Pancreatitis aguda: costos en un hospital universitario en Chile / Acute pancreatitis: costs in a university hospital in Chile

Background: Acute pancreatitis (AP) is a common disease. There is no information available on the costs of treatment in Chile. Aim: To obtain information on the cost of hospitalization for AP and identify the factors that influence the account, to analyze health insurance coverage and the economic charge for the patient. Patients and Method: Retrospective and descriptive study. Patients treated at the Hospital Clínico Universidad de Chile with diagnosis of AP between May 1, 2014 and April 30, 2016 were included. The clinical records were reviewed after the patient's discharge. Demographic characteristics, clinical evolution, the account issued, the insurance payment and patient's copayment were registered. Results: In the period studied, 176 patients (90 women) were discharged with diagnosis of AP. The dominant etiology was biliary in 61%. According to the Atlanta 2013 classification, 78.4% of the cases were mild, 10.2% moderate, and 11.4% severe. 3 patients (1.7%) died. The median cost in Chilean pesos was $ 2,537,918 (1,383,151-3,897,673) (p25-75). The total sum of the accounts of 176 patients was $ 885,261,241, with an average of $ 5,029,893. The average coverage of the health system (FONASA or ISAPRE) was $ 4,293,113, leaving a copayment of $ 801,661. The final cost was related to the severity of the disease, the length of hospitalization and the need for a high-complexity bed. Discussion: Hospitalization costs for PA are high. It is advisable to rationalize the critical care bed indication.

Introducción: La pancreatitis aguda (PA) es una patología frecuente. No hay información disponible del costo de su tratamiento en Chile. Objetivo: Obtener información del costo de hospitalización por PA, identificar los factores que influyen en la cuenta, estudiar la cobertura por seguros de salud y el cargo económico para el paciente. Pacientes y Métodos: Estudio retrospectivo, descriptivo. Se incluyeron pacientes tratados en el Hospital Clínico Universidad de Chile con diagnóstico de PA entre 01 de mayo de 2014 y 30 de abril de 2016. Las fichas clínicas fueron revisadas después del alta del paciente, se registraron sus características demográficas, evolución clínica, la cuenta emitida, el pago del seguro y el copago del paciente. Resultados: En el periodo estudiado 176 pacientes (90 mujeres) fueron dados de alta con diagnóstico de PA. La etiología dominante fue biliar en 61% . Según la clasificación de Atlanta 2013, 78,4% de los casos fueron leves, 10,2% moderados y 11,4% severos. Fallecieron 3 pacientes (1,7%). La mediana de costos fue de $2.537.918 (1.383.151-3.897.673) (p25-75). La suma total de las cuentas de 176 pacientes fue de $ 885.261.241, con un promedio de $ 5.029.893. La cobertura promedio del sistema de salud (FONASA o ISAPRE) fue de $ 4.293.113 dejando un copago de $ 801.661. El costo final se correlacionó con la severidad de la enfermedad, la duración de la hospitalización y la necesidad de cama de alta complejidad. Discusión: Los costos de hospitalización por PA son elevados. Es recomendable racionalizar la indicación de cama crítica.

Acute and Severe Acute Pancreatitis and the Effect of Cannabis in States Before and After Legalization Compared With States Without Legalized Cannabis.

OBJECTIVES: Cannabis legalization has increased its use. The incidence of acute pancreatitis (AP) and severe acute pancreatitis (SAP) has also increased. In this study, data on pancreatitis were obtained from 2 states before and after cannabis legalization and compared with 2 states without legalized cannabis. METHODS: Data were extracted from State Inpatient Databases from the states of Colorado and Washington before recreational cannabis legalization (2011) and after legalization (2015). Arizona and Florida were used as the nonlegalized cannabis states. Multivariable logistic regression models were fit for AP and SAP to determine a trend difference between legalized and nonlegalized cannabis states. RESULTS: Cannabis use, AP, and SAP increased in all states. The increase in AP and SAP was not significantly different between the states that legalized cannabis use and those that did not. Legalized cannabis states had lower charges for AP and SAP and shorter length of hospitalizations. CONCLUSIONS: The trend of AP and SAP increased during the study period, but this was not correlated to cannabis use. Cannabis users had lower hospitalization costs and hospital stay. The effects of other confounders such as cannabis dose and delivery methods, alcohol, tobacco, and others need to be studied further as use increases.

