Nutritional responsiveness affects novel neutrophil parameters and reduces in-hospital mortality and costs in elective cancer oesophagectomy - a single centre, prospective, observational study.

INTRODUCTION: Malnutrition in surgical patients remains a common issue affecting the perioperative period. Oesophageal cancer is a disease associated with one of the highest malnutrition rates. Assessment of patient nutritional status remains a challenge due to limited validated tools. Novel parameters to identify malnourished patients and the effectiveness of preoperative nutritional intervention might improve treatment results in the perioperative period. MATERIAL AND METHODS: This was a prospective, observational, single-centre study of patients scheduled for elective oesophagectomy. The primary aim of this study was to establish the correlation between neutrophil reactivity intensity (NEUT-RI) and neutrophil granularity intensity (NEUT-GI) and patients' nutritional status. We divided patients into nutritional responders (R group) and nutritional non-responders (NR group) defined as regaining at least 25% of the maximum preoperative body weight loss during the preoperative period. RESULTS: The R group had significantly shorter intensive care unit (ICU) stays: 5.5 (4-8) vs. 13 (7-31) days ( P = 0.01). It resulted in a lower cost of ICU stays in the R group: 4775.2 (3938.9-7640.7) vs. 12255.8 (7787.6-49108.7) euro in the NR group ( P = 0.01). Between the R group and the NR group, we observed statistically significant differences in both preoperative NEUT-RI (48.6 vs. 53.4, P = 0.03) and NEUT-GI (154.6 vs. 159.3, P = 0.02). Apart from the T grade, the only preoperative factor associated with reduced mortality was the nutritional responsiveness: 11.1% vs. 71.4% ( P = 0.008). CONCLUSIONS: Preoperative nutritional responsiveness affects neutrophil intensity indexes and reduces in-hospital mortality and costs associated with hospital stay. Further research is required to determine the correlation between novel neutrophil parameters and patients' nutritional status.

The cost of keeping patients waiting: retrospective treatment-control study of additional healthcare utilisation for UK patients awaiting elective treatment.

OBJECTIVE: Long waiting times for elective hospital treatments are common in many countries. This study seeks to address a deficit in the literature concerning the effect of long waits on the wider consumption of healthcare resources. METHODS: We carried out a retrospective treatment-control study in a healthcare system in South West England from 15 June 2021 to 15 December 2021. We compared weekly contacts with health services of patients waiting over 18 weeks for treatment ('Treatments') and people not on a waiting list ('Controls'). Controls were matched to Treatments based on age, sex, deprivation and multimorbidity. Treatments were stratified by the clinical specialty of the awaited hospital treatment, with healthcare usage assessed over various healthcare settings. Wilcoxon signed-rank tests assessed whether there was an increase in healthcare utilisation and bootstrap resampling was used to estimate the magnitude of any differences. RESULTS: A total of 44,616 patients were waiting over 18 weeks (the constitutional target in England) for treatment during the study period. There was an increase (p < 0.0004) in healthcare utilisation for all specialties. Patients in the Cardiothoracic Surgery specialty had the largest increase, with 17.9 [interquartile-range: 4.3, 33.8] additional contacts with secondary care and 17.3 [-1.1, 34.1] additional prescriptions per year. CONCLUSION: People waiting for treatment consume higher levels of healthcare than comparable individuals not on a waiting list. These findings are relevant for clinicians and managers in better understanding patient need and reducing harm. Results also highlight the possible 'false economy' in failing to promptly resolve long elective waits.

Higher Rates Of Emergency Surgery, Serious Complications, And Readmissions In Primary Care Shortage Areas, 2015-19.

Primary care physicians are often the first to screen and identify patients with access-sensitive surgical conditions that should be treated electively. These conditions require surgery that is preferably planned (elective), but, when access is limited, treatment may be delayed and worsening symptoms lead to emergency surgery (for example, colectomy for cancer, abdominal aortic aneurysm repair, and incisional hernia repair). We evaluated the rates of elective versus emergency surgery for patients with three access-sensitive surgical conditions living in primary care Health Professional Shortage Areas during 2015-19. Medicare beneficiaries in more severe primary care shortage areas had higher rates of emergency surgery compared with rates in the least severe shortage areas (37.8 percent versus 29.9 percent). They were also more likely to have serious complications (14.9 percent versus 11.7 percent) and readmissions (15.7 percent versus 13.5 percent). When we accounted for areas with a shortage of surgeons, the findings were similar. Taken together, these findings suggest that residents of areas with greater primary care workforce shortages may also face challenges in accessing elective surgical care. As policy makers consider investing in Health Professional Shortage Areas, our findings underscore the importance of primary care access to a broader range of services.

