Evaluating the Validity of the Clavien-Dindo Classification in Colectomy Studies: A 90-Day Cost of Care Analysis.

BACKGROUND: The Clavien-Dindo classification is widely used to report postoperative morbidity but may underestimate the severity of colectomy complications. OBJECTIVE: The purpose of this study was to assess how well the Clavien-Dindo classification represents the severity of all grades of complications after colectomy using cost of care modeling. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a comprehensive cancer center. PATIENTS: Consecutive patients (N = 1807) undergoing elective colon or rectal resections without a stoma performed at Memorial Sloan Kettering Cancer Center between 2009 and 2014 who were followed up for ≥90 days, were not transferred to other hospitals, and did not receive intraperitoneal chemotherapy were included in the study. MAIN OUTCOME MEASURES: Complication severity was measured by the highest-grade complication per patient and attributable outpatient and inpatient costs. Associations were evaluated between patient complication grade and cost during 3 time periods: the 90 days after surgery, index admission, and postdischarge (<90 d). RESULTS: Of the 1807 patients (median age = 62 y), 779 (43%) had a complication; 80% of these patients had only grade 1 or 2 complications. Increasing patient complication grade correlated with 90-day cost, driven by inpatient cost differences (p < 0.001). For grade 1 and 2 patients, most costs were incurred after discharge and were the same between these grade categories. Among patients with a single complication (52%), there was no difference in index hospitalization, postdischarge, or total 90-day costs between grade 1 and 2 categories. LIMITATIONS: The study was limited by its retrospective design and generalizability. CONCLUSIONS: The Clavien-Dindo classification correlates well with 90-day costs, driven largely by inpatient resource use. Clavien-Dindo does not discriminate well among patients with low-grade complications in terms of their substantial postdischarge costs. These patients represent 80% of patients with a complication after colectomy. Examining the long-term burden associated with complications can help refine the Clavien-Dindo classification for use in colectomy studies. See Video Abstract at http://links.lww.com/DCR/B521. EVALUACIN DE LA VALIDEZ DE LA CLASIFICACIN DE CLAVIENDINDO EN ESTUDIOS DE COLECTOMA ANLISIS DEL COSTO DE LA ATENCIN EN DAS: ANTECEDENTES:La clasificación de Clavien-Dindo es utilizada ampliamante para conocer la morbilidad posoperatoria, pero puede subestimar la gravedad de las complicaciones de la colectomía.OBJETIVO:Evaluar que tan bien representa la clasificación de Clavien-Dindo la gravedad de todos los grados de complicaciones después de la colectomía utilizando un modelo de costo de la atención.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Centro oncológico integral.PACIENTES:Pacientes consecutivos (n = 1807) sometidos a resecciones electivas de colon o recto sin estoma realizadas en el Memorial Sloan Kettering Cancer Center entre 2009 y 2014 que fueron seguidos durante ≥ 90 días, no fueron transferidos a otros hospitales y no recibieron quimioterapia intraperitoneal.PRINCIPALES MEDIDAS DE VALORACION:Gravedad de la complicación medida por la complicación de mayor grado por paciente y los costos atribuibles para pacientes ambulatorios y hospitalizados. Se evaluó la asociación entre el grado de complicación del paciente y el costo durante 3 períodos de tiempo: posterior a la cirugía (hasta 90 días), a su ingreso y posterior al egreso (hasta 90 días).RESULTADOS:De los 1807 pacientes (mediana de edad de 62 años), 779 (43%) tuvieron una complicación; El 80% de estos pacientes tuvieron solo complicaciones de grado 1 o 2. El aumento del grado de complicación del paciente se correlacionó con el costo a 90 días, impulsado por las diferencias en el costo de los pacientes hospitalizados (p <0,001). Para los pacientes de grado 1 y 2, la mayoría de los costos se incurrieron después del alta y fueron los mismos entre ambas categorías. Entre los pacientes con una sola complicación (52%), no hubo diferencia en el índice de hospitalización, posterior al alta o en el costo total de 90 días entre las categorías de grado 1 y 2.LIMITACIONES:Diseño retrospectivo, generalizabilidad.CONCLUSIONES:La clasificación de Clavien-Dindo se correlaciona bien con los costos a 90 días, impulsados en gran parte por la utilización de recursos de pacientes hospitalizados. Clavien-Dindo no discrimina entre los pacientes con complicaciones de bajo grado en términos de sus costos sustanciales posterior al alta. Estos pacientes representan el 80% de los pacientes aquellos con una complicación tras la colectomía. Examinar la carga a largo plazo asociada a las complicaciones puede ayudar a mejorar la clasificación de Clavien-Dindo para su uso en estudios de colectomía. Consulte Video Resumen en http://links.lww.com/DCR/B521.