Normalization of Serum Lipase Levels Versus Resolution of Abdominal Pain: A Comparison of Preoperative Management in Children With Biliary Pancreatitis.

BACKGROUND: Controversy exists over the timing of cholecystectomy for biliary pancreatitis in children. Some surgeons await normalization of serum lipase levels while others are guided by resolution of abdominal pain; however, there are minimal data to support either practice. We hypothesized that resolution of abdominal pain is equivalent in outcome to awaiting normalization of lipase levels in patients undergoing cholecystectomy for biliary pancreatitis. METHODS: After institutional review board (IRB) approval, the medical record was retrospectively queried for all cases of cholecystectomy for biliary pancreatitis at our institution from 2007 to 2017. Patients undergoing chemotherapy, admitted for another cause, or who had severe underlying comorbidities like ventilator dependence were excluded. Patients were stratified into two cohorts: those managed preoperatively by normalization of serum lipase levels versus resolution of abdominal pain. Demographics, serum lipase levels, postoperative complications, cost of stay, readmissions, and return to the emergency department were collected and analyzed using multivariate regression. RESULTS: Seventy-four patients met inclusion: 29 patients had lipase levels trended until normalization compared with 45 patients who had resolution of abdominal pain prior to cholecystectomy. Among the two cohorts there was no statistical difference in age, gender, race, ethnicity, or type of preoperative imaging used. Trended patients were found to have more serum lipase levels tested (8.5 ± 6.2 versus 3.4 ± 2.5, P < 0.0001). The trended lipase cohort was significantly more likely to require preoperative total parenteral nutrition (48% versus 11%, P = 0.007) and consequently a longer time before resuming a diet (10 ± 7.3 versus 4.6 ± 2.4 d, P < 0.0001). When comparing the two groups, we found no significant difference in the duration of surgery, postoperative complications, or readmissions. Lipase trended patients had a significantly longer length of stay compared with nontrended patients (11.5 ± 8.1 versus 4.2 ± 2.3 d, P < 0.0001) and had a higher total cost of stay ($38,094 ± 25,910 versus $20,205 ± 5918, P = 0.0007). CONCLUSIONS: Our data suggest that in children with biliary pancreatitis, proceeding with cholecystectomy after resolution of abdominal pain is equivalent in outcomes to trending serum lipase levels but is more cost-effective with a decreased length of stay and decreased need for preoperative total parenteral nutrition.

PROCalcitonin-based algorithm for antibiotic use in Acute Pancreatitis (PROCAP): study protocol for a randomised controlled trial.

BACKGROUND: Differentiating infection from inflammation in acute pancreatitis is difficult, leading to overuse of antibiotics. Procalcitonin (PCT) measurement is a means of distinguishing infection from inflammation as levels rise rapidly in response to a pro-inflammatory stimulus of bacterial origin and normally fall after successful treatment. Algorithms based on PCT measurement can differentiate bacterial sepsis from a systemic inflammatory response. The PROCalcitonin-based algorithm for antibiotic use in Acute Pancreatitis (PROCAP) trial tests the hypothesis that a PCT-based algorithm to guide initiation, continuation and discontinuation of antibiotics will lead to reduced antibiotic use in patients with acute pancreatitis and without an adverse effect on outcome. METHODS: This is a single-centre, randomised, controlled, single-blind, two-arm pragmatic clinical and cost-effectiveness trial. Patients with a clinical diagnosis of acute pancreatitis will be allocated on a 1:1 basis to intervention or standard care. Intervention will involve the use of a PCT-based algorithm to guide antibiotic use. The primary outcome measure will be the binary outcome of antibiotic use during index admission. Secondary outcome measures include: safety non-inferiority endpoint all-cause mortality; days of antibiotic use; clinical infections; new isolates of multiresistant bacteria; duration of inpatient stay; episode-related mortality and cause; quality of life (EuroQol EQ-5D); and cost analysis. A 20% absolute change in antibiotic use would be a clinically important difference. A study with 80% power and 5% significance (two-sided) would require 97 patients in each arm (194 patients in total): the study will aim to recruit 200 patients. Analysis will follow intention-to-treat principles. DISCUSSION: When complete, PROCAP will be the largest randomised trial of the use of a PCT algorithm to guide initiation, continuation and cessation of antibiotics in acute pancreatitis. PROCAP is the only randomised trial to date to compare standard care of acute pancreatitis as defined by the International Association of Pancreatology/American Pancreatic Association guidelines to patients having standard care but with all antibiotic prescribing decisions based on PCT measurement. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number, ISRCTN50584992. Registered on 7 February 2018.

