RESUMEN
BACKGROUND: The Gallstone Pancreatitis: Admission vs Normal Cholecystectomy (Gallstone PANC) Trial demonstrated that cholecystectomy within 24 hours of admission (early) compared with after clinical resolution (control) for mild gallstone pancreatitis, significantly reduced 30-day length-of-stay (LOS) without increasing major postoperative complications. We assessed whether early cholecystectomy decreased 90-day healthcare use and costs. STUDY DESIGN: A secondary economic evaluation of the Gallstone PANC Trial was performed from the healthcare system perspective. Costs for index admissions and all gallstone pancreatitis-related care 90 days post-discharge were obtained from the hospital accounting system and inflated to 2020 USD. Negative binomial regression models and generalized linear models with log-link and gamma distribution, adjusting for randomization strata, were used. Bayesian analysis with neutral prior was used to estimate the probability of cost reduction with early cholecystectomy. RESULTS: Of 98 randomized patients, 97 were included in the analyses. Baseline characteristics were similar in early (n = 49) and control (n = 48) groups. Early cholecystectomy resulted in a mean absolute difference in LOS of -0.96 days (95% CI, -1.91 to 0.00, p = 0.05). Ninety-day mean total costs were $14,974 (early) vs $16,190 (control) (cost ratio [CR], 0.92; 95% CI, 0.73-1.15, p = 0.47), with a mean absolute difference of $1,216 less (95% CI, -$4,782 to $2,349, p = 0.50) per patient in the early group. On Bayesian analysis, there was an 81% posterior probability that early cholecystectomy reduced 90-day total costs. CONCLUSION: In this single-center trial, early cholecystectomy for mild gallstone pancreatitis reduced 90-day LOS and had an 81% probability of reducing 90-day healthcare system costs.
Asunto(s)
Colecistectomía/estadística & datos numéricos , Cálculos Biliares/cirugía , Pancreatitis/cirugía , Complicaciones Posoperatorias/epidemiología , Tiempo de Tratamiento/estadística & datos numéricos , Adulto , Colecistectomía/efectos adversos , Colecistectomía/economía , Análisis Costo-Beneficio , Femenino , Cálculos Biliares/complicaciones , Cálculos Biliares/diagnóstico , Cálculos Biliares/economía , Costos de la Atención en Salud/estadística & datos numéricos , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Pancreatitis/diagnóstico , Pancreatitis/economía , Pancreatitis/etiología , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/etiología , Índice de Severidad de la Enfermedad , Factores de Tiempo , Tiempo de Tratamiento/economíaRESUMEN
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.
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Dolor Abdominal/diagnóstico , Colecistectomía Laparoscópica/normas , Cálculos Biliares/complicaciones , Lipasa/sangre , Pancreatitis/cirugía , Tiempo de Tratamiento/normas , Dolor Abdominal/economía , Dolor Abdominal/etiología , Dolor Abdominal/terapia , Adolescente , Niño , Colecistectomía Laparoscópica/efectos adversos , Colecistectomía Laparoscópica/economía , Colecistectomía Laparoscópica/estadística & datos numéricos , Toma de Decisiones Clínicas/métodos , Análisis Costo-Beneficio/estadística & datos numéricos , Femenino , Cálculos Biliares/sangre , Cálculos Biliares/economía , Cálculos Biliares/terapia , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Tempo Operativo , Dimensión del Dolor , Pancreatitis/sangre , Pancreatitis/economía , Pancreatitis/etiología , Nutrición Parenteral Total/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Guías de Práctica Clínica como Asunto , Cuidados Preoperatorios/economía , Cuidados Preoperatorios/estadística & datos numéricos , Estudios Retrospectivos , Factores de Tiempo , Tiempo de Tratamiento/economía , Tiempo de Tratamiento/estadística & datos numéricos , Resultado del TratamientoRESUMEN
OBJECTIVES: Many strategies have been either used or recommended to promote physician compliance with clinical practice guidelines and clinical pathways (CPs). This study examines the relationship between hospitals' use of financial incentives to encourage physician compliance with CPs and physician adherence to CPs. DESIGN: A retrospectively cross-sectional study of the relationship between the extent to which patient care was consistent with CPs and hospital's use of financial incentives to influence CP compliance. SETTING: Eighteen public hospitals in three provinces in China. PARTICIPANTS: Stratified sample of 2521 patients discharged between 3 January 2013 and 31 December 2014. PRIMARY OUTCOME MEASURES: The proportion of key performance indicators (KPIs) met for patients with (1) community-acquired pneumonia (pneumonia), (2) acute myocardial infarction (AMI), (3) acute left ventricular failure (heart failure), (4) planned caesarean section (C-section) and (5) gallstones associated with acute cholecystitis and associated cholecystectomy (cholecystectomy). RESULTS: The average implementation rate of CPs for five conditions (pneumonia, AMI, heart failure, C-section and cholecystectomy) based on 2521 cases in 18 surveyed hospitals was 57% (ranging from 44% to 67%), and the overall average compliance rate for the KPIs for the five conditions was 69.48% (ranging from 65.07% to 77.36%). Implementation of CPs was associated with greater compliance within hospitals only when hospitals adopted financial incentives directed at physicians to promote compliance. CONCLUSION: CPs are viewed as important strategies to improve medical care in China, but they have not been widely implemented or adhered to in Chinese public hospitals. In addition to supportive resources, education/training and better administration in general, hospitals should provide financial incentives to encourage physicians to adhere to CPs.