Associations of a Preoperative Anemia and Suboptimal Iron Stores Screening and Management Clinic in Colorectal Surgery With Hospital Cost, Reimbursement, and Length of Stay: A Net Cost Analysis.

BACKGROUND: In 2016, a preoperative clinic was implemented to screen, evaluate, and manage anemia and suboptimal iron stores at a major tertiary care medical center in Western Australia. Few studies compare the costs and reimbursements associated with preoperative anemia and suboptimal iron stores management. The objective of our study was to conduct a net cost analysis associated with the implementation of this clinic. METHODS: We designed a retrospective cohort study involving elective colorectal surgical admissions over a 3-year period. The baseline year selected was the 2015-2016 financial year, with outcomes in the 2016-2017 and 2017-2018 year compared to baseline. The study perspective was the Western Australian Health System. Hospital costs were extracted from the health service clinical costing system, which captures costs at the admission level. The primary outcome was net cost, defined as gross cost minus reimbursement (or funding) received. RESULTS: Our 3-year study included 544 admissions for elective colorectal surgery. After the implementation of the preoperative clinic, 73.4% (n = 257) of admissions were screened for anemia and suboptimal iron stores, and 31.4% (n = 110) received intravenous iron. In our adjusted analysis, when comparing the final year (2017-2018) with baseline (2015-2016), the units of red blood cells transfused per admission decreased 53% (142 vs 303 units per 1000 discharges; P = .006), and mean hospital length of stay decreased 15% (7.7 vs 9.1 days; P = .008). When comparing the final year with baseline, rectal resection admissions were associated with a mean decrease in the net cost of Australian dollar (A$) 7619 (95% confidence interval, 4230-11,008; P < .001) between 2015-2016 and 2017-2018. For small and large bowel procedures, there was a mean decrease of A$6744 (95% confidence interval, 2430-11,057; P = .002). CONCLUSIONS: The implementation of a preoperative anemia and suboptimal iron stores screening and management clinic in elective colorectal surgery was associated with reductions in red cell transfusions, length of stay, and net costs.

The cost-effectiveness of screening men who have sex with men for rectal chlamydial and gonococcal infection to prevent HIV Infection.

BACKGROUND: Men who have sex with men (MSM) who have a current or recent history of rectal Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infection are at greater risk for HIV than MSM with no history of rectal infection. Screening and treating MSM for rectal CT/GC infection may help reduce any increased biological susceptibility to HIV infection. METHODS: We used 2 versions of a Markov state-transition model to examine the impact and cost-effectiveness of screening MSM for rectal CT/GC infection in San Francisco: a static version that included only the benefits to those screened and a dynamic version that accounted for population-level impacts of screening. HIV prevention through reduced susceptibility to HIV was the only potential benefit of rectal CT/GC screening that we included in our analysis. Parameter values were based on San Francisco program data and the literature. RESULTS: In the base case, the cost per quality-adjusted life year gained through screening MSM for rectal CT/GC infection was $16,300 in the static version of the model. In the dynamic model, the cost per quality-adjusted life year gained was less than $0, meaning that rectal screening was cost-saving. The impact of rectal CT/GC infection on the risk of HIV acquisition was the most influential model parameter. CONCLUSIONS: Although more information is needed regarding the impact of rectal CT/GC screening on HIV incidence, rectal CT/GC screening of MSM can potentially be a cost-effective, scalable intervention targeted to at-risk MSM in certain urban settings such as San Francisco.