Incidence, Admission Rates, and Predictors, and Economic Burden of Adult Emergency Visits for Acute Pancreatitis: Data From the National Emergency Department Sample, 2006 to 2012.

INTRODUCTION: Acute pancreatitis (AP) is the most common gastroenterology-related reason for hospital admission, and a major source of morbidity and mortality in the United States. This study examines the National Emergency Database Sample, a large national database, to analyze trends in emergency department (ED) utilization and costs, risk factors for hospital admission, and associated hospital costs and length of stay (LOS) in patients presenting with AP. METHODS: The National Emergency Database Sample (2006 to 2012) was evaluated for trends in ED visits, ED charges, hospitalization rates, hospital charges, and hospital LOS in patients with primary diagnosis of AP (further subcategorized by age and etiology). A survey logistic-regression model was used to determine factors predictive of hospitalization. RESULTS: A total of 2,193,830 ED visits were analyzed. There was a nonsignificant 5.5% (P=0.07) increase in incidence of ED visits for AP per 10,000 US adults from 2006 to 2012, largely driven by significant increases in ED visits for AP in the 18 to <45 age group (+9.2%; P=0.025), AP associated with alcohol (+15.9%; P=0.001), and AP associated with chronic pancreatitis (+59.5%; P=0.002). Visits for patients aged ≥65 decreased over the time period. Rates of admission and LOS decreased during the time period, while ED and inpatient costs increased (62.1%; P<0.001 and 7.9%; P=0.0011, respectively). Multiple factors were associated with increased risk of hospital admission from the ED, with the strongest predictors being morbid alcohol use [odds ratio (OR), 4.53; P<0.0001], advanced age (age>84 OR, 3.52; P<0.0001), and smoking (OR, 1.75; P<0.0001). CONCLUSIONS: Despite a relative stabilization in the overall incidence of ED visits for AP, continued increases in ED visits and associated costs appear to be driven by younger patients with alcohol-associated and acute on chronic pancreatitis. While rates of hospitalization and LOS are decreasing, associated inflation-adjusted costs are rising. In addition, identified risk factors for hospitalization, such as obesity, alcohol use, and increased age, should be explored in further study for potential use in predictive models and clinical improvement projects.

What happened to health service utilization, health care expenditures, and quality of care in patients with acute pancreatitis after implementation of global budgeting in Taiwan?

AIM: Acute pancreatitis is associated with significant morbidity and mortality. In the United States, more than 3,00,000 patients are admitted and about 20,000 die from acute pancreatitis per year. In Taiwan, the incidence rate of acute pancreatitis is 0.03% and the mortality rate among severe acute pancreatitis is 16.3%. The aim of the study was to evaluate the impact of the global budgeting system on health service utilization, health care expenditures, and quality of care among patients with acute pancreatitis in Taiwan. MATERIALS AND METHODS: The National Health Insurance Research Database (NHIRD) was used for analysis. Data on patients with acute pancreatitis diagnosed during the period 2000 and 2001 were used as baseline data, and data from 2004 and 2005 were used as post-intervention data. The length of stay (LOS), diagnostic costs, drug cost, therapy costs, total costs, risk of readmission within 14 days, and risk of revisiting the emergency department (ED) within 3 days of discharge before and after implementation of the global budgeting system were compared and analyzed. RESULTS: Data on 2810 patients with acute pancreatitis were analyzed in this study. There was a significant difference in mean LOS before and after introduction of the global budget system (7.34 ±â€Š0.22 days and 7.82 ±â€Š0.22 days, respectively; P < .001)). The mean total costs before and after implementation of the global budget system were Taiwan dollars (NT$) 28,290.66 ±â€Š1576.32 and NT$ 42,341.83 ±â€Š2285.23, respectively. The mean rate of revisiting the ED within 3 days decreased from 9.9 ±â€Š0.9% before adoption of global budgeting to 7.2 ±â€Š0.6% after implementation of the system. The mean 14-day re-admission rates before and after introduction of global budgeting were 11.6 ±â€Š1.0% and 7.9 ±â€Š0.7%, respectively. CONCLUSION: The global budget system was associated with significantly longer length of stay, higher health care expenditures, and better quality of care in patients treated for acute pancreatitis.