Assessment of Preoperative Anxiety and Influencing Factors in Patients Undergoing Elective Surgery: An Observational Cross-Sectional Study.

Background and Objectives: Preoperative anxiety is a common emotional response before elective surgery that influences postoperative outcomes and can increase analgesic requirements. However, clinicians frequently overlook these concerns. This study aimed to quantify preoperative anxiety and evaluate its association with patient-related factors. Materials and Methods: Anxiety levels were evaluated in adult patients awaiting elective surgery using the Korean-translated version of the Amsterdam Preoperative Anxiety and Information Scale (APAIS) and the State-Trait Anxiety Inventory-Korean YZ form (STAI-KYZ). The patients were also surveyed regarding the subjective causes of preoperative anxiety. Results: The study found that a total of 55 adult patients had a well-balanced subject distribution. Both questionnaires showed high internal consistency (Cronbach's alpha values of 0.85 and 0.93). Significant correlations were observed in situational anxiety scores from the questionnaires, indicating differences between groups with high trait anxiety and those with normal anxiety levels (p < 0.05). Notably, female sex was the only patient-related factor that significantly affected the anxiety scores (p < 0.05). Furthermore, when considering additional patient factors stratified by sex, it became evident that younger females and females with prior general anesthesia experience displayed higher anxiety levels than their male counterparts. The most commonly reported subjective concern related to anesthesia was the fear of not regaining consciousness, followed by concerns about postoperative pain, intraoperative emergence, and other issues. Conclusions: This study confirms that being female is a significant risk factor for preoperative anxiety. Therefore, it is necessary to provide enhanced preoperative anxiolytic therapies, including preoperative patient education and other interventions, to individuals undergoing surgical procedures.

Urgent versus elective surgical disparities among American Indian and Alaska Native patients.

BACKGROUND: American Indian and Alaska Native (AIAN) health issues are understudied despite documentation of lower-than-average life expectancy. Urgent surgery is associated with higher rates of postsurgical complications and postoperative death. We assess whether American Indian and Alaska Native (AIAN) patients in Washington State are at greater risk of requiring urgent rather than elective surgery compared with non-Hispanic Whites (NHW). METHODS: We accessed data for the period 2009-2014 from the Washington State Comprehensive Hospital Abstract Reporting System (CHARS) database, which captures all statewide hospital admissions, to examine three common surgeries that are performed both urgently and electively: hip replacements, aortic valve replacements, and spinal fusions. We extracted patient race, age, insurance status, comorbidity, admission type, and procedures performed. We then constructed multivariable logistic regression models to identify factors associated with use of urgent surgical care. RESULTS: AIAN patients had lower mean age at surgery for all three surgeries compared with NHW patients. AIAN patients were at higher risk for urgent surgery for hip replacements (OR = 1.49, 95% CI 1.19-1.88), spinal fusions (OR = 1.39, 95% CI 1.04-1.87), and aortic valve replacements (OR = 2.06, 95% CI 1.12-3.80). CONCLUSION: AIAN patients were more likely to undergo urgent hip replacement, spinal fusion, and aortic valve replacement than NHW patients. AIAN patients underwent urgent surgery at younger ages. Medicaid insurance conferred higher risks for urgent surgery across all surgeries studied. Further research is warranted to more clearly identify the factors contributing to disparities among AIAN patients undergoing urgent surgery.

Cost saving in implementing ERAS protocol in emergency abdominal surgery.