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Vías Clínicas/economía , Adhesión a Directriz/estadística & datos numéricos , Hospitales Públicos/economía , Atención al Paciente/economía , Médicos/economía , Reembolso de Incentivo/estadística & datos numéricos , Cesárea/economía , Cesárea/estadística & datos numéricos , China , Colecistectomía/economía , Colecistectomía/estadística & datos numéricos , Colecistitis Aguda/economía , Colecistitis Aguda/cirugía , Infecciones Comunitarias Adquiridas/economía , Infecciones Comunitarias Adquiridas/terapia , Vías Clínicas/estadística & datos numéricos , Estudios Transversales , Femenino , Cálculos Biliares/economía , Cálculos Biliares/cirugía , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/terapia , Humanos , Masculino , Infarto del Miocardio/economía , Infarto del Miocardio/terapia , Atención al Paciente/métodos , Neumonía/economía , Neumonía/terapia , Embarazo , Estudios RetrospectivosRESUMEN
BACKGROUND: Although, 33% to 40% of symptomatic gallstone patients reported persistent abdominal pain after laparoscopic cholecystectomy, there is no data on the burden of this pain to the healthcare system and society at large. This study determined healthcare consumption, sick leave, and costs in patients with persistent abdominal pain after laparoscopic cholecystectomy. Secondly, predictive factors for healthcare consumption were assessed. METHODS: This cross-sectional study included all 146 patients with persistent abdominal pain (patient-reported on Gastro-Intestinal Quality of Life Index (score 0-3) 24 weeks after laparoscopic cholecystectomy, derived from a previous prospective cohort. Healthcare consumption was assessed using Medical Consumption Questionnaire and medical records, and sick leave using Productivity Cost Questionnaire. Costs were calculated according "Guideline for performing economic evaluations in healthcare." Predictors of healthcare consumption were assessed using logistic regression analysis. RESULTS: In the study, 124/146 patients (85%) responded after mean follow-up of 31.0 months (standard deviation 6.5); 104 were female, mean age of responders was 52 years. Sixty-nine patients needed additional healthcare; 30.6% primary care; 37.1% secondary care; 16% emergency department admission; 8.9% hospital admission; 33.9% diagnostic procedures; 17.7% medication; 5.6% other interventions. Medical costs were $555 (BCa 95% confidence interval, $329-$852) and costs of sick leave were $361 (Bias-corrected and accelerated (BCa) 95% confidence interval, $189-$566) per year per patient. Younger age (odds ratio 0.95, 95% confidence interval, 0.92-0.98) and higher postoperative pain score (odds ratio 1.02, 95% confidence interval, 1.01-1.04) were associated with increased healthcare consumption. CONCLUSION: Persistent abdominal pain after laparoscopic cholecystectomy is associated with additional healthcare in 56% of patients. Yearly, medical costs and costs of sick leave are 20% of the initial costs of laparoscopic cholecystectomy.
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Dolor Abdominal/economía , Colecistectomía Laparoscópica/efectos adversos , Atención a la Salud/estadística & datos numéricos , Costos de la Atención en Salud , Dolor Postoperatorio/economía , Ausencia por Enfermedad , Dolor Abdominal/etiología , Adulto , Anciano , Estudios Transversales , Atención a la Salud/economía , Femenino , Cálculos Biliares/complicaciones , Cálculos Biliares/economía , Cálculos Biliares/cirugía , Humanos , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/etiologíaRESUMEN
BACKGROUND: Evidence from controlled trials and meta-analyses suggests that laparoendoscopic rendezvous (LERV) is preferable to sequential treatment in the management of common bile duct stones. MATERIALS AND METHODS: With this retrospective analysis of a prospective database that included consecutive patients treated for cholecystocholedocholithiasis at our institution between January 2007 and July 2015, we compared LERV with sequential treatment. The primary endpoint was global cost, defined as the cost/patient/hospital stay, and the secondary end points were efficacy and morbidity. Fisher's exact test or Mann-Whitney test was used. RESULTS: Of a total of 249 consecutive patients, 143 underwent LERV (group A) and 106 a two-stage procedure (group B). Based on an average cost of 613 for 1 day of hospital stay in the General Surgery Department, the overall median cost of treatment was 6403 for group A and 8194 for group B (p < 0.001). Operative time was significantly shorter (p < 0.001), and length of hospital stay was significantly longer for group B (p < 0.001). No mortality in either group was observed. The postoperative complications rate was significantly higher in group B than in group A (24.5 vs. 10.5%; p = 0.003). No significant difference in the postoperative pancreatitis rate or the number of patients with increased serum amylase at 24 h was observed in either group. CONCLUSION: Our study suggests that LERV is preferable to sequential treatment not only in terms of less morbidity, but also of lower costs accrued by a shorter hospital stay. However, the longer operative time raises multiple organizational issues in the coordination of surgery and endoscopy services.