Robotic-assisted colorectal surgery in the United States: a nationwide analysis of trends and outcomes.

BACKGROUND: While robotic-assisted colorectal surgery (RACS) is becoming increasingly popular, data comparing its outcomes to other established techniques remain limited to small case series. Moreover, there are no large studies evaluating the trends of RACS at the national level. METHODS: The Nationwide Inpatient Sample 2009-2010 was retrospectively reviewed for robotic-assisted and laparoscopic colorectal procedures performed for cancer, benign polyps, and diverticular disease. Trends in different settings, indications, and demographics were analyzed. Multivariate regression analysis was used to compare selected outcomes between RACS and conventional laparoscopic surgery (CLS). RESULTS: An estimated 128,288 colorectal procedures were performed through minimally invasive techniques over the study period, and RACS was used in 2.78 % of cases. From 2009 to 2010, the use of robotics increased in all hospital settings but was still more common in large, urban, and teaching hospitals. Rectal cancer was the most common indication for RACS, with a tendency toward its selective use in male patients. On multivariate analysis, robotic surgery was associated with higher hospital charges in colonic ($11,601.39; 95 % CI 6,921.82-16,280.97) and rectal cases ($12,964.90; 95 % CI 6,534.79-19,395.01), and higher rates of postoperative bleeding in colonic cases (OR = 2.15; 95 % CI 1.27- 3.65). RACS was similar to CLS with respect to length of hospital stay, morbidity, anastomotic leak, and ileus. Conversion to open surgery was significantly lower in robotic colonic and rectal procedures (0.41; 95 % CI 0.25-0.67) and (0.10; 95 % CI 0.06-0.16), respectively. CONCLUSIONS: The use of RACS is still limited in the United States. However, its use increased over the study period despite higher associated charges and no real advantages over laparoscopy in terms of outcome. The one advantage is lower conversion rates.

[Multimodal rehabilitation program in elective colorectal surgery: Impact on hospital costs]. / Impacto de un programa de rehabilitación multimodal en cirugía electiva colorrectal sobre los costes hospitalarios.

INTRODUCTION: Multimodal rehabilitation (MMRH) programs in surgery have proven to be beneficial in functional recovery of patients. The aim of this study is to evaluate the impact of a MMRH program on hospital costs. METHOD: A comparative study of 2 consecutive cohorts of patients undergoing elective colorectal surgery has been designed. In the first cohort, we analyzed 134 patients that received conventional perioperative care (control group). The second cohort included 231 patients treated with a multimodal rehabilitation protocol (fast-track group). Compliance with the protocol and functional recovery after fast-track surgery were analyzed. We compared postoperative complications, length of stay and readmission rates in both groups. The cost analysis was performed according to the system «full-costing¼. RESULTS: There were no differences in clinical features, type of surgical excision and surgical approach. No differences in overall morbidity and mortality rates were found. The mean length of hospital stay was 3 days shorter in the fast-track group. There were no differences in the 30-day readmission rates. The total cost per patient was significantly lower in the fast-track group (fast-track: 8.107 ± 4.117 euros vs. control: 9.019 ± 4.667 Euros; P=.02). The main factor contributing to the cost reduction was a decrease in hospitalization unit costs. CONCLUSION: The application of a multimodal rehabilitation protocol after elective colorectal surgery decreases not only the length of hospital stay but also the hospitalization costs without increasing postoperative morbidity or the percentage of readmissions.

Effect of socio-economic factors on delayed access to health care among Chinese cervical cancer patients with late rectal complications after radiotherapy.

