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1.
World Neurosurg ; 133: e592-e599, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31568900

RESUMO

BACKGROUND: More than 120,000 anterior cervical discectomy and fusions (ACDFs) are performed annually. Pseudarthrosis is a potential delayed adverse event that affects up to 33% of patients. The degree to which this adverse event affects both patient quality-of-life (QOL) outcomes and health care costs is poorly understood. METHODS: Patients who underwent revision surgery for pseudarthrosis between 2007 and 2012 were identified and matched to controls not experiencing pseudarthrosis in a 1:2 fashion (case/control). Cases and controls were compared regarding total health care costs incurred in the year after the index ACDF and QOL outcomes on the following metrics: EuroQol Five-Dimensions Questionnaire, Patient Health Questionnaire-9, and Pain Disability Questionnaire. RESULTS: Of 738 patients who underwent ACDF, 11 underwent surgery for pseudarthrosis. No differences were noted between cases and controls regarding any of the matched variables. Patients in the pseudarthrosis cohort had poorer postoperative scores on the EuroQol Five-Dimensions Questionnaire mobility, usual activities, pain/discomfort, and quality-adjusted life-year dimensions. In addition, 64% of patients with pseudarthrosis had worsened quality-adjusted life-year scores compared with only 9% of controls (P < 0.01). Patients with pseudarthrosis also had poorer mental health (P < 0.01) and pain disability outcomes (P < 0.01) than did controls. Pseudarthrosis was associated with significant increases in direct costs, direct postoperative costs, and total costs (all P < 0.01). CONCLUSIONS: This is the first study to characterize the effect of surgical revision for pseudarthrosis on both QOL outcomes and care costs after ACDF. Patients requiring revision experienced significantly poorer QOL outcomes and higher care costs relative to controls.


Assuntos
Discotomia/efeitos adversos , Pseudoartrose/cirurgia , Qualidade de Vida , Fusão Vertebral/efeitos adversos , Adulto , Idoso , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Pseudoartrose/economia , Pseudoartrose/etiologia , Reoperação/economia
2.
Br J Anaesth ; 124(1): 73-83, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31860444

RESUMO

BACKGROUND: Socioeconomic circumstances can influence access to healthcare, the standard of care provided, and a variety of outcomes. This study aimed to determine the association between crude and risk-adjusted 30-day mortality and socioeconomic group after emergency laparotomy, measure differences in meeting relevant perioperative standards of care, and investigate whether variation in hospital structure or process could explain any difference in mortality between socioeconomic groups. METHODS: This was an observational study of 58 790 patients, with data prospectively collected for the National Emergency Laparotomy Audit in 178 National Health Service hospitals in England between December 1, 2013 and November 31, 2016, linked with national administrative databases. The socioeconomic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence. RESULTS: Overall, the crude 30-day mortality was 10.3%, with differences between the most-deprived (11.2%) and least-deprived (9.8%) quintiles (P<0.001). The more-deprived patients were more likely to have multiple comorbidities, were more acutely unwell at the time of surgery, and required a more-urgent surgery. After risk adjustment, the patients in the most-deprived quintile were at significantly higher risk of death compared with all other quintiles (adjusted odds ratio [95% confidence interval]: Q1 [most deprived]: reference; Q2: 0.83 [0.76-0.92]; Q3: 0.84 [0.76-0.92]; Q4: 0.87 [0.79-0.96]; Q5 [least deprived]: 0.77 [0.70-0.86]). We found no evidence that differences in hospital-level structure or patient-level performance in standards of care explained this association. CONCLUSIONS: More-deprived patients have higher crude and risk-adjusted 30-day mortality after emergency laparotomy, but this is not explained by differences in the standards of care recorded within the National Emergency Laparotomy Audit.


