Tibial plateau fractures in Belgium: epidemiology, financial burden and costs curbing strategies.

PURPOSE: We describe the incidence of tibial plateau fractures and the evolution of its management and financial burden in Belgium, perform a similar audit at University Hospitals Leuven, and define strategies to curb the increasing cost. METHODS: National data on tibial plateau fractures were collected from the NIHDI and compared to our performance. Several clinical parameters, such as age, sex, treatment modality and length-of-stay, were included. The total healthcare costs are considered as the sum of hospitalization costs and ambulatory care costs. RESULTS: Between 2006 and 2018, a total number of 35,226 tibial plateau fractures were diagnosed in Belgium and 861 at our center. The incidence increased 41% over time (mean 25/100,000 persons per year). The mean rate of surgery in Belgium was 37% and slightly decreased over time, due to a larger increase of non-operatively treated tibial plateau fractures. The rate of surgery at the UHL was 49%. Surprisingly, the average cost per patient was equal for operatively and non-operatively treated patients in Belgium, and driven by the length-of stay. CONCLUSION: Since length-of-stay is the main driver of the total healthcare costs of tibial plateau fractures, guidelines on appropriate length-of-stay can help to decrease variability and curb the total healthcare costs, particularly of the non-operatively treated patients. Our performance was in line with this. LEVEL OF EVIDENCE: Level IV.

Predictors of survival after surgery with curative intent for perihilar cholangiocarcinoma.

BACKGROUND: Several clinicopathological predictors of survival after curative surgery for perihilar cholangiocarcinoma (pCCA) have been identified; however, conflicting reports remain. The aim was to analyse clinical and oncological outcomes after curative resection of pCCA and to determine prognostic factors. METHODS: Eighty-eight consecutive patients with pCCA underwent surgery with curative intent between 1998 and 2017. Survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test. Twenty-one prognostic factors were evaluated using multivariate Cox regression models. RESULTS: Postoperative complications were observed in 73 (83%) patients of which 41 (47%) were severe complications (therapy-oriented severity grading system (TOSGS) grade > 2), including a 90-day mortality of 9% (n = 8). Overall survival (OS) and disease-free survival (DFS) rates at 5 and 10 years after surgery were 33% and 19%, and 37% and 30%, respectively. Independent predictors of OS were locoregional lymph node metastasis (LNM) (risk ratio (RR) 2.12, confidence interval (CI) 1.19-3.81, p = 0.011), patient American Society of Anesthesiologists (ASA) physical status classification system > 2 (RR 2.10, CI 1.03-4.26, p = 0.043), and depth of tumour penetration (pT) > 2 (RR 2.58, CI 1.03-6.30, p = 0.043). The presence of locoregional LNM (RR 2.95, CI 1.51-5.90, p = 0.002) and caudate lobe resection (RR 2.19, CI 1.01-5.14, p = 0.048) were found as independent predictors of DFS. CONCLUSIONS: Curative surgery for pCCA carries high risks with poor long-term survival. Locoregional LNM was the only predictor for both OS and DFS.

Variability in Hospital Costs of Adult Spinal Deformity Care.

STUDY DESIGN: Retrospective, single-center analysis. OBJECTIVE: To calculate the total clinical hospital cost of the Adult Spinal Deformity (ASD) care trajectory, to explain cost variability by patient and surgery characteristics, and to identify areas of process improvement opportunities. SUMMARY OF BACKGROUND DATA: ASD is associated with a high financial and clinical burden on society. ASD care thus requires improved insights in costs and its drivers as a critical step toward the improvement of value, i.e., the ratio between delivered health outcome and associated costs. METHODS: Patient characteristics and surgical variables were collected following ethical approval in a cohort of 139 ASD patients, treated between December, 2014 and January, 2018. Clinical hospital costs were calculated, including all care activities, from initial consultation to 1 year after initial surgery (excl. overhead) in a university hospital setting. Multiple linear regression analysis was performed to analyze the impact of patient and surgical characteristics on clinical costs. RESULTS: 75.5% of the total clinical hospital cost (&OV0556;27,865) was incurred during initial surgery with costs related to the operating theatre (80.3%), nursing units (11.9%), and intensive care (2.9%) being the largest contributors. 57.5% of the variation in total cost could be explained in order of importance by surgical invasiveness, age, coronary disease, single or multiple-staged surgery, and mobility status. Revision surgery, unplanned surgery due to complications, was found to increase average costs by 87.6% compared with elective surgeries (&OV0556; 44,907 (± &OV0556; 23,429) vs. &OV0556; 23,944 (± &OV0556; 7302)). CONCLUSION: This study identified opportunities for process improvement by calculating the total clinical hospital costs. In addition, it identified patient and treatment characteristics that predict 57.5% of cost variation, which could be taken into account when developing a payment system. Future research should include outcome data to assess variation in value. LEVEL OF EVIDENCE: 4.

Cost-Utility Analysis of Surgery and Radiotherapy for Symptomatic Spinal Metastases in a Belgian Specialist Center.