OBJECTIVES: To determine the effect of socio-economic status (SES) on delayed access to medical treatment by Chinese cervical cancer patients who suffered from late rectal sequelae (LRS) after external beam radiation therapy (EBRT) and intracavitary brachytherapy. METHODS: Patients diagnosed with LRS were interviewed for their SES, factors including age, residing district, religion, marital status, income, education, insurance and patient delay (the time interval from the onset of symptoms to the first medical consultation) and other factors such as weight, symptom duration and disease stage at diagnosis. RESULTS: One hundred and twenty nine patients were interviewed. Seventy-one patients (55%) sought medical treatment within three months after the first symptom being recognized and fifty-eight patients (45%) delayed their medical treatment over 3 months. The study shows that age ≥ 55 (OR=12.1; 95% CI: 3.3-43.9), lower education (OR=4.6; 95% CI: 2.0-10.4 for women with primary school education or illiterate), low annual household income (OR=2.3; 95% CI: 1.2-5.1) and widow/divorce (OR=0.1; 95% CI: 0.01-0.07) were the high risk factors for delayed reporting. Patients with bleeding or bleeding plus other symptoms (61.2%) were more likely to seek treatment within three months, compared to patients with other symptoms only (38.8%) (p=0.002). Additionally, delayed reporting was found to be significantly associated with the late stage of late rectal sequelae (LRS) (p=0.000) and the patients with 55 years or older (p=0.000). CONCLUSIONS: Delayed reporting and late-stage presentation of late rectal sequelae are more prevalent among Chinese cervical cancer patients with 55 years or older, low education, poor marital status, or poor financial status. Effective social support and educational programs should be implemented to encourage these patients to seek medical treatment as soon as possible.

[Cost analysis of the fast track concept in elective colonic surgery]. / Kostenanalyse des Fast-Track-Konzeptes bei elektiver Kolonchirurgie.

INTRODUCTION: Fast track (FT) is a modern concept to enhance postoperative recovery after elective surgery. It has been approved during the last years. Beside its medical benefits, fast-track (FT) concepts may provide an economic incentive, although a cost-benefit analysis in the daily clinical routine has not yet been realised. In addition to this an elevated consumption of resources is postulated. PATIENTS AND METHODS: In 2007 we prospectively studied the implementation of the FT concept for elective colonic surgery in the daily clinical routine at the Department of General Surgery of Nuremberg Hospital. In a representative subgroup of patients studied, we performed a cost-cost analysis by comparing these patients to a retrospectively analysed group that had been treated in a conventional traditional manner in 2002. RESULTS: 369  patients were included and treated according to the FT concept. Discharge criteria were met at the 4(th) postoperative day in median (SD 3.9  days, minimum  1, maxiumum 29  days). The rate of general postoperative complications was 24.4 % (16 % minor complications) for all patients and 6.6 % in the group of patients who were discharged within 9 postoperative days or less (n=182). With respect to the main FT items, implementation of the FT concept was considered as effective. Cost-cost analyses showed a cost reduction of 32 % in favour of patients treated with the FT concept. CONCLUSION: This study clearly shows the clinical and economic benefits of the FT concept considering health services research. Therefore further clinical implementation of the FT concept seems beneficial, not only in the view of medical aspects, but also for economic reasons.

Laparoscopic versus open colectomy for patients with American Society of Anesthesiology (ASA) classifications 3 and 4: the minimally invasive approach is associated with significantly quicker recovery and reduced costs.