INTRODUCTION: ERAS (Enhanced Recovery After Surgery) protocol is now proposed as the standard of care in elective major abdominal surgery. Implementation of the ERAS protocol in emergency setting has been proposed but his economic impact has not been investigated. Aim of this study was to evaluate the cost saving of implementing ERAS in abdominal emergency surgery in a single institution. METHODS: A group of 80 consecutive patients treated by ERAS protocol for gastrointestinal emergency surgery in 2021 was compared with an analogue group of 75 consecutive patients treated by the same surgery the year before implementation of ERAS protocol. Adhesion to postoperative items, length of stay, morbidity and mortality were recorded. Cost saving analysis was performed. RESULTS: 50% Adhesion to postoperative items was reached on day 2 in the ERAS group in mean. Laparoscopic approach was 40 vs 12% in ERAS and control group respectively (p ,002). Length of stay was shorter in ERAS group by 3 days (9 vs 12 days p ,002). Morbidity and mortality rate were similar in both groups. The ERAS group had a mean cost saving of 1022,78 € per patient. CONCLUSIONS: ERAS protocol implementation in the abdominal emergency setting is cost effective resulting in a significant shorter length of stay and cost saving per patient.

The effect of a bundle intervention for ambulatory otorhinolaryngology procedures on same-day case cancellation rate and associated costs.

Cancellations within 24 h of planned elective surgical procedures reduce operating theatre efficiency, add unnecessary costs and negatively affect patient experience. We implemented a bundle intervention that aimed to reduce same-day case cancellations. This consisted of communication tools to improve patient engagement and new screening instruments (automated estimation of ASA physical status and case cancellation risk score plus four screening questions) to identify patients in advance (ideally before case booking) who needed comprehensive pre-operative risk stratification. We studied patients scheduled for ambulatory surgery with the otorhinolaryngology service at a single centre from April 2021 to December 2022. Multivariable logistic regression and interrupted time-series analyses were used to analyse the effects of this intervention on case cancellations within 24 h and costs. We analysed 1548 consecutive scheduled cases. Cancellation within 24 h occurred in 114 of 929 (12.3%) cases pre-intervention and 52 of 619 (8.4%) cases post-intervention. The cancellation rate decreased by 2.7% (95%CI 1.6-3.7%, p < 0.01) during the first month, followed by a monthly decrease of 0.2% (95%CI 0.1-0.4%, p < 0.01). This resulted in an estimated $150,200 (£118,755; €138,370) or 35.3% cost saving (p < 0.01). Median (IQR [range]) number of days between case scheduling and day of surgery decreased from 34 (21-61 [0-288]) pre-intervention to 31 (20-51 [1-250]) post-intervention (p < 0.01). Patient engagement via the electronic health record patient portal or text messaging increased from 75.9% at baseline to 90.8% (p < 0.01) post-intervention. The primary reason for case cancellation was patients' missed appointment on the day of surgery, which decreased from 7.2% pre-intervention to 4.5% post-intervention (p = 0.03). An anaesthetist-driven, clinical informatics-based bundle intervention decreases same-day case cancellation rate and associated costs in patients scheduled for ambulatory otorhinolaryngology surgery.

Effects of private health insurance on waiting time in public hospitals.

The Australian government pays $6.7 billion per year in rebates to encourage Australians to purchase private health insurance (PHI) and an additional $6.1 billion to cover services provided in private hospitals. What is the justification for large government subsidies to a private industry when all Australians already have free coverage under Medicare? The government argues that more people buying PHI will relieve the burden on the public system and may reduce waiting times. However, the evidence supporting this is sparse. We use an instrumental variable approach to study the causal effects of higher PHI coverage in the area on waiting times in public hospitals in the same area. The instrument used is area-level average house prices, which correlate with average income and wealth, thus influencing the purchase of PHI due to tax incentives, but not directly affecting waiting times in public hospitals. We use 2014-2018 hospital admission and elective surgery waiting list data linked at the patient level from the Victorian Center for Data Linkage. These data cover all inpatient admissions in all hospitals in Victoria (both public and private hospitals) and those registered on the waiting list for elective surgeries in public hospitals in Victoria. We find that one percentage point increase in PHI coverage leads to about 0.34 days (or 0.5%) reduction in waiting times in public hospitals on average. The effects vary by surgical specialities and age groups. However, the practical significance of this effect is limited, if not negligible, despite its statistical significance. The small effect suggests that raising PHI coverage with the aim to taking the pressure off the public system is not an effective strategy in reducing waiting times in public hospitals. Alternative policies aiming at improving the efficiency of public hospitals and advancing equitable access to care should be a priority for policymakers.

How much does it cost to be fit for operation? The economics of prehabilitation.