Comparison between Endoscopic Treatment and Surgical Drainage of the Pancreatic Duct in Chronic Pancreatitis.

BACKGROUND: Treatment of recurrent chronic obstructive pancreatitis is pancreatic duct decompression with endoscopic drainage (endoscopic pancreatic stenting [EPS] with extracorporeal shockwave lithotripsy [ESWL]) or surgical drainage. Despite the recent popularization of endoscopic drainage, treatment or stent removal is difficult in many patients. We compared the efficacy, safety, and medical cost of endoscopic and surgical treatments. PATIENTS AND METHODS: We retrospectively compared the treatment course and medical cost of hospitalization between 41 patients who had undergone pancreatic stenting between 2006 and 2010 (EPS group) and 10 patients who had undergone surgery for poor control of pancreatitis between 2001 and 2005 (surgical drainage group). RESULTS: No intergroup differences were observed in causes, symptoms, disease duration, smoking history, or endocrine and exocrine functions. The technical success rate was 100% in both groups, and pain had improved in all of the patients in both groups. The incidences of complications did not differ significantly, and the mortality rate was 0% in both groups. The rehospitalization rate was significantly higher in the EPS group (78%) than that in the surgical drainage group (20%; P<0.01). This was considered attributable to rehospitalization for stent replacement. The effects to improve endocrine and exocrine functions were not different between the two groups before and after treatment, and the current condition was maintained in 80% or more of the patients. For the entire EPS group, the mean hospitalization period was 18 days and the mean medical cost of hospitalization was 2,133,330 yen. For the entire surgical drainage group, the mean hospitalization period was 23 days and the mean medical cost of hospitalization was 2,246,548 yen, thus indicating no significant differences between the two groups. CONCLUSIONS: Although both endoscopic and surgical treatments achieved high symptom control and safety rates, re-hospitalization is required for stent replacement, which leads to poor cost-effectiveness, particularly in patients in whom stent removal is difficult. Endoscopic treatment for severe pancreatic duct stenosis will need to be advanced and evaluated in the future.

Nationwide Trends in Acute and Chronic Pancreatitis Among Privately Insured Children and Non-Elderly Adults in the United States, 2007-2014.

BACKGROUND & AIMS: Epidemiologic analyses of acute pancreatitis (AP) and chronic pancreatitis (CP) provide insight into causes and strategies for prevention and affect allocation of resources to its study and treatment. We sought to determine current and accurate incidences of AP and CP, along with the prevalence of CP, in children and adults in the United States. METHODS: We collected data from the Truven MarketScan Research Databases of commercial inpatient and outpatient insurance claims in the United States from 2007 through 2014 (patients 0-64 years old). We calculated the incidences of AP and CP and prevalence of CP based on International Classification of Diseases, 9th Revision diagnosis codes. Children were defined as 18 years or younger and adults as 19 to 64 years old. RESULTS: The incidence of pediatric AP was stable from 2007 through 2014, remaining at 12.3/100,000 persons in 2014. Meanwhile, the incidence for adult AP decreased from 123.7/100,000 persons in 2007 to 111.2/100,000 persons in 2014. The incidence of CP decreased over time in children (2.2/100,000 persons in 2007 to 1.9/100,000 persons in 2014) and adults (31.7/100,000 persons in 2007 to 24.7/100,000 persons in 2014). The prevalences of pediatric and adult CP were 5.8/100,000 persons and 91.9/100,000 persons, respectively, in 2014. Incidences of AP and CP increased with age. We found little change in incidence during the first decade of life but linear increases starting in the second decade. CONCLUSIONS: We performed a comprehensive epidemiologic analysis of privately insured, non-elderly adults and children with AP and CP in the United States. Changes in gallstone formation, smoking, and alcohol consumption, along with advances in pancreatitis management, may be responsible for the stabilization and even decrease in the incidences of AP and CP.