BACKGROUND: Conceivably, the benefits of earlier recovery associated with a minimally invasive technique used in laparoscopic colectomy (LC) may be amplified for patients with comorbid disease. The dearth of evidence supporting the safety of laparoscopy for these patients led to a comparison of outcomes between LC and open colectomy (OC) for patients with American Society of Anesthesiology (ASA) classifications 3 and 4. METHODS: Data for all ASA 3 and 4 patients who underwent elective LC were reviewed from a prospectively maintained laparoscopic database. The patients who underwent LC were matched with OC patients by age, gender, diagnosis, year, and type of surgery. Estimated blood loss, operation time, time to return of bowel function, length of hospital stay, readmission rate, and 30-day complication and mortality rates were compared using chi-square, Fisher's exact, and Wilcoxon tests as appropriate. A p value <0.05 was considered statistically significant. RESULTS: In this study, 231 LCs were matched with 231 OCs. The median age of the patients was 68 years, and 234 (51%) of the patients were male. There were 44 (19%) conversions from LC to OC. More patients in the OC group had undergone previous major laparotomy (5 vs. 15%; p < 0.001). Estimated blood loss, return of bowel function, length of hospital stay, and total direct costs were decreased in the LC group. Wound infection was significantly greater with OC (p = 0.02). When patients with previous major laparotomy were excluded, the two groups had similar overall morbidity. The other benefits of LC, however, persisted. CONCLUSION: The findings show that LC is a safe option for patients with a high ASA classification. The LC approach is associated with faster postoperative recovery, lower morbidity rates, and lower hospital costs than the OC approach.

Treating pediatric colorectal patients in low and middle income settings: Creative adaptation to the resources available.

Colorectal disease profiles for children in low- and middle-income settings (LMIC) are characterized by late presentation, increased complications and limited follow-up in many cases. There is a high prevalence of infectious conditions causing secondary colorectal disease such as Mycobacterium Tuberculosis(TB), Human Immunodeficiency Virus(HIV) and Human Papilloma Virus(HPV), which also impact the management of other primary colorectal conditions, such as wound-healing and intestinal anastomosis. Perineal trauma from sexual assault, motor vehicle or pedestrian accidents, burns, and traditional enemas are commonly encountered and may require adaptation of principles used in treatment of congenital anomalies such as Hirschsprung's disease and Anorectal Malformations for reconstruction. Endemic conditions in certain LMIC require further research to delineate underlying causes and optimize management, such as "African" degenerative visceral leiomyopathy, congenital pouch colon in the Indian subcontinent, and congenital H-type rectal fistulae prevalent in Asia. These unique disease profiles require creative adaptations of resources within poor healthcare infrastructure settings. These special challenges and pitfalls in colorectal care and complications of adverse socioeconomic conditions, are discussed.

Preoperative oral antibiotic bowel preparation in elective resectional colorectal surgery reduces rates of surgical site infections: a single-centre experience with a cost-effectiveness analysis.

INTRODUCTION: Surgical site infections cause considerable postoperative morbidity and mortality. The aim of this study was to determine the effect on surgical site infection rates following introduction of a departmental oral antibiotic bowel preparation protocol. METHODS: A prospective single-centre study was performed for elective colorectal resections between May 2016-April 2018; with a control group with mechanical bowel preparation and treatment group with oral antibiotic bowel preparation (neomycin and metronidazole) and mechanical bowel preparation. The primary outcome of surgical site infection and secondary outcomes of anastomotic leak, length of stay and mortality rate were analysed using Fisher's exact test and independent samples t-tests. A cost-effectiveness analysis was also performed. RESULTS: A total of 311 patients were included; 156 in the mechanical bowel preparation group and 155 in the mechanical bowel preparation plus oral antibiotic bowel preparation group. The study included 180 (57.9%) men and 131 (42.1%) women with a mean age of 68 years. There was a significant reduction in surgical site infection rates (mechanical bowel preparation 16.0% vs mechanical bowel preparation plus oral antibiotic bowel preparation 4.5%; P = 0.001) and mean length of stay (mechanical bowel preparation 10.2 days vs mechanical bowel preparation plus oral antibiotic bowel preparation 8.2 days; P = 0.012). There was also a reduction in anastomotic leak and mortality rates. Subgroup analyses demonstrated significantly reduced surgical site infection rates in laparoscopic resections (P = 0.008). There was an estimated cost saving of £239.13 per patient and £37,065 for our institution over a one-year period. CONCLUSION: Oral antibiotic bowel preparation is a feasible and cost-effective intervention shown to significantly reduce the rates of surgical site infection and length of stay in elective colorectal surgery.

Failure of efforts to contain costs of care after colorectal procedures: Nationwide trends in length of stay, costs and post-acute care utilization.