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Colangiopancreatografia Retrógrada Endoscópica/economía , Colecistectomía Laparoscópica/economía , Coledocolitiasis/cirugía , Cálculos Biliares/cirugía , Costos de la Atención en Salud , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colecistectomía Laparoscópica/mortalidad , Colecistitis/cirugía , Costos y Análisis de Costo , Femenino , Cálculos Biliares/economía , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias/cirugía , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: The aim of this study was to determine the cost-effectiveness of a new strategy for the preoperative detection of patients that will likely benefit from a cholecystectomy, using simple criteria that can be applied by surgeons. Criteria for a cholecystectomy indication are: (1) having episodic pain; (2) onset of pain 1 year or less before the outpatient clinic visit. METHODS: The cost-effectiveness of the new strategy was evaluated against current practice using a decision analytic model. The incremental cost-effectiveness of applying criteria for a cholecystectomy for a patient with abdominal pain and gallstones was compared to applying no criteria. The incremental cost-effectiveness ratio (ICER) was expressed as extra costs to be invested to gain one more patient with absence of pain. Scenarios were analyzed to assess the influence of applying different criteria. RESULTS: The new strategy of applying one out of two criteria resulted in a 4 % higher mean proportion of patients with absence of pain compared to current practice with similar costs. The 95 % upper limit of the ICER was 4114 ($4633) per extra patient with relief of upper abdominal pain. Application of two out of two criteria resulted in a 3 % lower mean proportion of patients with absence of pain with lower costs. CONCLUSION: The new strategy of using one out of two strict selection criteria may be an effective but also a cost-effective method to reduce the proportion of patients with pain after cholecystectomy.
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Dolor Abdominal/diagnóstico , Colecistectomía , Cálculos Biliares/diagnóstico , Adulto , Colecistectomía/economía , Análisis Costo-Beneficio , Técnicas de Apoyo para la Decisión , Femenino , Cálculos Biliares/economía , Cálculos Biliares/cirugía , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Espera VigilanteRESUMEN
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.
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Colecistectomía/economía , Cálculos Biliares/economía , Pancreatitis/economía , Enfermedad Aguda , Adulto , Anciano , Análisis Costo-Beneficio , Femenino , Cálculos Biliares/complicaciones , Cálculos Biliares/cirugía , Costos de la Atención en Salud , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Pancreatitis/complicaciones , Pancreatitis/cirugía , Admisión del Paciente/economía , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
Objetivos: analizar los reingresos de pacientes con pancreatitis aguda biliar edematosa (PABE) sin colecistectomía a pesar de un episodio previo de pancreatitis aguda biliar leve o colecistitis litiásica. Calcular el coste sanitario asociado a la no realización de colecistectomía. Material y métodos: estudio observacional prospectivo realizado en el Hospital de Cabueñes, entre julio y noviembre de 2014. Se incluyeron consecutivamente los pacientes ingresados en el Servicio de Digestivo con PABE que: a) habían presentado un episodio previo de pancreatitis aguda biliar leve o colecistitis al menos dos semanas antes del reingreso; y b) no se les había realizado colecistectomía pese a ausencia de contraindicaciones. Resultados: durante el periodo de estudio reingresaron 9 pacientes, 7 mujeres y 2 varones, con una edad media de 65,3 años (desviación estándar [DE] = 19,2). La mediana de días transcurridos desde el episodio previo de PABE o colecistitis hasta su reingreso fue de 114 días (recorrido intercuartílico [RIC] = 111,0). La estancia global mediana de los pacientes fue de 10 días (RIC = 2,0). Los pacientes realizaron una media de 2,8 (DE = 1,2) ecografías, 1,3 (DE = 0,9) TC abdómino-pélvicos, 0,8 (DE = 1,0) RM y 0,2 (DE = 0,4) CPRE. El coste medio de cada reingreso por paciente, incluyendo la estancia hospitalaria (143,0 /día), en el servicio de Urgencias (332,31 ) y las pruebas realizadas, fue de 2.381,70 /paciente. Conclusiones: la no realización de colecistectomía en las 2 semanas posteriores a un primer episodio de PABE leve o colecistitis contribuye a los reingresos por pancreatitis recurrentes con los consecuentes gastos evitables asociados