Evolution of incidence, mortality and cost of nontraumatic abdominal emergencies treated in Brasil in a period of nine years

SUMMARY OBJECTIVE: To evaluate the incidence, mortality and cost of non-traumatic abdominal emergencies treated in Brazilian emergency departments. METHODS: This paper used DataSus information from 2008 to 2016 (http://www.tabnet.datasus.gov.br). The number of hospitalizations, costs - AIH length of stay and mortality rates were described in acute appendicitis, acute cholecystitis, acute pancreatitis, acute diverticulitis, gastric and duodenal ulcer, and inflammatory intestinal disease. RESULTS: The disease that had the highest growth in hospitalization was diverticular bowel disease with an increase of 68.2%. For the period of nine years, there were no significant changes in the average length of hospital stay, with the highest increase in gastric and duodenal ulcer with a growth of 15.9%. The mortality rate of gastric and duodenal ulcer disease increased by 95.63%, which is significantly high when compared to the other diseases. All had their costs increased but the one that proportionally had the highest increase in the last nine years was the duodenal and gastric ulcer, with an increase of 85.4%. CONCLUSION: Non-traumatic abdominal emergencies are extremely prevalent. Hence, the importance of having updated and comparative data on the mortality rate, number of hospitalization and cost generated by these diseases to provide better healthcare services in public hospitals.

RESUMO OBJETIVO: Avaliar a evolução da Incidência, mortalidade e custo das urgências abdominais não traumáticas atendidas nos serviços de emergência do Brasil durante o período de nove anos. MÉTODOS: Este trabalho utilizou informações do DataSus de 2008 a 2016, (http://www.tabnet.datasus.gov.br). Foram analisados número de internações, valor médio das internações (AIH), valor total das internações, dias de permanência hospitalar e taxa de mortalidade das seguintes doenças: apendicite aguda, colecistite aguda, pancreatite aguda, diverticulite aguda, úlcera gástrica e duodenal, e doença inflamatória intestinal. RESULTADOS: A doença que teve o maior crescimento do número de internações foi a doença diverticular do intestino, com o valor de 68,2%. Ao longo dos nove anos não houve grandes variações da média de permanência hospitalar, sendo que o maior aumento foi o da úlcera gástrica e duodenal, com crescimento de 15,9%. A taxa de mortalidade da doença por úlcera gástrica e duodenal teve um aumento de 95,63%, consideravelmente significante quando comparada com as outras doenças. Todas tiveram seus valores de AIH aumentados, porém, a que proporcionalmente teve o maior aumento nos últimos nove anos foi a úlcera gástrica e duodenal, com um acréscimo de 85,4%. CONCLUSÃO: As urgências abdominais de origem não traumática são de extrema prevalência, por isso a importância em ter dados atualizados e comparativos sobre a taxa de mortalidade, o número de internações e os custos gerados por essas doenças, para melhor planejamento dos serviços públicos de saúde.

Acute care surgery: a means for providing cost-effective, quality care for gallstone pancreatitis.

BACKGROUND: Modern practice guidelines recommend index cholecystectomy (IC) for patients admitted with gallstone pancreatitis (GSP). However, this benchmark has been difficult to widely achieve. Previous work has demonstrated that dedicated acute care surgery (ACS) services can facilitate IC. However, the associated financial costs and economic effectiveness of this intervention are unknown and represent potential barriers to ACS adoption. We investigated the impact of an ACS service at two hospitals before and after implementation on cost effectiveness, patient quality-adjusted life years (QALY) and impact on rates of IC. METHODS: All patients admitted with non-severe GSP to two tertiary care teaching hospitals from January 2008-May 2015 were reviewed. The diagnosis of GSP was confirmed upon review of clinical, biochemical and radiographic criteria. Patients were divided into three time periods based on the presence of ACS (none, at one hospital, at both hospitals). Data were collected regarding demographics, cholecystectomy timing, resource utilization, and associated costs. QALY analyses were performed and incremental cost effectiveness ratios were calculated comparing pre-ACS to post-ACS periods. RESULTS: In 435 patients admitted for GSP, IC increased from 16 to 76% after implementing an ACS service at both hospitals. There was a significant reduction in admissions and emergency room visits for GSP after introduction of ACS services (p < 0.001). There was no difference in length of stay or conversion to an open operation. The implementation of the ACS service was associated with a decrease in cost of $1162 per patient undergoing cholecystectomy, representing a 12.6% savings. The time period with both hospitals having established ACS services resulted in a highly favorable cost to quality-adjusted life year ratio (QALY gained and financial costs decreased). CONCLUSIONS: ACS services facilitate cost-effective management of GSP. The result is improved and timelier patient care with decreased healthcare costs. Hospitals without a dedicated ACS service should strongly consider adopting this model of care.

Acute biliary pancreatitis: focus on recurrence rate and costs when current guidelines are not complied.