BACKGROUND: This study aims to report trends in healthcare resource utilization and costs after colorectal surgery in the US. METHODS: From all-payer inpatient data, patients who were discharged after elective colorectal procedures (2002-2011) were identified. Trends in postoperative hospital stay, costs and post-acute care were evaluated. RESULTS: Of 251,583 included patients, median length of stay was 6 days. Trends over time suggested a progressive reduction in hospital stay after surgery until 2008 after which there was an increase (6.6 days in 2002, 5.9 days in 2008 and 6.1 days in 2010). Costs (peak:2011, $51,731) and post-acute care (peak:2011, 19.4%) continued to increase throughout. CONCLUSIONS: While length of stay over the last decade reduced, a further reduction may not be feasible. Meanwhile, inpatient costs as well as the use of post-acute care programs have continued to rise. Healthcare planning needs to focus on patients who cannot be discharged early, and more comprehensively evaluate the interplay between length of stay, readmissions, inpatient and post-acute care utilization if we are to contain overall healthcare costs.

Cost-revenue analysis in the surgical treatment of the obstructed defecation syndrome.

The obstructed defecation syndrome is a frequent condition in the female population. Rectocele and rectal intussusception may cause symptoms of obstructed defecation. The aim of this study is to carry out an economic cost-revenue analysis comparing the rectocele and the rectal intussusception surgical techniques using a double-transanal, circular stapler (Stapled Trans-Anal Rectal Resection - STARR) with other techniques used to repair the same defects. The analysis involved the systematic calculation of the costs incurred during hospitalisation. The revenue estimate was obtained according to the rate quantification of the Diagnosis Related Group (DRG) associated with each hospitalisation. Our analysis confirmed that the global expenditure for the STARR technique amounts to 3,579.09 Euro as against 5,401.15 Euro for rectocele abdominal repair and 3,469.32 Euro for perineal repair. The intussusception repair cost according to Delorme's procedure amounts to 5,877.41Euro as against 3,579.09 Euro for the STARR technique. The revenue analysis revealed a substantial gain for the Health Authority as regards the treatment of rectocele and rectal intussusception for obstructed defecation syndrome. The highest revenue, 6,168. 52 Euro, was obtained with intussusception repair with STARR as compared to Delorme's procedure which presented revenue amounting to 2,359.04. Lower revenues are recorded if the STARR technique is intended for rectocele repair; in this case the revenue amounts to 1,778.12 Euro as against 869.67 Euro and 1,887.89 Euro for abdominal and perineal repair, respectively.

Initial evaluation of rectal bleeding in young persons: a cost-effectiveness analysis.

BACKGROUND: Evaluation of rectal bleeding in young patients is a frequent diagnostic challenge. OBJECTIVE: To determine the relative cost-effectiveness of alternative diagnostic strategies for young patients with rectal bleeding. DESIGN: Cost-effectiveness analysis using a Markov model. DATA SOURCES: Probability estimates were based on published medical literature. Cost estimates were based on Medicare reimbursement rates and published medical literature. TARGET POPULATION: Persons 25 to 45 years of age with otherwise asymptomatic rectal bleeding. TIME HORIZON: The patient's lifetime. PERSPECTIVE: Modified societal perspective. INTERVENTIONS: Diagnostic strategies included no evaluation, colonoscopy, flexible sigmoidoscopy, barium enema, anoscopy, or any feasible combination of these procedures. OUTCOME MEASURES: Life expectancy and costs. RESULTS OF BASE-CASE ANALYSIS: For 35-year-old patients, the no-evaluation strategy yielded the least life expectancy. The incremental cost-effectiveness of flexible sigmoidoscopy compared with no evaluation or with any strategy incorporating anoscopy (followed by further evaluation if no anal disease was found on anoscopy) was less than $5300 per year of life gained. A strategy of flexible sigmoidoscopy plus barium enema yielded the greatest life expectancy, with an incremental cost of $23 918 per additional life-year gained compared with flexible sigmoidoscopy alone. RESULTS OF SENSITIVITY ANALYSIS: As patient age at presentation of rectal bleeding increased, evaluation of the entire colon became more cost-effective. The incremental cost-effectiveness of flexible sigmoidoscopy plus barium enema compared with colonoscopy was sensitive to estimates of the sensitivity of the tests. In a probabilistic sensitivity analysis comparing flexible sigmoidoscopy with anoscopy followed by flexible sigmoidoscopy if needed, the middle 95th percentile of the distribution of the incremental cost-effectiveness ratios ranged from flexible sigmoidoscopy yielding an increased life expectancy at reduced cost to $52 158 per year of life gained (mean, $11 461 per year of life saved). CONCLUSIONS: Evaluation of the colon of persons 25 to 45 years of age with otherwise asymptomatic rectal bleeding increases the life expectancy at a cost comparable to that of colon cancer screening.