Aims: Analyzing the readmission of patients with acute biliary edematous pancreatitis (ABEP) without cholecystectomy despite a previous episode of mild acute gallstone pancreatitis or lithiasic cholecystitis. Calculating the health costs associated with the non-performance of cholecystectomy. Material and methods: Prospective observational study conducted at a tertiary hospital from July to November 2014. The study has consecutively included inpatients suffering from ABEP who: a) had suffered a previous episode of mild acute gallstone pancreatitis or cholecystitis at least 2 weeks before readmission; and b) had not undergone cholecystectomy despite the lack of contraindications. Results: During the research period, 9 patients (7 females and 2 males) with a mean age of 65.3 years (standard deviation [SD] 19.2) were readmitted. The median number of days between the previous episode of ABEP or cholecystitis and the readmission was 114 days (interquartile range [IQR] 111.0). Reported median overall length of hospital stay was 10 days (IQR = 2.0). Patients underwent a mean of 2.8 (SD = 1.2) ultrasound scans, 1.3 (SD = 0.9) abdominal and pelvic CT, 0.8 (SD = 1.0) MRCP and 0.2 (SD = 0.4) ERCP. The mean cost per patient for each readmission, including hospital stay (143.0 /day), Emergency Service (332.31 ) and tests performed was 2,381.70 /patient. Conclusions: Not performing a cholecystectomy within two weeks after a first episode of mild ABEP or cholecystitis contributes to patient readmission due to recurrent pancreatitis, resulting in avoidable treatment costs
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Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Readmisión del Paciente/economía , Readmisión del Paciente/tendencias , Pancreatitis/complicaciones , Pancreatitis/economía , Pancreatitis/cirugía , Colecistectomía/métodos , Hospitalización/economía , Tiempo de Internación/economía , Estudios Prospectivos , Cálculos Biliares/complicaciones , Cálculos Biliares/economía , Cálculos Biliares/cirugía , Costos Directos de Servicios/normas , Análisis de Datos/métodosRESUMEN
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 %.
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Cálculos Biliares/complicaciones , Pancreatitis/cirugía , Protocolos Clínicos , Análisis Costo-Beneficio , Costos y Análisis de Costo , Femenino , Cálculos Biliares/diagnóstico , Cálculos Biliares/economía , Cálculos Biliares/cirugía , Indicadores de Salud , Humanos , Masculino , Persona de Mediana Edad , Pancreatitis/diagnóstico , Pancreatitis/economía , Pancreatitis/etiología , Estudios ProspectivosRESUMEN
AIM: To evaluate short-term outcomes following intraoperative biliary lavage for hepatolithiasis. METHODS: A total of 932 patients who were admitted to the West China Medical Center of Sichuan University between January 2010 and January 2014 and underwent bile duct exploration and lithotomy were retrospectively included in our study. The patients were divided into the lavage group and the control group. Related pre-, intra-, and postoperative factors were recorded, analyzed, and compared between the two groups in order to verify the effects of biliary lavage on the short-term outcome of patients with hepatolithiasis. RESULTS: Amongst the patients who were included, 678 patients with hepatolithiasis were included in the lavage group, and the other 254 patients were enrolled in the control group. Data analyses revealed that preoperative baseline and related intraoperative variables were not significantly different. However, patients who underwent intraoperative biliary lavage had prolonged postoperative hospital stays (6.67 d vs 7.82 d, P = 0.024), higher hospitalization fees (RMB 28437.1 vs RMB 32264.2, P = 0.043), higher positive rates of bacterial cultures from blood (13.3% vs 25.8%, P = 0.001) and bile (23.6% vs 40.7%, P = 0.001) samples, and increased usage of advanced antibiotics (26.3% vs 38.2%, P = 0.001). In addition, in the lavage group, more patients had fever (> 37.5â °C, 81.4% vs 91.1%, P = 0.001) and hyperthermia (> 38.5°C, 39.7% vs 54.9%, P = 0.001), and higher white blood cell counts within 7 d after the operation compared to the control group. CONCLUSION: Intraoperative biliary lavage might increase the risk of postoperative infection, while not significantly increasing gallstone removal rate.
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Infecciones Bacterianas/microbiología , Procedimientos Quirúrgicos del Sistema Biliar , Cálculos Biliares/terapia , Irrigación Terapéutica/efectos adversos , Adulto , Anciano , Antibacterianos/uso terapéutico , Infecciones Bacterianas/diagnóstico , Infecciones Bacterianas/tratamiento farmacológico , Infecciones Bacterianas/economía , Procedimientos Quirúrgicos del Sistema Biliar/efectos adversos , Procedimientos Quirúrgicos del Sistema Biliar/economía , China , Femenino , Cálculos Biliares/diagnóstico , Cálculos Biliares/economía , Cálculos Biliares/cirugía , Costos de Hospital , Humanos , Cuidados Intraoperatorios , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Irrigación Terapéutica/economía , Irrigación Terapéutica/métodos , Factores de Tiempo , Resultado del TratamientoRESUMEN
This study uses a discrete choice experiment (DCE) to measure patients' preferences for public and private hospital care in New Zealand. A labeled DCE was administered to 583 members of the general public, with the choice between a public and private hospital for a non-urgent surgery. The results suggest that cost of surgery, waiting times for surgery, option to select a surgeon, convenience, and conditions of the hospital ward are important considerations for patients. The most important determinant of hospital choice was whether it was a public or private hospital, with respondents far more likely to choose a public hospital than a private hospital. The results have implications for government policy toward using private hospitals to clear waiting lists in public hospitals, with these results suggesting the public might not be indifferent to policies that treat private hospitals as substitutes for public hospitals.