Assuntos
Serviços Médicos de Emergência , Laparotomia/mortalidade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Fatores Socioeconômicos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Inglaterra/epidemiologia , Feminino , Hospitais/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/economia , Assistência Perioperatória/normas , Pobreza , Risco Ajustado , Medicina Estatal , Adulto Jovem
3.
J Surg Res ; 245: 207-211, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31421364

RESUMO

BACKGROUND: Males and females are known to have varied responses to medical interventions. Our study aimed to determine the effect of sex on surgical outcomes after pyloromyotomy. MATERIALS AND METHODS: Using the Kids' Inpatient Database for the years 2003-2012, we performed a serial, cross-sectional analysis of a nationally representative sample of all patients aged <1 y who underwent pyloromyotomy for hypertrophic pyloric stenosis. The primary predictor of interest was sex. Outcomes included mortality, in-hospital complications, cost, and length of stay. Regression models were adjusted by race, age group, comorbidity, complications, and whether operation was performed on the day of admission with region and year fixed effects. RESULTS: Of 48,834 weighted operations, 81.8% were in males and 18.2% were in females. The most common reported race was white (47.3%) and most of the patients were ≥29 days old (72.5%). There was no difference in the odds of postoperative complications, but females had a significantly longer length of stay (incidence rate ratio, 1.28; 95% confidence interval [95% CI], 1.18-1.39; P ≤ 0.01), higher cost (5%, 95% CI, 1.02-1.08; P ≤ 0.01), and higher odds of mortality (odds ratio, 3.26; 95% CI, 1.52-6.98; P ≤ 0.01). CONCLUSIONS: Our study demonstrated that females had worse outcomes after pyloromyotomy compared with males. These findings are striking and are important to consider when treating either sex to help set physician and family expectations perioperatively. Further studies are needed to determine why such differences exist and to develop targeted treatment strategies for both females and males with pyloric stenosis.


Assuntos
Disparidades nos Níveis de Saúde , Complicações Pós-Operatórias/epidemiologia , Estenose Pilórica Hipertrófica/cirurgia , Piloromiotomia/efeitos adversos , Estudos Transversais , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Custos Hospitalares/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Tempo de Internação/estatística & dados numéricos , Masculino , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Estenose Pilórica Hipertrófica/economia , Estenose Pilórica Hipertrófica/mortalidade , Estudos Retrospectivos , Fatores Sexuais
4.
J Cardiothorac Surg ; 14(1): 192, 2019 Nov 08.
Artigo em Inglês | MEDLINE | ID: mdl-31703606

RESUMO

BACKGROUND: Chest tubes are routinely used to evacuate shed mediastinal blood in the critical care setting in the early hours after heart surgery. Inadequate evacuation of shed mediastinal blood due to chest tube clogging may result in retained blood around the heart and lungs after cardiac surgery. The objective of this study was to compare if active chest tube clearance reduces the incidence of retained blood complications and associated hospital resource utilization after cardiac surgery. METHODS: Propensity matched analysis of 697 consecutive patients who underwent cardiac surgery at a single center. 302 patients served as a baseline control (Phase 0), 58 patients in a training and compliance verification period (Phase 1) and 337 were treated prospectively using active tube clearance (Phase 2). The need to drain retained blood, pleural effusions, postoperative atrial fibrillation, ICU resource utilization and hospital costs were assessed. RESULTS: Propensity matched patients in Phase 2 had a reduced need for drainage procedures for pleural effusions (22% vs. 8.1%, p < 0.001) and reduced postoperative atrial fibrillation (37 to 25%, P = 0.011). This corresponded with fewer hours in the ICU (43.5 [24-79] vs 30 [24-49], p = < 0.001), reduced median postoperative length of stay (6 [4-8] vs 5 [4-6.25], p < 0.001) median costs reduced by $1831.45 (- 3580.52;82.38, p = 0.04) and the mean costs reduced by an average of $2696 (- 6027.59;880.93, 0.116). CONCLUSIONS: This evidence supports the concept that efforts to actively maintain chest tube patency in early recovery is useful in improving outcomes and reducing resource utilization and costs after cardiac surgery. TRIAL REGISTRATION: Clinicaltrial.gov, NCT02145858, Registered: May 23, 2014.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Tubos Torácicos , Drenagem/métodos , Custos Hospitalares/estatística & dados numéricos , Complicações Pós-Operatórias/prevenção & controle , Idoso , Drenagem/economia , Drenagem/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , New Hampshire , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Pontuação de Propensão , Estudos Prospectivos , Estudos Retrospectivos , Resultado do Tratamento
5.
Am Surg ; 85(9): 949-955, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31638505

