Laparoscopic transverse abdominis plane block: how I do it and a cost efficiency analysis.

PURPOSE: To determine the efficacy and efficiency of laparoscopic transverse abdominis plane block (Lap-TAP) in patients undergoing pancreatoduodenectomy and gastrectomy compared to those of ultrasound-guided TAP (US-TAP). METHODS: We retrospectively analyzed the records of patients who underwent open or minimally invasive (MIS) pancreatoduodenectomy and major gastrectomy with the use of Lap-TAP or US-TAP at our institution between November 1, 2018, and September 30, 2021. We compared the estimated time and cost associated with Lap-TAP and US-TAP. We also compared postoperative opioid use and pain scores between patients who underwent open laparotomy with these TAPs. RESULTS: A total of 194 patients were included. Overall, 114 patients (59%) underwent pancreatectomy, and 80 patients (41%) underwent gastrectomy. Additionally, 138 patients (71%) underwent an open procedure, and 56 patients (29%) underwent MIS. A total of 102 patients (53%) underwent US-TAP, and 92 (47%) underwent Lap-TAP. The median time to skin incision was significantly shorter in the Lap-TAP group (US-TAP, 59 min vs. Lap-TAP, 45 min; P < 0.001), resulting in an estimated reduction in operation cost by $602. Pain scores and postoperative opioid use were similar between Lap-TAP and US-TAP among open surgery patients, indicating equivalent pain control between Lap-TAP and US-TAP. CONCLUSION: Lap-TAP was equally effective in pain control as US-TAP after pancreatectomy and gastrectomy, and Lap-TAP can reduce operation time and cost. Lap-TAP is considered the preferred approach for MIS pancreatectomy and gastrectomy, which occasionally needs conversion to laparotomy.

Why bundled payments could drive innovation: an example from interventional oncology.

Some have suggested that the current fee-for-service health care payment system in the United States stifles innovation. However, there are few published examples supporting this concept. We implemented an innovative temporary balloon occlusion technique for yttrium 90 radioembolization of nonresectable liver cancer. Although our balloon occlusion technique was associated with similar patient outcomes, lower cost, and faster procedure times compared with the standard-of-care coil embolization technique, our technique failed to gain widespread acceptance. Financial analysis revealed that because the balloon occlusion technique avoided a procedural step associated with a lucrative Current Procedural Terminology billing code, this new technique resulted in a significant decrease in hospital and physician revenue in the current fee-for-service payment system, even though the new technique would provide a revenue enhancement through cost savings in a bundled payment system. Our analysis illustrates how in a fee-for-service payment system, financial disincentives can stifle innovation and advancement of health care delivery.

Quality initiatives: Establishing an interventional radiology patient radiation safety program.

The Interventional Radiology Patient Radiation Safety Program was created to better educate patients who are scheduled to undergo high-dose interventional radiologic procedures about the risks of radiation, better monitor the delivered doses, and reduce the risk for deterministic effects. The program combines preprocedure evaluation and counseling, intraprocedure monitoring, and postprocedure documentation and counseling with the guidelines of the National Cancer Institute and the Society of Interventional Radiology. Between July 2009, when the program was implemented, and September 2010, over 3500 interventional radiologic procedures were monitored and documented, and 63 procedures with an adjusted cumulative dose of more than 3 Gy were identified and further analyzed; four procedures were found to be outside the control limits. Additional review of these four procedures resulted in practice modifications. Anecdotal feedback from physician assistants and attending physicians indicated that the program had another positive effect: Patients who required postprocedure counseling about the potential for radiation-induced skin injuries were no longer surprised by this information. Implementation of this program is straightforward, requires little infrastructure and few resources, and may be applied in most interventional radiology practices. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.321115002/-/DC1.