Cost analysis of functional restoration surgery for extremity soft-tissue sarcoma.

BACKGROUND: Limb-sparing surgery, consisting of wide-margin tumor resection and preoperative or postoperative radiotherapy/chemotherapy, has become the surgical treatment of choice for extremity sarcomas. However, adequate tumor resection can sometimes compromise crucial limb function, necessitating functional restoration surgery. The purpose of this study was to determine the cost impact and functional outcomes of such procedures. METHODS: Patients receiving either functional restoration surgery or soft-tissue-only reconstruction following extremity soft-tissue sarcoma excision were identified. Patients were then compared along several dimensions: overall length of stay and its subdivisions, surgical time, and total charges and its subdivisions. Patients' functional outcomes were assessed with the Toronto Extremity Salvage Score. RESULTS: Sixty-seven patients who underwent 69 limb-sparing procedures were identified. Fifteen of these procedures (eight upper extremity, seven lower extremity) required functional restoration surgery; 54 of these procedures (13 upper extremity, 41 lower extremity) required only soft-tissue coverage. In the upper extremity, there was a statistically significant increase in overall length of stay (2.8 days) and its subdivisions, surgical time (3.7 hours), and total charges (12,484 dollars) and its subdivisions associated with performing functional restoration surgery. In lower extremity cases, statistically significant increases were determined in only the total charges (9190 dollars) and medical supply charges (13,204 dollars) following functional restoration. Patients who underwent functional restoration surgery had better postoperative function (mean Toronto Extremity Salvage Score, 82 versus 80), but this difference was not statistically significant. CONCLUSION: Although functional restoration surgery is more costly than soft-tissue reconstruction alone, the authors believe that the associated better functional outcome justifies its performance.

Surgical care of elderly women with ovarian cancer: a population-based perspective.

OBJECTIVE: To characterize the primary surgical care and short-term outcomes for ovarian cancer in women aged 80 years and older compared to women younger than 80 years. METHODS: A statewide hospital discharge database was used to identify women undergoing primary surgery for ovarian cancer from 1990 to 2000. Logistic regression models were used to evaluate for significant differences in demographic characteristics and short-term outcomes comparing women aged > or = 80 years with those aged <80 years. RESULTS: A total of 2417 women were identified; women aged > or = 80 years comprised 7.0% (n = 168) of cases. Compared to younger women, those aged > or = 80 years were significantly more likely to be admitted under emergent conditions (25.6% vs. 14.9%, P < 0.0003) and less likely to undergo surgery at a university hospital (6.6% vs. 18.6%, P = 0.001). Ovarian cancer patients aged > or = 80 years were significantly more likely to have a longer hospital stay (median 10 days vs. 7 days, P < 0.0001) and a higher adjusted cost of hospital related care (median dollar 76,760 vs. dollar 52,649, P < 0.0001). The 30-day mortality rate was 2.3-fold higher for women aged > or = 80 years (5.4% vs. 2.4%, P = 0.036). For women aged > or = 80 years, there was a trend toward a higher risk of peri-operative death among low-volume hospitals (8.8%) compared to high-volume hospitals (3.0%, P = 0.16). CONCLUSION: Primary surgical care for ovarian cancer in women aged > or = 80 years is associated with utilization of significant health care resources and worse short-term outcomes compared to younger women. Additional research is needed to identify opportunities for improving the cost-effectiveness of care in this population.

Ovarian cancer surgery in Maryland: volume-based access to care.

PURPOSE: To characterize the patterns of primary surgical care for ovarian cancer in a statewide population according to annual surgeon and hospital case volume. METHODS: The Maryland hospital discharge database was accessed for annual surgeon and hospital ovarian cancer case volume for the time intervals: 1990-1992, 1993-1995, 1996-98, and 1999-2000. Annual surgeon case volume was categorized as low (/=10). Annual hospital case volume was categorized as low (/=20). Logistic regression models were used to evaluate for significant trends in case volume distribution over time and factors associated with access to high-volume care. RESULTS: Overall, 2417 cases were performed by 531 surgeons at 49 hospitals. The distribution according to annual surgeon case volume was low (56.3%), intermediate (9.2%), and high (34.5%). Between 1993 and 2000, there was no significant increase in the proportion of cases performed by high-volume surgeons (OR = 1.03, 95% CI = 0.81-1.33, P = 0.79). Access to high-volume surgeons was positively associated with care at high-volume hospitals and negatively associated with residence >/=50 miles from a high-volume hospital. The overall hospital volume case distribution was low (49.6%), intermediate (27.6%), and high (22.8%). There was a statistically significant decrease in access to high-volume hospitals between 1990 and 1998 (OR = 0.39, 95% CI = 0.30-0.50, P < 0.0001). CONCLUSION: A large proportion of primary ovarian cancer surgeries are performed by low-volume surgeons at low-volume hospitals. In light of positive volume-outcomes data for malignancies treated with technically complex operative procedures, increased efforts to concentrate the surgical care of women with ovarian cancer are warranted. Condensed abstract. A large proportion of primary ovarian cancer surgeries are performed by low-volume surgeons at low-volume hospitals. In light of positive volume-outcomes data for malignancies treated with technically complex operative procedures, increased efforts to concentrate the surgical care of women with ovarian cancer are warranted.