OBJECTIVE: Spinal metastases represent the most common site of bony metastases and frequently reduce quality of life. A beneficial effect of surgery and radiotherapy versus radiotherapy alone has been demonstrated in symptomatic patients. The goal of our study was to perform a cost-utility analysis of surgery for spinal metastases based on patient-level costs and health status data in a specialist spine center in Belgium. METHODS: A cost-utility analysis was performed in a prospective cohort of patients undergoing surgery for symptomatic spinal metastases in 2011-2015. EQ-5D-3L measure of health-related quality of life data were collected preoperatively and at 3, 6, 12, and 24 months. Hospital costs relating to surgical management including postoperative radiotherapy were analyzed. A retrospective cohort of patients treated with radiotherapy alone between 2011 and 2015, which matched the surgical patients for disease load and presentation, also was assessed. Quality-adjusted life years (QALYs) for nonsurgical patients were modelled against the surgical group. RESULTS: In total, 38 consecutive surgical patients had information for cost-utility analysis and 8 nonsurgical patients were matched. Mean total cost in the surgical group was €16,989 (SD €8148), largely comprising nonmedical staffing cost (mean €7721, 45.9%), followed by daily operational costs (€2963, 17.6%) and medical staffing costs (€2621, 15.6%). Median initial health status was 0.33 (interquartile range 0.15-0.55), and median postoperative QALYs were 0.70 (interquartile range 0.18-1.70). Mean total cost in the nonsurgical cohort was €9354. The incremental cost-effectiveness ratio for surgical management was €13,635 (range €12,726-€14,407) per QALY. CONCLUSIONS: Surgery for symptomatic spinal metastases in a specialist hospital in Belgium is cost-effective.

Are the current guidelines for surgical delay in hip fractures too rigid? A single center assessment of mortality and economics.

PURPOSE: Controversy remains around acceptable surgical delay of acute hip fractures with current guidelines ranging from 24 to 48 h. Increasing healthcare costs force us to consider the economic burden as well. We aimed to evaluate the adjusted effect of surgical delay for hip fracture surgery on early mortality, healthcare costs and readmission rate. We hypothesized that shorter delays resulted in lower early mortality and costs. METHODS: In this retrospective cohort study 2573 consecutive patients aged ≥50 years were included, who underwent surgery for acute hip fractures between 2009 and 2017. Main endpoints were thirty- and ninety-day mortality, total cost, and readmission rate. Multivariable regression included sex, age and ASA score as covariates. RESULTS: Thirty-day mortality was 5% (n = 133), ninety-day mortality 12% (n = 304). Average total cost was €11960, dominated by hospitalization (59%) and honoraria (23%). Per 24 h delay, the adjusted odds ratio was 1.07 (95% CI 0.98-1.18) for thirty-day mortality, 1.12 (95% CI 1.04-1.19) for ninety-day mortality, and 0.99 (95% CI = 0.88-1.12) for readmission. Per 24 h delay, costs increased with 7% (95% CI 6-8%). For mortality, delay was a weaker predictor than sex, age, and ASA score. For costs, delay was the strongest predictor. We did not find clear cut-points for surgical delay after which mortality or costs increased abruptly. CONCLUSIONS: Despite only modest associations with mortality, we observed a steady increase in healthcare costs when delaying surgery. Hence, a more pragmatic approach with surgery as soon as medically and organizationally possible seems justifiable over rigorous implementation of the current guidelines.

Health Care Usage and Related Costs in Fibular Plating for AO Type 44-B Ankle Fractures in a Belgian University Hospital: An Exploratory Analysis.

Open reposition and internal fixation (ORIF) is the reference standard for unstable Arbeitsgemeinschaft für Osteosynthesefragen (AO)-type 44-B ankle fractures. Age, comorbidity, delayed-staged surgery, and length-of-stay (LOS) are all factors that presumably correlate positively with health care costs. We performed an exploratory analysis of the health care costs associated with the treatment of this type of fracture and hypothesized that these costs will be significantly greater for the elderly. A total of 217 patients with an acute AO type 44-B ankle fracture were included. We studied 14 variables, and 5 main cost categories were defined. The health care costs associated with the treatment of ankle fractures in the present study constituted more than one half (53%) of the hospitalization costs, which, in turn, were strongly related to the LOS. Delayed-staged surgery and age were the most important clinical variables driving the total health care costs and LOS (p < .001). The median LOS before ORIF was 6 times greater (12 versus 2 days) for patients treated using a delayed-staged surgery protocol. The cutoff age above which the costs differed significantly was 65 years. Thus, the median total health care costs for the treatment of these fractures were doubled in the older group ($9207 versus $4559), mainly owing to a 2 times greater LOS before ORIF (2 versus 4 days) and 3 times greater total LOS (4 versus 12.5 days) in the elderly. Surprisingly, the complication rate was equal (27.7% versus 29.3%) in the 2 groups. Therefore, to decrease the total health care costs, we should focus on a reduction of the costly LOS before ORIF in the elderly population.