PURPOSE OF REVIEW: Prehabilitation before elective surgery can include physical, nutritional, and psychological interventions or a combination of these to allow patients to return postoperatively to baseline status as soon as possible. The purpose of this review is to analyse the current date related to the cost-effectiveness of such programs. RECENT FINDINGS: The current literature regarding the economics of prehabilitation is limited. However, such programs have been mainly associated with either a reduction in total healthcare related costs or no increase. SUMMARY: Prehabilitation before elective surgery has been shown to minimize the periprocedural complications and optimization of short term follow up after surgical procedures. Recent studies included cost analysis, either based on hospital accounting data or on estimates costs. The healthcare cost was mainly reduced by shortening the number of hospitalization day. Other factors included length of ICU stay, place of the prehabilitation program (in-hospital vs. home-based) and compliance to the program.

Quality Assessment of Elective Abdominal Aortic Aneurysm Repair Patient Information on the Internet Using the Modified Ensuring Quality Information for Patients Tool.

OBJECTIVE: This study aimed to assess the quality of patient information material regarding elective abdominal aortic aneurysm (AAA) repair on the internet using the Modified Ensuring Quality Information for Patients (MEQIP) tool. METHODS: A qualitative assessment of internet based patient information was performed. The 12 most used search terms relating to AAA repair were identified using Google Trends, with the first 10 pages of websites retrieved for each term searched. Duplicates were removed, and information for patients undergoing elective AAA were selected. Further exclusion criteria were marketing material, academic journals, videos, and non-English language sites. The remaining websites were then MEQIP scored independently by two reviewers, producing a final score by consensus. RESULTS: A total of 1 297 websites were identified, with 235 (18.1%) eligible for analysis. The median MEQIP score was 18 (interquartile range [IQR] 14, 21) out of a possible 36. The highest score was 33. The 99th percentile MEQIP scoring websites scored > 27, with four of these six sites representing online copies of hospital patient information leaflets, however hospital sites overall had lower median MEQIP scores than most other institution types. MEQIP subdomain median scores were: content, 8 (IQR 6, 11); identification, 3 (IQR 1, 3); and structure, 7 (IQR 6, 9). Of the analysed websites, 77.9% originated from the USA (median score 17) and 12.8% originated in the UK (median score 22). Search engine ranking was related to website institution type but had no correlation with MEQIP. CONCLUSION: When assessed by the MEQIP tool, most websites regarding elective AAA repair are of questionable quality. This is in keeping with studies in other surgical and medical fields. Search engine ranking is not a reliable measure of quality of patient information material regarding elective AAA repair. Health practitioners should be aware of this issue as well as the whereabouts of high quality material to which patients can be directed.

Telephone assessment of new hernia referrals-is it possible?

PURPOSE: Utilisation of remote clinics is increasing in healthcare settings worldwide. During the height of the COVID pandemic, our UK-based teaching hospital has trialled telephone assessment for new patients presenting with primary hernias. Selected cases are listed for elective repair of primary hernia direct from telephone clinic assessment. In March 2021, after this process had been in place for 13 months, departmental triage criteria were introduced, allocating patients to initial assessment in Face to Face or Telephone Clinics. Here, we evaluate the effectiveness of telephone assessment, with specific attention to 'Day of Surgery' cancellation. We also assess the effect of our triage criteria on rate of 'Day of Surgery' cancellation. METHODS: Departmental diaries were studied retrospectively to identify patients listed for hernia repair between February 2020 and February 2022. Data were obtained from clinic letters, discharge paperwork and operating lists, as well as from management teams. Fishers Exact test was used to compare groups seen either face to face or remotely as well and pre- and post-intervention. RESULTS: 325 patients were listed for hernia repair, 56 after telephone assessment. 6 (11%) of those listed from telephone clinic were cancelled on the day of surgery, compared with 34 (13%) of those seen face to face. With triage criteria in place, listing from telephone clinic increased significantly from 14 to 27%. Overall day of surgery cancellations reduced from 13 to 9%. Rate of day of surgery cancellation in those assessed in telephone clinic reduced from 12 to 9%. CONCLUSIONS: There is no significant difference between day of surgery cancellations after face to face or telephone clinic assessment. Triage criteria for telephone assessment appear to increase the numbers being listed after remote clinics. This did not significantly impact the number of day of surgery cancellations.