BACKGROUND: International guidelines recommend cholecystectomy within 2-4 weeks after mild to moderate acute biliary pancreatitis (ABP) to prevent recurrence. We aimed to investigate the compliance to guidelines concerning early cholecystectomy and the associated costs. METHODS: Admissions for ABP 2011-2013 were retrospectively reviewed. Classification was made according to the revised Atlanta classification. Treatment, time to surgery and recurrence, as well as cost analysis for both in-hospital costs and loss of production (LOP) were performed. RESULTS: In total, 254 patients were included. Some 202 of the ABP patients (80%) underwent definitive treatment during their first attack of ABP (68% cholecystectomy, 17% endoscopic retrograde cholangiopancreatography (ERCP), 15% both interventions) and 186 (73%) were treated within 1 month of discharge. Patients with ERCP alone were significantly older than cholecystectomy cases (p < .001), but no significant difference was observed between those who underwent ERCP or no treatment (p = .071). Mild ABP had intervention earlier (p < .001). In all, 52 patients (20%) had no intervention, out of which 15 were readmitted due to pancreatitis, compared to 3 patients of those treated at the initial admission (p < .001). The mean cost for hospital care and LOP in mild ABP was €6882 ± 3010 and €9580 ± 7047 for moderate ABP (p = .001). The cost for a recurrent episode was €16,412 ± 22,367. CONCLUSION: By improved compliance to current guidelines concerning the management of ABP, recurrence rate and associated costs can potentially be reduced.

Cost-effectiveness of same-admission versus interval cholecystectomy after mild gallstone pancreatitis in the PONCHO trial.

BACKGROUND: Same-admission cholecystectomy is indicated after gallstone pancreatitis to reduce the risk of recurrent disease or other gallstone-related complications, but its impact on overall costs is unclear. This study analysed the cost-effectiveness of same-admission versus interval cholecystectomy after mild gallstone pancreatitis. METHODS: In a multicentre RCT (Pancreatitis of biliary Origin: optimal timiNg of CHOlecystectomy; PONCHO) patients with mild gallstone pancreatitis were randomized before discharge to either cholecystectomy within 72 h (same-admission cholecystectomy) or cholecystectomy after 25-30 days (interval cholecystectomy). Healthcare use of all patients was recorded prospectively using clinical report forms. Unit costs of resources used were determined, and patients completed multiple Health and Labour Questionnaires to record pancreatitis-related absence from work. Cost-effectiveness analyses were performed from societal and healthcare perspectives, with the costs per readmission prevented as primary outcome with a time horizon of 6 months. RESULTS: All 264 trial participants were included in the present analysis, 128 randomized to same-admission cholecystectomy and 136 to interval cholecystectomy. Same-admission cholecystectomy reduced the risk of acute readmission for recurrent gallstone-related complications from 16·9 to 4·7 per cent (P = 0·002). Mean total costs from a societal perspective were €234 (95 per cent c.i. -1249 to 738) less per patient in the same-admission cholecystectomy group. Same-admission cholecystectomy was superior to interval cholecystectomy, with a societal incremental cost-effectiveness ratio of -€1918 to prevent one readmission for gallstone-related complications. CONCLUSION: In mild biliary pancreatitis, same-admission cholecystectomy was more effective and less costly than interval cholecystectomy.

Scoring System for the Management of Acute Gallstone Pancreatitis: Cost Analysis of a Prospective Study.

Predicting the presence of a persistent common bile duct (CBD) stone is a difficult and expensive task. The aim of this study is to determine if a previously described protocol-based scoring system is a cost-effective strategy. The protocol includes all patients with gallstone pancreatitis and stratifies them based on laboratory values and imaging to high, medium, and low likelihood of persistent stones. The patient's stratification then dictates the next course of management. A decision analytic model was developed to compare the costs for patients who followed the protocol versus those that did not. Clinical data model inputs were obtained from a prospective study conducted at The Mount Sinai Medical Center to validate the protocol from Oct 2009 to May 2013. The study included all patients presenting with gallstone pancreatitis regardless of disease severity. Seventy-three patients followed the proposed protocol and 32 did not. The protocol group cost an average of $14,962/patient and the non-protocol group cost $17,138/patient for procedural costs. Mean length of stay for protocol and non-protocol patients was 5.6 and 7.7 days, respectively. The proposed protocol is a cost-effective way to determine the course for patients with gallstone pancreatitis, reducing total procedural costs over 12 %.

Direct Costs of Acute Recurrent and Chronic Pancreatitis in Children in the INSPPIRE Registry.