RESUMO

Regionalizing surgical care to high-volume centers has improved outcomes for endocrine surgery. This shift is associated with increased travel time, costs, and morbidity within certain patient populations. We examined travel time-related differences in demographics, health-care utilization, thyroid-specific disease, and cost for patients undergoing thyroid surgery at a single high-volume center. Data were extracted from the 2005 to 2014 ACS-NSQIP and clinical data repository for patients undergoing thyroid surgery. Travel times between patients' home address and the hospital were calculated using Google Earth under assumptions of standard road conditions and speed restrictions. Travel time was divided into <2 hours versus ≥2 hours. Primary outcomes were hospital cost and 30-day morbidity. Factors associated with travel time and primary outcomes were analyzed using appropriate bivariate tests and multivariable regression modeling. A total of 1046 thyroid procedures were included, with median (IQR) travel time of 68.8 (40.1-107.2) minutes. Eight hundred forty-seven (80.9%) patients traveled <2 hours compared with 199 (19.1%) traveled ≥2 hours. Patients traveling ≥2 hours were more likely to have complex thyroid disease (37.7% vs 27.6%, P = 0.005), uninsured status (31.1% vs 11.8%, P < 0.001), lower preoperative morbidity risk (2.3% vs 2.7%, P = 0.02), and longer length of stay (1.21 vs 1.07 days, P = 0.04), but similar median operative times (163 vs 165 minutes, P = 0.89). Average cost was higher for patients traveling ≥2 hours ($7300 vs $6846 [2014 USD], P = 0.05). Despite observed patient differences, hospital costs and postoperative morbidity did not differ after adjustment. Existing management practices and the nature of the disease process may be protective against the potential negative effects of regionalization.


Assuntos
Custos Hospitalares , Hospitais com Alto Volume de Atendimentos , Aceitação pelo Paciente de Cuidados de Saúde , Complicações Pós-Operatórias , Doenças da Glândula Tireoide/economia , Doenças da Glândula Tireoide/cirurgia , Viagem , Adulto , Feminino , Humanos , Tempo de Internação/economia , Masculino , Pessoas sem Cobertura de Seguro de Saúde , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/economia , Centros de Atenção Terciária , Fatores de Tempo , Virginia
6.
Am Surg ; 85(9): 1044-1050, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31638522

RESUMO

Enhanced recovery after surgery (ERAS) may improve patients' postoperative course. Our center implemented the ERAS protocol for the colorectal service in 2016, and then expanded to multiple service lines over the course of 1.5 years. Our aim was to determine whether broad implementation of ERAS protocols across different service lines could improve patient care. All ERAS patients from 2018 were captured prospectively. For each service line using ERAS, one full year of data preceding ERAS was compared. ERAS service lines included colorectal, gynecology laparoscopic, gynecology open, hepatopancreaticobiliary, urology - nephrectomy and cystectomy, spinal fusion, cardiac surgery-coronary artery bypass grafting. ERAS and pre-ERAS services were compared based on length of stay (LOS), complications, readmission, and mortality rates. In addition, hospital costs were collected during this time frame. ERAS protocols significantly decreased LOS for colorectal, gynecology, and spine. Complications were significantly decreased in colorectal, gynecology, urology, and spine. Readmissions did not significantly increase in any service line except spine. There was no significant change in mortality. ERAS proved to save the hospital 1847 days and cost saving of almost $5 million in 2018. Implementing ERAS broadly improved patient outcomes (LOS, complications, readmission, and mortality) while providing cost savings to the hospital.


Assuntos
Protocolos Clínicos , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/normas , Custos Hospitalares , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/normas , Melhoria de Qualidade , Mortalidade Hospitalar , Humanos , Tempo de Internação/economia , Readmissão do Paciente/economia , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/prevenção & controle
7.
J Laparoendosc Adv Surg Tech A ; 29(11): 1436-1445, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31556797