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Procedimientos Quirúrgicos Electivos/normas , Hospitales Privados/estadística & datos numéricos , Hospitales Públicos/estadística & datos numéricos , Prioridad del Paciente/psicología , Adolescente , Adulto , Distribución por Edad , Conducta de Elección , Costos y Análisis de Costo , Procedimientos Quirúrgicos Electivos/economía , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Femenino , Cálculos Biliares/economía , Cálculos Biliares/cirugía , Encuestas de Atención de la Salud , Hospitales Privados/economía , Hospitales Privados/normas , Hospitales Públicos/economía , Hospitales Públicos/normas , Humanos , Masculino , Persona de Mediana Edad , Nueva Zelanda , Prioridad del Paciente/economía , Prioridad del Paciente/estadística & datos numéricos , Distribución por Sexo , Factores de Tiempo , Listas de Espera , Adulto JovenRESUMEN
AIM: To investigate whether screening for gallstone disease was economically feasible and clinically effective. METHODS: This clinical study was initially conducted in 2002 in Taipei, Taiwan. The study cohort total included 2386 healthy adults who were voluntarily admitted to a regional teaching hospital for a physical check-up. Annual follow-up screening with ultrasound sonography for gallstone disease continued until December 31, 2007. A decision analysis using the Markov Decision Model was constructed to compare different screening regimes for gallstone disease. The economic evaluation included estimates of both the cost-effectiveness and cost-utility of screening for gallstone disease. RESULTS: Direct costs included the cost of screening, regular clinical fees, laparoscopic cholecystectomy, and hospitalization. Indirect costs represent the loss of productivity attributable to the patient's disease state, and were estimated using the gross domestic product for 2011 in Taiwan. Longer time intervals in screening for gallstone disease were associated with the reduced efficacy and utility of screening and with increased cost. The cost per life-year gained (average cost-effectiveness ratio) for annual screening, biennial screening, 3-year screening, 4-year screening, 5-year screening, and no-screening was new Taiwan dollars (NTD) 39076, NTD 58059, NTD 72168, NTD 104488, NTD 126941, and NTD 197473, respectively (P < 0.05). The cost per quality-adjusted life-year gained by annual screening was NTD 40725; biennial screening, NTD 64868; 3-year screening, NTD 84532; 4-year screening, NTD 110962; 5-year screening, NTD 142053; and for the control group, NTD 202979 (P < 0.05). The threshold values indicated that the ultrasound sonography screening programs were highly sensitive to screening costs in a plausible range. CONCLUSION: Routine screening regime for gallstone disease is both medically and economically valuable. Annual screening for gallstone disease should be recommended.
Asunto(s)
Endosonografía/economía , Cálculos Biliares/diagnóstico por imagen , Cálculos Biliares/economía , Costos de la Atención en Salud , Absentismo , Adulto , Colecistectomía Laparoscópica/economía , Análisis Costo-Beneficio , Técnicas de Apoyo para la Decisión , Eficiencia , Estudios de Factibilidad , Femenino , Cálculos Biliares/cirugía , Costos de Hospital , Hospitalización/economía , Hospitales de Enseñanza/economía , Humanos , Masculino , Cadenas de Markov , Persona de Mediana Edad , Modelos Económicos , Valor Predictivo de las Pruebas , Ausencia por Enfermedad/economía , TaiwánRESUMEN
BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) for stone can be carried out by either laparoscopic transcystic stone extraction (LTSE) or laparoscopic choledochotomy (LC). It remains unknown as to which approach is optimal for management of gallbladder stone with common bile duct stones (CBDS) in Chinese patients. METHODS: From May 2000 to February 2009, we prospective treated 346 consecutive patients with gallbladder stones and CBDS with laparoscopic cholecystectomy and LCBDE. Intraoperative findings, postoperative complications, postoperative hospital stay and costs were analyzed. RESULTS: Because of LCBDE failure,16 cases (4.6%) required open surgery. Of 330 successful LCBDE-treated patients, 237 underwent LTSE and 93 required LC. No mortality occurred in either group. The bile duct stone clearance rate was similar in both groups. Patients in the LTSE group were significantly younger and had fewer complications with smaller, fewer stones, shorter operative time and postoperative hospital stays, and lower costs, compared to those in the LC group. Compared with patients with T-tube insertion, patients in the LC group with primary closure had shorter operative time, shorter postoperative hospital stay, and lower costs. CONCLUSIONS: In cases requiring LCBDE, LTSE should be the first choice, whereas LC may be restricted to large, multiple stones. LC with primary closure without external drainage of the CBDS is as effective and safe as the T-tube insertion approach.