OBJECTIVE: To estimate selected direct medical care costs of children with chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP). METHODS: We performed a cross-sectional study of data from International Study Group of Pediatric Pancreatitis: In Search for a Cure (INSPPIRE), a multinational registry of children with ARP or CP. We determined health care utilization and estimated costs of hospitalizations, surgical and endoscopic procedures, and medications in our study population. Health care utilization data were obtained from all subjects enrolled in the study, and costs were calculated using national United States costs. RESULTS: We included 224 subjects (median age 12.7 years), 42% of whom had CP. Mean number of hospitalizations, including for surgery and endoscopic retrograde cholangiopancreatography, was 2.3 per person per year, costing an estimated average $38,755 per person per year. Including outpatient medications, estimated total mean cost was $40,589 per person per year. Subjects using surgical procedures or endoscopic retrograde cholangiopancreatography incurred mean annual costs of $42,951 per person and $12,035 per person, respectively. Estimated annual costs of pancreatic enzyme replacement therapy, diabetic medications, and pain medications were $4114, $1761, and $614 per person, respectively. In an exploratory analysis, patients with the following characteristics appear to accrue higher costs than those without them: more frequent ARP attacks per year, reported constant or episodic pain, family history of pancreatic cancer, and use of pain medication. CONCLUSIONS: ARP and CP are uncommon childhood conditions. The severe burden of disease associated with these conditions and their chronicity results in high health care utilization and costs. Interventions that reduce the need for hospitalization could lower costs for these children and their families.

Individualized perfusion of sargent gloryvine decoction for clinical severe acute pancreatitis treatment.

BACKGROUND/AIMS: To observe the effects of Sargent gloryvine decoction (SGD) on severe acute pancreatitis (SAP) treatment and to evaluate its clinical value. METHODOLOGY: 112 patients of SAP in our hospital from January, 2005 to December, 2012 were recruited for retrospective analysis. They were divided into two groups, SGD group (62 patients) and control group without treated with SGD (50 patients). Inflammation factor, CT grade and Ranson grade were used to estimate the severity of SAP, and were compared in these two groups. In addition, peripancreatic infection, incidence of pseudo pancreatic cyst, time of anal exsufflation and duration of fever were used to evaluate the effect of SGD treatment. After perfusion of SGD for different time, hospitalization days and cost were recorded to evaluate clinical value of SGD. RESULTS: After perfusion, many indexes in SGD were remarkably superior to those of control group, such as duration of fever, incidence of pseudo pancreatic cyst, peripancreatic infection and Ranson grade. Meanwhile, SGD can sharply down-regulate inflammation reaction levels of SAP patients, so that the hospitalization days and costs can be obviously saved. CONCLUSION: According to comparison, perfusion of SGD is a potential candidate for SAP treatment and is valuable in clinical application.

Enhanced recovery in the management of mild gallstone pancreatitis: a prospective cohort study.

PURPOSE: The aim of this study was to establish enhanced recovery protocols for the management of mild gallstone pancreatitis. METHODS: Sixty consecutive patients were divided into enhanced recovery and traditional recovery (TR) groups in a randomized observational study. The basic enhanced recovery elements included early laparoscopic cholecystectomy, restrictive endoscopic intervention, and early oral nutrition. The incidence of complications, readmission, length of stay, and total medical cost were analyzed during the hospital course. RESULTS: The length of hospital stay and medical cost were significantly lower in the enhanced recovery group in comparison to the TR group: 5.9 days vs. 10.6 days (P < 0.01) and ¥10,023 vs. ¥15,035 (P < 0.01). The complications and readmission rates in the two groups were similar. CONCLUSIONS: The implementation of enhanced recovery protocols is feasible in the management of mild gallstone pancreatitis. The utilization of these protocols can achieve shorter hospital stays and reduced costs, with no increase in either the re-admission or peri-operative complication rates.

Laparoscopic and open surgical treatment of left-sided pancreatic lesions: clinical outcomes and cost-effectiveness analysis.