RESUMO

Introduction: Major colorectal surgery procedures are complex operations that can result in significant postoperative pain and complications. More evidence is needed to demonstrate how opioid-related adverse drug events (ORADEs) after colorectal surgery can affect hospital length of stay (LOS), hospital revenue, and what their association is with clinical conditions. By understanding the clinical and economic impact of potential ORADEs within colorectal surgery, we hope to further guide approaches to perioperative pain management in an effort to improve patient care and reduce hospital costs. Materials and Methods: We conducted a retrospective study utilizing the Centers for Medicare and Medicaid Services (CMS) Administrative Database to analyze Medicare discharges involving three colorectal surgery diagnosis-related groups (DRGs) to identify potential ORADEs. The impact of potential ORADEs on mean hospital LOS and hospital revenue was analyzed. Results: The potential ORADE rate in patients undergoing colorectal surgery was 23.92%. The mean LOS for discharges with a potential ORADE was 5.35 days longer than without an ORADE. The mean hospital revenue per day with a potential ORADE was $418 less than without an ORADE. Any type of open surgery had a statistically significant higher potential ORADE rate than the matched laparoscopic case (P < .001). Clinical conditions most strongly associated with ORADEs in colorectal surgery included septicemia, pneumonia, shock, and fluid and electrolyte disorders. Conclusion: The incidence of ORADEs in colorectal surgery is high and is associated with longer hospital stays and reduced hospital revenue. Reducing the use of opioids in the perioperative setting, such as using multimodal analgesia strategies, may lead to positive outcomes with shorter hospital stays, increased hospital revenue, and improved patient care.


Assuntos
Analgésicos Opioides/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Custos Hospitalares , Laparoscopia/estatística & dados numéricos , Tempo de Internação , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Colo/cirurgia , Bases de Dados Factuais , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/economia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Feminino , Humanos , Incidência , Laparoscopia/efeitos adversos , Laparoscopia/economia , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Pneumonia/epidemiologia , Complicações Pós-Operatórias/economia , Reto/cirurgia , Estudos Retrospectivos , Sepse/epidemiologia , Choque/epidemiologia , Resultado do Tratamento , Estados Unidos/epidemiologia , Desequilíbrio Hidroeletrolítico/epidemiologia
8.
Urology ; 134: 109-115, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31487509

RESUMO

OBJECTIVE: To examine the potential of LACE+ scores, in patients undergoing urologic surgery, to predict short-term undesirable outcomes. METHODS: Coarsened exact matching was used to assess the predictive value of the LACE+ index among all urologic surgery cases over a 2-year period (2016-2018) at 1 health system (n = 9824). Study subjects were matched on characteristics not assessed by LACE+, including duration of surgery and race, among others. For comparison of outcomes, matched populations were compared by LACE+ quartile with Q4 as the referent group: Q4 vs Q1, Q4 vs Q2, Q4 vs Q3. RESULTS: Seven hundred and twenty-two patients were matched for Q1-Q4; 1120 patients were matched for Q2-Q4; 2550 patients were matched for Q3-Q4. Escalating LACE+ score significantly predicted increased readmission (2.86% vs 4.91% for Q2 vs Q4; P = .012) and Emergency Room (ER) visits at 30 days postop (5.69% vs 11.37% for Q1 vs Q4, 4.11% vs 11.45% for Q2 vs Q4, 8.29% vs 13.32% for Q3 vs Q4; P <.001 for all). Increasing LACE score did not predict reoperation within 30 days or rate of death over follow-up within 30 postoperative days. CONCLUSION: The results of this study suggest that the LACE+ index is suitable as a prediction model for important patient outcomes in a urologic surgery population including unanticipated readmission and ER evaluation.


Assuntos
Serviço Hospitalar de Emergência , Readmissão do Paciente , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Urológicos , Adulto , Idoso , Continuidade da Assistência ao Paciente/normas , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Sobremedicalização/prevenção & controle , Pessoa de Meia-Idade , Duração da Cirurgia , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Prognóstico , Reoperação/estatística & dados numéricos , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Procedimentos Cirúrgicos Urológicos/estatística & dados numéricos
9.
J Shoulder Elbow Surg ; 28(11): 2090-2097, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31451349