Asunto(s)
Colecistectomía Laparoscópica , Coledocolitiasis/cirugía , Cálculos Biliares/cirugía , Adulto , Anciano , China , Colecistectomía Laparoscópica/economía , Coledocolitiasis/diagnóstico , Coledocolitiasis/economía , Femenino , Cálculos Biliares/diagnóstico , Cálculos Biliares/economía , Costos de Hospital/estadística & datos numéricos , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/economía , Estudios Prospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of this study was to determine the etiology tendency of acute pancreatitis (AP) in the Beijing region and the relationship with influencing factors. METHODS: This retrospective multicenter study enrolled 8 representative general hospitals from January 1, 2006 to December 31, 2010. The etiology tendency was analyzed, and the relationship was defined with sex, aging, severity, mortality, recrudesce rate, length of stay, and hospitalization cost. RESULTS: The study enrolled 2461 patients. The total number was increasing year by year. Causes included biliary (1372, 55.75%), alcoholism (246, 10%), hypertriglyceridemia (255, 10.36%), and the others (588, 23.89%). Biliary AP was the most frequent primary cause. Hypertriglyceridemic AP increased at a faster rate than alcoholic AP. There was higher proportion of alcoholic and hypertriglyceridemic AP in men than in women. There is an increase of AP patients with ages 40 to 49 years and older than 70 years. Alcoholic and hypertriglyceridemic AP were higher in patients younger than the age of 50 years, and biliary pancreatitis was higher in patients older than 70 years. Severe AP was classified among 736 patients (29.9%). Etiology distribution was different between severe AP and mild AP (P < 0.001). Mortality in the hospital was 1.54%, and there was no difference in each group. Recrudesce of hypertriglyceridemic AP was higher (P < 0.01). CONCLUSIONS: Acute pancreatitis patients increased year by year in Beijing. Gallstones were the predominant etiological factor. There were different etiology proportion of AP according age, sex, and severity.
Asunto(s)
Cálculos Biliares/epidemiología , Hipertrigliceridemia/epidemiología , Pancreatitis/epidemiología , Enfermedad Aguda , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Niño , China/epidemiología , Femenino , Cálculos Biliares/diagnóstico , Cálculos Biliares/economía , Cálculos Biliares/mortalidad , Cálculos Biliares/terapia , Costos de Hospital , Humanos , Hipertrigliceridemia/diagnóstico , Hipertrigliceridemia/economía , Hipertrigliceridemia/mortalidad , Hipertrigliceridemia/terapia , Incidencia , Tiempo de Internación , Masculino , Persona de Mediana Edad , Pancreatitis/diagnóstico , Pancreatitis/economía , Pancreatitis/mortalidad , Pancreatitis/terapia , Pancreatitis Alcohólica/diagnóstico , Pancreatitis Alcohólica/epidemiología , Admisión del Paciente , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores Sexuales , Factores de Tiempo , Adulto JovenRESUMEN
BACKGROUND: Gallstone disease is a common gastrointestinal disorder in industrialised countries. Although symptoms can be severe, some people can be symptom free for many years after the original attack. Surgery is the current treatment of choice, but evidence suggests that observation is also feasible and safe. We reviewed the evidence on cholecystectomy versus observation for uncomplicated symptomatic gallstones and conducted a cost-effectiveness analysis. METHODS: We searched six electronic databases (last search April 2014). We included randomised controlled trials (RCTs) or non-randomised comparative studies where adults received either cholecystectomy or observation/conservative management for the first episode of symptomatic gallstone disease (biliary pain or cholecystitis) being considered for surgery in secondary care. Meta-analysis was used to combine results. A de novo Markov model was developed to assess the cost effectiveness of the interventions. RESULTS: Two RCTs (201 participants) were included. Eighty-eight percent of people randomised to surgery and 45 % of people randomised to observation underwent cholecystectomy during the 14-year follow-up period. Participants randomised to observation were significantly more likely to experience gallstone-related complications (RR = 6.69, 95 % CI = 1.57-28.51, p = 0.01), in particular acute cholecystitis (RR = 9.55, 95 % CI = 1.25-73.27, p = 0.03), and less likely to undergo surgery (RR = 0.50, 95 % CI = 0.34-0.73, p = 0.0004) or experience surgery-related complications (RR = 0.36, 95 % CI = 0.16-0.81, p = 0.01) than those randomised to surgery. Fifty-five percent of people randomised to observation did not require surgery, and 12 % of people randomised to cholecystectomy did not undergo surgery. On average, surgery costs £1,236 more per patient than conservative management, but was more effective. CONCLUSIONS: Cholecystectomy is the preferred treatment for symptomatic gallstones. However, approximately half the observation group did not require surgery or suffer complications indicating that it may be a valid alternative to surgery. A multicentre trial is needed to establish the effects, safety and cost effectiveness of observation/conservative management relative to cholecystectomy.