Healthcare Spending and Performance of Specialty Hospitals: Nationwide Evidence from Colorectal-Anal Specialty Hospitals in South Korea.

PURPOSE: Aim of this study is to investigate the characteristics and performance of colorectal-anal specialty vs. general hospitals for South Korean inpatients with colorectal-anal diseases, and assesses the short-term designation effect of the government's specialty hospital. MATERIALS AND METHODS: Nationwide all colorectal-anal disease inpatient claims (n=292158) for 2010-2012 were used to investigate length of stay and inpatient charges for surgical and medical procedures in specialty vs. general hospitals. The patients' claim data were matched to hospital data, and multi-level linear mixed models to account for clustering of patients within hospitals were performed. RESULTS: Inpatient charges at colorectal-anal specialty hospitals were 27% greater per case and 92% greater per day than those at small general hospitals, but the average length of stay was 49% shorter. Colorectal-anal specialty hospitals had shorter length of stay and a higher inpatient charges per day for both surgical and medical procedures, but per case charges were not significantly different. A "specialty" designation effect also found that the colorectal-anal specialty hospitals may have consciously attempted to reduce their length of stay and inpatient charges. Both hospital and patient level factors had significant roles in determining length of stay and inpatient charges. CONCLUSION: Colorectal-anal specialty hospitals have shorter length of stay and higher inpatient charges per day than small general hospitals. A "specialty" designation by government influence performance and healthcare spending of hospitals as well. In order to maintain prosperous specialty hospital system, investigation into additional factors that affect performance, such as quality of care and patient satisfaction should be carried out.

Stereotactic body radiotherapy for primary prostate cancer: a systematic review.

Stereotactic body radiotherapy (SBRT) for prostate cancer allows overall treatment times to be reduced to as little as 1 week while maintaining a non-invasive approach. This study provides a comprehensive summary of the literature relating to SBRT in prostate cancer. A systematic review of the relevant literature was performed using structured search terms. Fourteen phase I-II trials and retrospective studies using SBRT for the treatment of prostate cancer were used. Three studies were identified which addressed cost. Dose fractionation, radiotherapy procedures, biochemical progression-free survival, toxicity, cost and quality of life were critically appraised. A total of 1472 patients were examined across studies. Median follow-up ranged from 11 to 60 months. The most common dose fractionation was 35-36.25 Gy in five fractions, used in nine out of 14 studies. Ten of 14 studies used CyberKnife. The overall biochemical progression-free survival ranged 81-100%. Acute grade 2 urinary and rectal toxicities were reported in 5-42% and 0-27% of patients, respectively. Acute grade 3 or more urinary and rectal toxicity were 0.5% and 0%, respectively. Late grade 2 urinary toxicity was reported in 0-29% of patients, while 1.3% had a late grade 3 urinary toxicity. There were no late grade 4 urinary toxicities seen. Late grade 2 rectal toxicity was reported in 0-11%, while 0.5% had a late grade 3 rectal toxicity. Late grade 4 rectal toxicity was reported in 0.2% of patients.