RESUMO

PURPOSE: The purpose of this study was to compare clinical outcome and cost-effectiveness between arthroscopic and open repair using TightRope in acromioclavicular joint dislocation III and IV. PATIENTS AND METHODS: Fifty-two patients with acute acromioclavicular joint dislocation type III and IV were included. Patients were randomly allocated to either of 2 groups: Arthroscopic Repair Group (ARG) and Open Repair Group (ORG). Constant-Murley Score (CMS), visual analog scale (VAS) score, and coracoclavicular (CC) distance were measured preoperatively and 3 months, 6 months, 1 year, and 2 years postoperatively. RESULTS: CMS increased from 40.68 for the ARG and 40.70 for the ORG preoperatively to 84.18 and 84.45 after 2 years from operation. VAS score decreased from 60.59 for the ARG and 64.50 for the ORG 1 day after surgery to 18.04 and 17.87 respectively after 6 months. CC distance decreased from 29.27 mm in the ARG and 28.16 mm in the ORG preoperatively to 9.86 mm in the ARG and 10.54 mm in the ORG on postoperative day 1. Rewidening of the CC distance occurred after 6 months (13.27 mm for the ARG and 13.62 mm for the ORG) and 1 year postoperatively (15.77 for the ARG and 15.41 for the ORG) but remained stable at final follow-up. There was a significant difference in surgical time (80.00 minutes in the ARG compared to 52.79 minutes in the ORG) and cost of consumables (US$1729.95 in the ARG compared to US$851.87 in the ORG). CONCLUSION: Open and arthroscopic repair of acute acromioclavicular joint dislocation yielded good clinical results, yet the arthroscopic technique is more expensive and has a longer surgical time.


Assuntos
Articulação Acromioclavicular , Artroscopia/economia , Luxações Articulares/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adulto , Análise Custo-Benefício , Feminino , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/economia , Resultado do Tratamento , Adulto Jovem
10.
World Neurosurg ; 131: e447-e453, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31415887

RESUMO

BACKGROUND: Lumbar fusions are routinely performed by either orthopedic or neurologic spine surgeons. Controversy still exists as to whether a provider's specialty (orthopedic vs. neurosurgery) influences outcomes. METHODS: The 2007-2015Q2 Humana Commercial Database was queried using Current Procedural Terminology codes (22612, 22614, 22630, 22632, 22633 and 22634) to identify patients undergoing elective 1-to-2 level posterior lumbar fusions (PLFs) with active enrollment up to 90 days after procedure. Ninety-day complication rates were calculated for the 2 specialties. The surgical and 90-day resource utilization costs for the 2 groups were compared, by studying average reimbursements for acute-care and post-acute-care categories. Ninety-day complications and costs were compared using multivariable logistic and linear regression analyses. RESULTS: A total of 10,509 patients (5523 orthopedic and 4986 neurosurgery) underwent an elective 1-to-2 level PLF during the period. With the exception of a significantly lower odds of wound complications (odds ratio, 0.81) and a higher odds of dural tears (odds ratio, 1.29) in elective PLFs performed by orthopedic surgeons, no statistically strong differences were seen in 90-day complication rates between the 2 groups. Total 90-day costs were also similar between orthopedic surgeons and neurosurgeons, with the only exception being that surgeon reimbursement was lower for orthopedic surgery versus neurosurgery ($1202 vs. $1372; P < 0.001). CONCLUSIONS: It seems that a provider's specialty does not largely influence 90-day surgical outcomes and costs after elective PLFs. The results of the study promote the formation and acceptance of dual training pathways for entry into spine surgery.


Assuntos
Custos de Cuidados de Saúde , Vértebras Lombares/cirurgia , Neurocirurgiões , Cirurgiões Ortopédicos , Complicações Pós-Operatórias/epidemiologia , Fusão Vertebral/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Dura-Máter/lesões , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Humanos , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/economia , Fusão Vertebral/economia , Infecção da Ferida Cirúrgica/economia , Infecção da Ferida Cirúrgica/epidemiologia
11.
World Neurosurg ; 131: e579-e585, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31404690