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Colecistectomía/economía , Colecistitis/terapia , Cálculos Biliares/terapia , Observación/métodos , Colecistitis/economía , Análisis Costo-Beneficio , Cálculos Biliares/economía , HumanosRESUMEN
BACKGROUND: Approximately 10-15% of the adult population suffer from gallstone disease, cholelithiasis, with more women than men being affected. Cholecystectomy is the treatment of choice for people who present with biliary pain or acute cholecystitis and evidence of gallstones. However, some people do not experience a recurrence after an initial episode of biliary pain or cholecystitis. As most of the current research focuses on the surgical management of the disease, less attention has been dedicated to the consequences of conservative management. OBJECTIVES: To determine the clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management in people presenting with uncomplicated symptomatic gallstones (biliary pain) or cholecystitis. DATA SOURCES: We searched all major electronic databases (e.g. MEDLINE, EMBASE, Science Citation Index, Bioscience Information Service, Cochrane Central Register of Controlled Trials) from 1980 to September 2012 and we contacted experts in the field. REVIEW METHODS: Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies that enrolled people with symptomatic gallstone disease (pain attacks only and/or acute cholecystitis). Two reviewers independently extracted data and assessed the risk of bias of included studies. Standard meta-analysis techniques were used to combine results from included studies. A de novo Markov model was developed to assess the cost-effectiveness of the interventions. RESULTS: Two Norwegian RCTs involving 201 participants were included. Eighty-eight per cent of people randomised to surgery and 45% of people randomised to observation underwent cholecystectomy during the 14-year follow-up period. Participants randomised to observation were significantly more likely to experience gallstone-related complications [risk ratio = 6.69; 95% confidence interval (CI) 1.57 to 28.51; p = 0.01], in particular acute cholecystitis (risk ratio = 9.55; 95% CI 1.25 to 73.27; p = 0.03), and less likely to undergo surgery (risk ratio = 0.50; 95% CI 0.34 to 0.73; p = 0.0004), experience surgery-related complications (risk ratio = 0.36; 95% CI 0.16 to 0.81; p = 0.01) or, more specifically, minor surgery-related complications (risk ratio = 0.11; 95% CI 0.02 to 0.56; p = 0.008) than those randomised to surgery. Fifty-five per cent of people randomised to observation did not require an operation during the 14-year follow-up period and 12% of people randomised to cholecystectomy did not undergo the scheduled operation. The results of the economic evaluation suggest that, on average, the surgery strategy costs £1236 more per patient than the conservative management strategy but was, on average, more effective. An increase in the number of people requiring surgery while treated conservatively corresponded to a reduction in the cost-effectiveness of the conservative strategy. There was uncertainty around some of the parameters used in the economic model. CONCLUSIONS: The results of this assessment indicate that cholecystectomy is still the treatment of choice for many symptomatic people. However, approximately half of the people in the observation group did not require surgery or suffer complications in the long term indicating that a conservative therapeutic approach may represent a valid alternative to surgery in this group of people. Owing to the dearth of current evidence in the UK setting a large, well-designed, multicentre trial is needed. STUDY REGISTRATION: The study was registered as PROSPERO CRD42012002817. FUNDING: The National Institute for Health Research Health Technology Assessment programme.
Asunto(s)
Colecistectomía , Colecistitis/cirugía , Cálculos Biliares/cirugía , Espera Vigilante , Adulto , Colecistectomía/economía , Colecistitis/economía , Colecistitis/prevención & control , Colecistitis/terapia , Análisis Costo-Beneficio , Femenino , Cálculos Biliares/economía , Cálculos Biliares/prevención & control , Cálculos Biliares/terapia , Humanos , Masculino , Recurrencia , Resultado del TratamientoRESUMEN
In the clinical experience at a community hospital, younger patients appear to be receiving more laparoscopic cholecystectomy (LC). The purpose of this study was to determine if LC is increasing in the younger patient population and if obesity is associated with the increase in LC. Patients undergoing LC were identified from the Healthcare Cost Utilization Project Nationwide Inpatient Sample database. There were 4,449,643 LCs from 1998 to 2010. Patients 15 to 24 years of age had the largest increase in LC (3.2%) and obesity (10.8%) from 1998 to 2010. In the 15- to 24-year age group, the following variables were associated with obesity: female, white, private payer, nonteaching hospital, urban location, southern region, large hospital bed size, and 3+ Charlson group, all P < 0.05. Additionally in the 15- to 24-year age group, median length of stay (nonobese 2 days vs obese 3 days) and median cost (nonobese $19,170 vs obese $22,802) were both increased (P < 0.001). The percentage of younger people having LC is increasing with highest increases in the obese population. The obese youth also have longer length of stay with an increase in hospital cost. These results suggest a rising disease burden associated with obesity among people ages 15 to 24 years. Gallstone disease burden will likely increase with the increase in prevalence of obesity and would add to healthcare economic burden.
