Management of Nonoperative Diverticulitis : Is Surgical Admission Always Best?

BACKGROUND: Institutional pathways (IPs) allow efficient utilization of health care resources. Recent literature reports decreased hospital length of stay (LOS), complications, and costs with the admittance of surgical disease to surgical services. Our study aimed to demonstrate that admission to surgery for nonoperative, acute diverticulitis reduces hospital LOS, and cost, with comparable complication rates. METHODS: In January 2017, we defined IPs for diverticulitis, mandating emergency department admission to a surgical service. Patients admitted from October 2015 to June 2016 (pre-protocol, control cohort) were compared with those admitted January 2017-September 2018 (post-protocol, IP cohort). Primary outcomes included hospital LOS, direct cost, indirect cost, total cost, and 30-day readmission. Student's 2-tailed t-test and chi-square analysis were utilized, with statistical significance P < .05. RESULTS: Nonoperative management of acute diverticulitis occurred in 62 (74%) patients in the control cohort. One hundred and eleven patients (85%) were admitted to the IP cohort. Patient characteristics were similar, except for a higher percentage of surgical patients utilizing private insurance and younger in age. Interestingly, no difference in hospital LOS (3.8 vs 4.7 days; P = 0.07), direct cost ($2639.44 vs $3251.52; P = .19), or overall cost ($5968.67 vs $6404.08, P = .61) was found between cohorts. Thirty-day readmission rates were comparable at 8% and 11% (P = .59). CONCLUSION: Institutional policy mandating admissions for patients receiving nonoperative management of diverticulitis to surgical services does not reduce hospital LOS or cost. This argues that admission to medical services may be an acceptable practice. This raises the question, is acute diverticulitis always a surgical issue?

Enhanced Recovery after Partial and Radical Nephrectomy Reduces Length of Stay, Opioid Use and Cost.

INTRODUCTION: Enhanced recovery after surgery pathways are multidisciplinary, multimodal approaches to perioperative care that aim to improve patient outcomes. In this study we evaluate the outcomes of the implementation of enhanced recovery after surgery pathways in patients undergoing nephrectomy. METHODS: A retrospective analysis was performed comparing patients who underwent renal surgery before vs after implementation of enhanced recovery after surgery pathways. Data analyzed included length of stay, opioid use, cost and complications before and after the enhanced recovery after surgery protocol was implemented. RESULTS: There were 76 patients in the pre-enhanced recovery after surgery group and 42 in the enhanced recovery after surgery group. Median length of stay in the pre-enhanced vs enhanced recovery after surgery group was 3 days vs 2 days (p <0.005). For open procedures median length of stay was 5 days vs 2 days (p <0.001). For robotic procedures median length of stay decreased from 3 days to 2 days (p <0.001). Median length of stay was lower in the enhanced recovery after surgery group independent of age, sex, body mass index, American Society of Anesthesiologists® score and anesthesia time. Median total morphine equivalents decreased from 4 mg to 0 mg (p <0.005) while median total oxycodone went from 52.5 mg to 8.75 mg (p <0.005). Direct cost per patient decreased from $13,036 pre-enhanced recovery after surgery to $9,779 (p <0.001) in the enhanced recovery after surgery group, representing a 25% decrease. The 30-day readmission rates did not change after implementation of enhanced recovery after surgery protocol, and a National Surgical Quality Improvement Program sampling showed similar rates in complications, although this was not amenable to statistical analysis. CONCLUSIONS: Enhanced recovery after surgery improves the care of patients undergoing renal surgery. It significantly decreased length of stay, opioid use and hospital cost without having a significant effect on complications.