studies suggest higher morbidity and decreased survival in uninsured patients with colorectal cancer (CRC). It remains elusive, however, whether these findings apply to European countries with mandatory, government-driven insurance systems. We aimed to analyze whether operative techniques, quality of surgery, and complication rates differ among patients covered by statutory (SI) versus private (PI) healthcare insurance. METHODS: Based on a prospective national surgical quality database, patients undergoing elective resection for CRC during 2007-2015 were identified. A propensity score match of eligible patients with SI and PI yielded 765 patients per group. RESULTS: Hierarchical status of the operating surgeon differed substantially (p = 0.001): junior surgeons operated on > 50% of patients with SI, whereas over 80% of patients with PI were operated by senior surgeons. Minimally invasive techniques were used more frequently in patients with PI (p = 0.001) and patients with SI undergoing colonic resection showed an increased conversion rate (OR 2.44). Median duration of surgery (p = 0.001) and blood loss (p = 0.002) were higher in patients with SI; however, length of hospital stay was equal. Neither the rate of positive resection margins nor the number of resected lymph nodes differed among groups. Complications and mortality occurred with similar frequencies for patients undergoing colon (p = 0.140) and rectal (p = 0.335) resection. CONCLUSION: The use of minimally invasive techniques was favored in patients with PI; however, the quality of oncological resection was not affected by insurance status and only minor differences in perioperative complications observed.