Plastic freezer bags: a cost-effective method to protect extraction sites in laparoscopic colorectal procedures?

PURPOSE: To review surgical-site infection (SSI) and retrieval-site tumor recurrence rates in laparoscopic colorectal procedures when using a plastic freezer bag as a wound protector. METHODS: Laparoscopic colorectal procedures where a plastic freezer bag used as a wound protector at the extraction site were reviewed between 1991 and 2008 from a prospectively collected database. χ test was used to compare SSI and tumor recurrence rates between groups. Costing data were obtained from the operating room supplies department. RESULTS: A total of 936 cases with 51 (5.45%) surgical-site infections were identified. SSI rates did not differ when comparing groups based on demographic factors, diagnosis, or location of procedure. Retrieval-site tumor recurrence rate was 0.21% (1/474). Cost of plastic freezer bags including sterilization ranged from $0.25 to $3. CONCLUSIONS: Plastic freezer bags as wound protectors in laparoscopic colorectal procedures are cost effective and have SSI and retrieval-site tumor recurrence rates that compare favorably to published data.

Orifice Diseases Project--experience of the "Hospital das Clínicas" University of São Paulo Medical Center in day-hospital of anorectal disease.

The treatment of malignant or benign colorectal pathologies that require more complex management are priorities in tertiary hospitals such as "Hospital das Clínicas" University of São Paulo Medical Center (HCFMUSP). Therefore, benign, uncomplicated orifice conditions are relegated to second place. The number of patients with hemorrhoids, perianal fistulas, fissures, condylomas and pilonidal cysts who seek treatment at the HFMUSP is very great, resulting in over-crowding in the outpatient clinics and a long waiting list for recommended surgical treatment (at times over 18 months). The authors describe the experience of the HCFMUSP over an eight-day period with day-hospital surgery in which 140 patients underwent surgery. Data was prospectively taken on the patients undergoing surgery for benign orifice pathologies including age, sex, diagnosis, surgery performed, immediate and late postoperative complications, and follow-up, 140 patients operated on over eight days were studied, 68 were males (48.75%) with ages ranging from 25 to 62 (mean 35.2 yrs.). Hemorrhoids was the most frequent condition encountered (82 hemorrhoidectomies, 58.6%), followed by perineal fistula (28 fistula repairs, 20.0%). The most common complication was headache secondary to rachianesthesia occurring in 9 patients (6.4%). One patient (0.7%) developed bleeding immediately PO that required reoperation. Mean follow-up was 104 days. Day-surgery characterized by quality care and low morbidity is feasible in tertiary public hospitals, permitting surgery for benign orifice pathologies on many patients within a short period of time.

Cost-effectiveness of blood transfusion and white cell reduction in elective colorectal surgery.

BACKGROUND: The use of white cell (WBC)-reduced blood in elective colorectal surgery appears to reduce the frequency of postoperative infection. The question to be addressed is whether the cost:benefit ratio justifies the recommendation that WBC-reduced blood should be used for all colorectal surgery. STUDY DESIGN AND METHODS: Patients admitted for elective colorectal surgery (n = 197) were randomly assigned to receive transfusion consisting of whole blood or WBC-reduced whole blood. Postoperative complications, postoperative stay, and hospital charges were compared. RESULTS: Forty-eight patients received WBC-reduced whole blood, 56 received unfiltered whole blood, and 93 received no transfusion. Postoperative infections were significantly higher (p < 0.001) in the group that received unfiltered whole blood. That group also had longer hospital stays: 17 days as compared to stays of 10 and 11 days for the group receiving no transfusion and the group receiving filtered whole blood transfusions, respectively (p < 0.01). The total hospital cost per patient receiving unfiltered whole blood was $12,347, as compared to $7,867 for those who received WBC-reduced whole blood and $7,030 for those who received no transfusion. CONCLUSION: The use of WBC-reduced whole blood transfusions in elective colorectal surgery significantly reduces the frequency of postoperative infection, the length of hospital stay, and the total hospital charges for patients needing blood transfusion.