Patient-specific Predictors of Surgical Delay in a Large Tertiary-care Hospital Operating Room.

PURPOSE: The purpose of this study was to describe patient-specific factors predictive of surgical delay in elective surgical cases. DESIGN: Retrospective cohort study. METHODS: Data were extracted retrospectively from the electronic health record of 32,818 patients who underwent surgery at a large academic hospital in Los Angeles between May 2012 and April 2017. Following bivariate analysis of patient-specific factors and surgical delay, statistically significant predictors were entered into a logistic regression model to determine the most significant predictors of surgical delay. FINDINGS: Predictors of delay included having monitored anesthesia care (odds ratio [OR], 1.28; 95% confidence intervals [CI], 1.20-1.36), American Society of Anesthesiologist class 3 or above (OR, 1.21; 95% CI, 1.15-1.28), African American race (OR, 1.25; 95% CI, 1.12-1.39), renal failure (OR, 1.20; 95% CI, 1.09-1.32), steroid medication (OR, 1.13; 95% CI, 1.04-1.23) and Medicaid (OR,1.18; 95%CI, 1.09-1.30) or medicare insurance (OR, 1.14; 95% CI, 1.07-1.21). Six surgical specialties also increased the odds of delay. Obesity and cardiovascular anesthesia decreased the odds of delay. CONCLUSIONS: Certain patient-specific factors including type of insurance, health status, and race were associated with surgical delay. Whereas monitored anesthesia care anesthesia was predictive of a delay, cardiovascular anesthesia reduced the odds of delay. Additionally, obese patients were less likely to experience a delay. While the electronic health record provided a large amount of detailed information, barriers existed to accessing meaningful data.

Low-Volume Elective Surgery and Outcomes in Medicare Beneficiaries Treated at Hospital Networks.

Importance: Minimum volume standards have been advocated as a strategy to improve outcomes for certain surgical procedures. Hospital networks could avoid low-volume surgery by consolidating cases within network hospitals that meet volume standards, thus optimizing outcomes while retaining cases and revenue. The rates of compliance with volume standards among hospital networks and the association of volume standards with outcomes at these hospitals remain unknown. Objective: To quantify low-volume surgery and associated outcomes within hospital networks. Design, Setting, and Participants: This cross-sectional study used Medicare Provider Analysis and Review data to examine fee-for-service beneficiaries aged 66 to 99 years who underwent 1 of 10 elective surgical procedures (abdominal aortic aneurysm repair, carotid endarterectomy, mitral valve repair, hip or knee replacement, bariatric surgery, or resection for lung, esophageal, pancreatic, or rectal cancers) in a network hospital from 2016 to 2018. Hospital volume for each procedure (calculated with the use of the National Inpatient Sample) was compared with yearly hospital volume standards for that procedure recommended by The Leapfrog Group. Networks were then categorized into 4 groups according to whether or not that hospital or another hospital in the network met low-volume standards for that procedure. Data were analyzed from February to June 2023. Exposure: Receipt of surgery in a low-volume hospital within a network. Main Outcomes and Measures: Primary outcomes were postoperative complications, 30-day readmission, and 30-day mortality, stratified by the volume status of the hospital and network type. The secondary outcome was the availability of a different high-volume hospital within the same network or outside the network and its proximity to the patient (based on hospital referral region and zip code). Results: In all, data were analyzed for 950 079 Medicare fee-for-service beneficiaries (mean [SD] age, 74.4 [6.5] years; 621 138 females [59.2%] and 427 931 males [40.8%]) who underwent 1 049 069 procedures at 2469 hospitals within 382 networks. Of these networks, 380 (99.5%) had at least 1 low-volume hospital performing the elective procedure of interest. In 35 137 of 44 011 procedures (79.8%) that were performed at low-volume hospitals, there was a hospital that met volume standards within the same network and hospital referral region located a median (IQR) distance of 29 (12-60) miles from the patient's home. Across hospital networks, there was 43-fold variation in rates of low-volume surgery among the procedures studied (from 1.5% of carotid endarterectomies to 65.0% of esophagectomies). In adjusted analyses, postoperative outcomes were inferior at low-volume hospitals compared with hospitals meeting volume standards, with a 30-day mortality of 8.1% at low-volume hospitals vs 5.5% at hospitals that met volume standards (adjusted odds ratio, 0.67 [95% CI, 0.61-0.73]; P < .001). Conclusions and Relevance: Findings of this study suggest that most US hospital networks had hospitals performing low-volume surgery that is associated with inferior surgical outcomes despite availability of a different in-network hospital that met volume standards within a median of 29 miles for the vast majority of patients. Strategies are needed to help patients access high-quality care within their networks, including avoidance of elective surgery at low-volume hospitals. Avoidance of low-volume surgery could be considered a process measure that reflects attention to quality within hospital networks.