BACKGROUND: Previous studies comparing open distal pancreatectomy (ODP) and laparoscopic distal pancreatectomy (LDP) have found advantages related to minimal-access surgery. Few studies have compared direct and associated costs after LDP versus ODP. The purpose of the current study was to compare perioperative outcomes of patients undergoing LDP and ODP and to assess whether LDP was a cost-effective procedure compared with the traditional ODP. METHODS: A retrospective analysis of a prospectively maintained database of 52 distal pancreatic resections that were performed during a 10-year period was performed. RESULTS: Patients included in the analysis were 16 in the LDP group and 29 in the ODP. Tumors operated laparoscopically were smaller than those removed at open operation, but the length of pancreatic resection was similar. The mean operating time for LDP was longer than ODP (204 ± 31 vs. 160 ± 35; P < 0.0001), whereas blood loss was higher in the open group (365 ± 215 vs. 160 ± 185, P < 0.0001). Morbidity (25 vs. 41; P = 0.373) and pancreatic fistula (18 vs. 20%; P = 0.6) rates were similar after LDP and ODP, as was 30-day mortality (0 vs. 2%; P = 0.565). LDP had a shorter mean length of hospital stay than ODP (6.4 (2.3) vs. 8.8 (1.7) days; P < 0.0001). Operative cost for LDP was higher than ODP (2889 vs. 1989; P < 0.0001). The entire cost of the associated hospital stay was higher in the ODP group (8955 vs. 6714; P < 0.043). The total cost was comparable in LDP and ODP groups (9603 vs. 10944; P = 0.204). CONCLUSIONS: Laparoscopic distal pancreatectomy for left-sided lesions can be performed safely and effectively in selected patients, with reduced hospital stay and operative blood loss. Major complications, including pancreatic leak, were not reduced, whereas total cost was comparable between LDP and ODP. A selective use of LDP seems to be an effective and cost-efficient alternative to ODP.

Randomized clinical trial of laparoendoscopic single-site versus conventional laparoscopic cholecystectomy.

BACKGROUND: Conventional laparoscopy with three or more ports remains the 'gold standard' for cholecystectomy, but a laparoendoscopic single-site (LESS) approach is emerging, designed to decrease parietal trauma and improve cosmesis. This study compared conventional laparoscopic (CL) with LESS cholecystectomy, with short-term clinical results as the main outcomes. METHODS: A randomized trial of CL and LESS cholecystectomies involving 150 patients was undertaken. Follow-up was for 1 month after surgery. The primary endpoint was body image results evaluated by means of validated scales. Secondary endpoints were: postoperative pain measured on a visual analogue scale, analgesia requirement, morbidity, quality of life (QoL) measured with Short Form 12, duration of operation, hospital stay, time to return to work and cost analysis. RESULTS: Operating times and complications were similar in the two groups. Two LESS procedures (3 per cent) were converted to two-port laparoscopy owing to difficulties with exposure, and one CL operation was achieved through a single port because extensive fibrous peritoneal adhesions prevented placement of other ports. There were three and four port-site seroma/haematomas in the LESS and CL groups respectively. Better pain profiles and lower analgesia requirements were recorded in the LESS group (P < 0·001). QoL, body image and scar scale results were also better (P < 0·001). Operative costs were higher for LESS procedures (P < 0·001), although median time to return to work was shorter (P = 0·003). CONCLUSION: LESS is an alternative to CL cholecystectomy associated with better cosmesis, body image, QoL and an improved postoperative pain profile.

Early crystalloid fluid volume management in acute pancreatitis: association with mortality and organ failure.

AIMS: Guidelines recommend aggressive fluid resuscitation in patients with acute pancreatitis (AP) to minimize organ failure. This study aimed to determine whether early crystalloid fluid management is associated with mortality and/or critical care. METHODS: 9,489 AP patients aged ≥18 years were categorized into four study groups: ventilation, hemodialysis, a combination of ventilation and hemodialysis, and neither ventilation nor hemodialysis. We analyzed demographics, mortality, comorbidities, complications, AP severity, surgery of the biliary/pancreatic system, and fluid volume (FV) during the initial 48 h (FV48) and during hospitalization (FVH), and calculated the FV ratio (FVR) as FV48/FVH. The impact of FV48 and FVR on mortality and the care process was assessed according to AP severity. RESULTS: 1.1% of AP patients received ventilation, 1.7% received hemodialysis and 1.0% received both treatments. FV48 and FVR were higher in patients requiring ventilation compared with those not requiring ventilation. A high FV48 increased mortality and a high FVR decreased mortality in patients with severe AP. A high FV48 required ventilation in patients with severe AP, which was independently associated with mortality. CONCLUSION: Since relatively too much or too little early FV is associated with mortality, FV should be continuously monitored and managed according to AP severity. and IAP.