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Colecistectomía Laparoscópica/tendencias , Cálculos Biliares/cirugía , Obesidad/complicaciones , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Colecistectomía Laparoscópica/economía , Costo de Enfermedad , Bases de Datos Factuales , Femenino , Cálculos Biliares/economía , Cálculos Biliares/epidemiología , Cálculos Biliares/etiología , Costos de Hospital/estadística & datos numéricos , Costos de Hospital/tendencias , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Hospitalización/tendencias , Humanos , Masculino , Persona de Mediana Edad , Obesidad/economía , Estados Unidos/epidemiología , Adulto JovenRESUMEN
INTRODUCTION: Limited resources and organisational problems often result in significant waiting times for patients presenting with an indication for cholecystectomy. This study investigated the potential false economy of such practice. METHODS: Retrospective analysis of all patients on a waiting list for cholecystectomy between July 2007 and October 2010 was performed. The hospital computer document management system and patients' notes were used to collect data. RESULTS: A total of 1,021 patients were included in the study; 701 were listed from clinic and 320 were listed following an emergency admission. The median time on a waiting list before surgery was 96 days (range: 5-381 days). Eighty-seven patients (8.5%) had an emergency admission with a gallstone related problem while on a waiting list. This resulted in 488 cumulative inpatient days. There was a significant correlation between increased time spent on the waiting list and increased chance of an emergency admission (p=0.01). Patients added to the waiting list from emergency admissions were more likely to be admitted with complications than those listed from clinic (15.3% vs 5.4%, p<0.01). There was no association between age (p=0.53) or sex (p=0.23) and likelihood of emergency admission while on a waiting list. CONCLUSIONS: Prompt elective surgery and same-admission emergency laparoscopic cholecystectomy can reduce waiting list patient morbidity and is likely to save resources in the long term.
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Colecistectomía Laparoscópica/economía , Cálculos Biliares/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Colecistectomía Laparoscópica/estadística & datos numéricos , Procedimientos Quirúrgicos Electivos/economía , Tratamiento de Urgencia/economía , Femenino , Cálculos Biliares/complicaciones , Cálculos Biliares/economía , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tiempo de Tratamiento , Listas de Espera , Adulto JovenRESUMEN
INTRODUCTION: Single-incision laparoscopic cholecystectomy (SILC) is considered to be less invasive and have less morbidity than conventional laparoscopic cholecystectomy (CLC). However, there is a relative paucity of data regarding postoperative pain scores in rural Indian populations following SILC. Also, data pertaining to the applicability of SILC in rural Indian population are scant. METHODS: In the present randomized control trial, pain scores after SILC and CLC were evaluated. Sixty patients with gallstone disease were randomly assigned to one of two groups with 30 patients each: the CLC group and the SILC group. Postoperative pain scores were recorded on the visual analog scale at 8 hours, 24 hours and 7 days after surgery. RESULTS: The patients were comparable with respect to age, sex and BMI. Operative time was longer for the SILC group (47.73 ± 5.57 min vs 69.53 ± 8.96 min; P < 0.0001).The pain scores were similar in both groups at 8 hours (3.61 ± 0.41 vs 3.50 ± 0.51; P = 0.36) and 24 hours (3.30 ± 0.59 vs 3.20 ± 0.40; P = 0.44) postoperatively. On day 7, the SILC group had lower pain scores than the CLC group (2.56 ± 0.56 vs 1.16 ± 0.37; P < 0.01). CONCLUSION: There was no distinct advantage to SILC with regard to immediate postoperative pain. Pain was significantly less (P < 0.01) in the SILC group on postoperative day 7.
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Colecistectomía Laparoscópica/métodos , Cálculos Biliares/cirugía , Dolor Postoperatorio/prevención & control , Adolescente , Adulto , Anciano , Colecistectomía Laparoscópica/economía , Análisis Costo-Beneficio , Femenino , Cálculos Biliares/economía , Humanos , India , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/etiología , Estudios Prospectivos , Salud Rural , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Several randomized clinical trials have compared laparoscopic cholecystectomy (LC) and small-incision open cholecystectomy (SIOC). Most have had wide exclusion criteria and none was expertise-based. The aim of this expertise-based randomized trial was to compare healthcare costs, quality of life (QoL), pain and clinical outcomes after LC and SIOC. METHODS: Patients scheduled for cholecystectomy were randomized to treatment by one of two teams of surgeons with a preference for either LC or SIOC. Each team performed their specific method (SIOC or LC) as a first-choice operation, but converted to open cholecystectomy and common bile duct exploration when necessary. Intraoperative cholangiography was carried out routinely. The intention was to include all patients undergoing cholecystectomy, including emergency operations and procedures involving surgical training for residents. RESULTS: Some 74·9 per cent of all patients undergoing cholecystectomy were included. Of 355 patients randomized, 333 were analysed. Self-estimated QoL scores in 258 patients, analysed by the area under the curve method, were significantly lower in the SIOC group at 1 month after surgery: median 2326 (95 per cent confidence interval 2187 to 2391) compared with 2411 (2334 to 2502) for the LC group (P = 0·030). The mean(s.d.) duration of operation was shorter for SIOC: 97(41) versus 120(48) min (P < 0·001). There were no significant differences between the groups in conversion rate, pain, complications, length of hospital stay or readmissions. CONCLUSION: SIOC had comparable surgical results but slightly worse short-term QoL compared with LC. REGISTRATION NUMBER: NCT00370344 (http://www.clinicaltrials.gov).