The impact of a preanesthesia assessment clinic on scheduled elective case cancelations at a Thai university hospital.

Elective surgical case cancelations negatively impact healthcare systems and patient dissatisfaction. Preanesthesia assessment clinics (PACs) have been established in many countries to facilitate preoperative medical optimization. However, their benefits for elective procedure cancelations in Thailand have not been formally assessed. This study evaluated the impact of a PAC on scheduled elective surgical case cancelations at a Thai university hospital. A retrospective cross-sectional study was conducted for the period covering from May 2016 to April 2017. We included all scheduled elective surgical cases at Siriraj Hospital, Thailand, canceled on the day of surgery. The cancelation incidences of patients attending and not attending the PAC were compared. Cancellation reasons were categorized as "patient issue," "hospital-facility issue," "surgeon issue," "anesthesiologist issue," "medical condition," and "miscellaneous." The PAC patients' reasons were rigorously explored to determine their preventability. There were 30,351 scheduled elective procedures during the study period. The case-cancelation incidences were 0.9% (95% confidence interval [CI], 0.7-1.2%) for patients visiting the PAC and 5.9% (95% CI, 5.6-6.3%) for those who did not. Medical conditions were the most common reason for cancelation for non-PAC patients (27.3%), whereas hospital-facility issues were the most frequent for PAC patients (43.8%). The cancelation rate for patient issues was significantly lower in the PAC group (4.2% vs 20.7%; P < .05). Thirty-one (64.6%) of the PAC patients' cancelations were potentially preventable. Of the 15 PAC patient cancelations related to medical conditions, 12 were for patients with a history of acute illness and were determined to be nonpreventable. Visiting the PAC was significantly associated with a decreased elective-case cancelation rate. Cancellations were most frequently related to hospital-facility issues for patients visiting the PAC and medical conditions for those who did not. Some PAC patient cancelations for medical conditions involved unpreventable acute patient illnesses. Clinical Trials.gov (NCT02816281).

Malnutrition risk, outcomes, and costs among older adults undergoing elective surgical procedures: A retrospective cohort study.

BACKGROUND: We examine here the association between malnutrition risk and adverse health outcomes among older adult patients undergoing elective surgical procedures. METHODS: We conducted a retrospective study using linked clinical and administrative databases. Malnutrition risk was assessed prior to surgery, defined by unintentional weight loss and decreased food intake. We performed a logistic regression analysis of the primary outcome, a composite adverse outcome measure, including death, bleeding, pneumonia, and other surgical complications. We conducted Fine-Gray proportional hazard regression analysis of hospital length of stay (LOS). We performed a generalized linear regression analysis of in-hospital cost data. All regression analyses controlled for frailty, age, sex, surgical category, and comorbidities. RESULTS: Of a total of 3457 older adult elective surgical patients (65-102 years), 310 (9.0%) screened positive for malnutrition risk. In multivariable regression analyses, malnutrition risk was associated with an increased risk of the composite adverse outcome (odds ratio [OR] = 1.74; 95% CI = 1.25-2.39), higher hospitalization costs (relative cost = 1.84; 95% CI = 1.59-2.13), and a decreased risk of discharge from the hospital (hazard ratio = 0.67; 95% CI = 0.59-0.77) compared with those who screened negative. CONCLUSION: Older adult patients with malnutrition risk were at an increased risk of adverse surgical outcomes, had longer LOS in the hospital, and incurred higher costs of care. It is important to screen for malnutrition risk and refer older adults for dietetic consults prior to elective surgery.

Health-Care Patterns for Three Common Elective Surgeries: Implications for Bundled Payment Models.

INTRODUCTION: The study objectives were to assess the timing, duration, and nature of health-care service utilization before and after three common elective surgical procedures not currently included in federal episode-based bundled payment programs. METHODS: We performed a retrospective cohort study of patients undergoing one of three low-risk surgical procedures (breast reduction, upper extremity nerve decompression, and panniculectomy) between 2010 and 2017 using a private insurer's national claims database. All professional and facility billing claims for health-care services were identified during the 12-mo preoperative and 12-mo postoperative periods for each patient. We compared trends in monthly utilization of health-care services to estimate surgery-related utilization patterns with interrupted time series analyses. RESULTS: The cohort included 7885 patients receiving breast reduction, 99,404 patients receiving upper extremity nerve decompression, and 955 patients receiving panniculectomy. The mean monthly encounters gradually increased before each procedure, with a gradual decline in services postoperatively. Claims in the preoperative period for all procedures were primarily diagnostic testing and outpatient evaluation and management. There was limited use of postacute care services across the surgical procedures. There were notable differences in service utilization between the three surgeries, including differing inflection points for preoperative services (approximately 7 mo for breast reduction and panniculectomy, compared with at least 9 mo for nerve decompression) and postoperative services (up to 3 mo for panniculectomy and 4 mo for nerve decompression, compared with 6 mo for breast reduction). CONCLUSIONS: This study highlights important differences in utilization of health-care services by type of surgery. These findings suggest that prior to expanding episode-based bundled payment models to surgical conditions with limited utilization of postacute care services and fewer complications, the Centers for Medicare and Medicaid Services and private payers should consider tailoring the timing and duration of clinical episodes to individual surgical procedures.

Association between preoperative cardiac risk assessment and health care costs in major noncardiac surgery: a multicentre health economic analysis.

PURPOSE: Patients with impaired functional capacity who undergo major surgery are at increased risk of postoperative morbidity including complications and increased length of stay. These outcomes have been associated with increased hospital and health system costs. We aimed to assess whether common preoperative risk indices are associated with postoperative cost. METHODS: We conducted a health economic analysis focused on the subset of Measurement of Exercise Tolerance before Surgery (METS) study participants in Ontario, Canada. Participants were scheduled for major elective noncardiac surgery and underwent several preoperative assessments of cardiac risk, including physicians' subjective assessment, Duke Activity Status Index (DASI) questionnaire, peak oxygen consumption, and N-terminal pro-B-type natriuretic peptide concentration. Using linked health administrative data, postoperative costs were calculated for both one year and in-hospital. Using multiple regression models, we tested for association between the preoperative measures of cardiac risk and postoperative costs. RESULTS: Our study included 487 patients (mean [standard deviation] age 68 [11] yr and 47.0% female) who underwent noncardiac surgery between 13 June 2013 and 8 March 2016. Overall, the median [interquartile range] cost incurred within one year postoperatively was CAD 27,587 [13,902-32,590], of which CAD 12,928 [10,253-12,810] were incurred in-hospital and CAD 14,497 [10,917-15,017] were incurred by 30 days. None of the four preoperative measures of cardiac risk assessment were associated with costs incurred in hospital or at one year postoperatively. This lack of strong association persisted in sensitivity analyses considering type of surgical procedure, burden of preoperative cost, and when costs were categorized as quantiles. CONCLUSION: In patients undergoing major noncardiac surgery, common measures of functional capacity are not consistently associated with total postoperative cost. Until further data exist that differ from this analysis, clinicians and health care funders should not assume that preoperative measures of cardiac risk are associated with annual health care or hospital costs for such surgeries.

RéSUMé: OBJECTIF: La patientèle présentant une capacité fonctionnelle dégradée qui bénéficie d'une intervention chirurgicale majeure court un risque accru de morbidité postopératoire, y compris de complications et de prolongation de la durée de séjour. Ces issues ont été associées à une augmentation des coûts hospitaliers et du système de santé. Notre objectif était d'évaluer si des indices de risque préopératoires communs étaient associés aux coûts postopératoires. MéTHODE: Nous avons effectué une analyse de l'économie de la santé axée sur le sous-ensemble des participant·es à l'étude METS (Measurement of Exercise Tolerance before Surgery) en Ontario, au Canada. Les participant·es devaient bénéficier d'une chirurgie non cardiaque et non urgente majeure et ont complété plusieurs évaluations préopératoires du risque cardiaque, notamment l'évaluation subjective des médecins, le questionnaire DASI (Duke Activity Status Index), la consommation maximale d'oxygène et la concentration de prohormone N-terminale du peptide natriurétique de type B (cérébral) (NT-proBNP). À l'aide de données administratives couplées de santé, les coûts postopératoires ont été calculés à la fois pour une année et à l'hôpital. À l'aide de modèles de régression multiples, nous avons testé l'association entre les mesures préopératoires du risque cardiaque et les coûts postopératoires. RéSULTATS: Notre étude a inclus 487 personnes (âge moyen [écart type] 68 [11] ans et 47,0 % de femmes) ayant bénéficié d'une chirurgie non cardiaque entre le 13 juin 2013 et le 8 mars 2016. Dans l'ensemble, le coût médian [écart interquartile] engagé dans l'année qui a suivi l'opération était de 27 587 CAD [13 902­32 590], dont 12 928 CAD [10 253­12 810] ont été encourus à l'hôpital et 14 497 CAD [10 917­15 017] ont été encourus dans les premiers 30 jours. Aucune des quatre mesures préopératoires de l'évaluation du risque cardiaque n'était associée aux coûts engagés à l'hôpital ou un an après l'opération. Cette absence d'association forte persistait dans les analyses de sensibilité tenant compte du type d'intervention chirurgicale, du fardeau des coûts préopératoires et lorsque les coûts étaient classés en quantiles. CONCLUSION: Chez la patientèle bénéficiant d'une chirurgie non cardiaque majeure, les mesures courantes de la capacité fonctionnelle ne sont pas systématiquement associées au coût postopératoire total. Jusqu'à ce qu'il existe d'autres données qui diffèrent de cette analyse, les cliniciens et cliniciennes et les organismes finançant les soins de santé ne devraient pas présumer que les mesures préopératoires du risque cardiaque sont associées aux coûts annuels des soins de santé ou des hôpitaux pour de telles chirurgies.

Cost-effectiveness of prehabilitation prior to elective surgery: a systematic review of economic evaluations.

BACKGROUND: Prehabilitation aims at enhancing patients' functional capacity and overall health status to enable them to withstand a forthcoming stressor like surgery. Our aim was to synthesise the evidence on the cost-effectiveness of prehabilitation for patients awaiting elective surgery compared with usual preoperative care. METHODS: We searched PubMed, Embase, the CRD database, ClinicalTrials.gov, the WHO ICTRP and the dissertation databases OADT and DART. Studies comparing prehabilitation for patients with elective surgery to usual preoperative care were included if they reported cost outcomes. All types of economic evaluations (EEs) were included. The primary outcome of the review was cost-effectiveness based on cost-utility analyses (CUAs). The risk of bias of trial-based EEs was assessed with the Cochrane risk of bias 2 tool and the ROBINS-I tool and the credibility of model-based EEs with the ISPOR checklist. Methodological quality of full EEs was assessed using the CHEC checklist. The EEs' results were synthesised narratively using vote counting based on direction of effect. RESULTS: We included 45 unique studies: 25 completed EEs and 20 ongoing studies. Of the completed EEs, 22 were trial-based and three model-based, corresponding to four CUAs, three cost-effectiveness analyses, two cost-benefit analyses, 12 cost-consequence analyses and four cost-minimization analyses. Three of the four trial-based CUAs (75%) found prehabilitation cost-effective, i.e. more effective and/or less costly than usual care. Overall, 16/25 (64.0%) EEs found prehabilitation cost-effective. When excluding studies of insufficient credibility/critical risk of bias, this number reduced to 14/23 (60.9%). In 8/25 (32.0%), cost-effectiveness was unclear, e.g. because prehabilitation was more effective and more costly, and in one EE prehabilitation was not cost-effective. CONCLUSIONS: We found some evidence that prehabilitation for patients awaiting elective surgery is cost-effective compared to usual preoperative care. However, we suspect a relevant risk of publication bias, and most EEs were of high risk of bias and/or low methodological quality. Furthermore, there was relevant heterogeneity depending on the population, intervention and methods. Future EEs should be performed over a longer time horizon and apply a more comprehensive perspective. TRIAL REGISTRATION: PROSPERO CRD42020182813.