RESUMO

BACKGROUND: Spinal arteriovenous malformations (AVM) are an abnormal interconnection of vasculature in the spine than can lead to significant neurologic deficit if left untreated. OBJECTIVE: The objective of this study was to characterize how patients with spinal AVM initially presented, what treatment options were used, and their overall outcomes on a national scale. METHODS: The MarketScan database was queried to identify adult patients diagnosed with a spinal AVM from 2007 to 2015. Trends in management, postoperative complication rates, and costs were determined. RESULTS: In total, 976 patients were identified with having a diagnosis of a spinal AVM. Patients were more commonly treated with an open incision than an embolization (40.1% vs. 15.4%). The overall complication rate was 33.61%. Spinal AVM admissions have been stable over the past decade, and mean cost of hospitalization has risen from of $48,700 in 2007 to $71,292 in 2015. Patients who underwent open surgery had a greater complication rate than those treated with embolization (31.15% vs. 18.25%, P < 0.005); however, this may be strongly influenced by complexity of spinal AVM pathology and not treatment modality. CONCLUSIONS: Costs of spinal AVM management continue to rise, even when treatment modalities have reduced length of stay significantly. Open surgery may lead to more postoperative complications and a greater length of stay than endovascular approaches. Further studies should look to identify the efficacy of endovascular approaches for spinal cord AVMs, particularly in complex spinal AVM traditionally treated with open surgery and to isolate factors leading to the elevated hospitalization costs.


Assuntos
Malformações Arteriovenosas/terapia , Embolização Terapêutica/métodos , Procedimentos Neurocirúrgicos/métodos , Complicações Pós-Operatórias/epidemiologia , Medula Espinal/irrigação sanguínea , Adulto , Idoso , Malformações Arteriovenosas/economia , Malformações Arteriovenosas/epidemiologia , Embolização Terapêutica/economia , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/economia , Complicações Pós-Operatórias/economia , Estados Unidos/epidemiologia
12.
World Neurosurg ; 131: e468-e473, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31404695

RESUMO

BACKGROUND: The landmark Patchell trial established surgical decompression followed by adjuvant radiotherapy as standard-of-care for patients with spinal cord compression caused by metastatic cancer. However, little comparative evidence exists with regard to the choice of specific surgical approaches for these patients. We sought to conduct a comparative analysis of outcomes of surgical options for spinal metastatic disease. METHODS: This was an epidemiologic study using national administrative data from the MarketScan database. We queried the MarketScan database (2007-2016), identifying patients with a diagnosis of spinal metastasis treated with surgical decompression (N = 1054). We used descriptive statistics and hypothesis testing to compare baseline characteristics, complications, quality metrics, and costs. RESULTS: We identified patients with spinal metastases undergoing laminectomy (N = 760), corpectomy (N = 193), or both combined procedures (laminectomy and corpectomy, N = 101). No significant differences in baseline demographics, follow-up time, or primary tumor histology were observed. We found a greater 30-day postoperative complication rate among patients undergoing corpectomy (P < 0.0001), driven by increased rate of postoperative anemia and pulmonary complications. Length of stay and 30-day readmission rates did not vary between surgical approaches. Total index hospitalization and 30-day payments were greatest among patients undergoing combined procedures and lowest for patients undergoing laminectomy alone. CONCLUSIONS: Our findings highlight distinct complication profiles and quality outcomes associated with selection of surgical approach for patients with spinal metastases. These findings must be interpreted with a clear understanding of the limitations.


Assuntos
Descompressão Cirúrgica/métodos , Laminectomia/métodos , Compressão da Medula Espinal/cirurgia , Neoplasias da Coluna Vertebral/cirurgia , Adulto , Descompressão Cirúrgica/economia , Feminino , Custos de Cuidados de Saúde , Humanos , Laminectomia/economia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Compressão da Medula Espinal/etiologia , Neoplasias da Coluna Vertebral/complicações , Neoplasias da Coluna Vertebral/secundário
13.
World Neurosurg ; 131: e116-e127, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31323403

RESUMO

BACKGROUND: The aim of our study was to compare the health care utilization and outcomes after surgery for anterior cranial fossa skull base meningioma (AFM), middle cranial fossa skull base meningioma (MFM), and posterior cranial fossa skull base meningioma (PFM) across the United States. METHODS: We queried the MarketScan database using International Classification of Diseases, Ninth Revision and Current Procedural Terminology 4, from 2000 to 2016. We included adult patients who had at least 24 months of enrollment after the surgical procedure. The outcome of interest was length of hospital stay, disposition, complications, and reoperation after the procedure. RESULTS: A cohort of 1191 patients was identified from the database. Less than half of patients (43.66%) were in the AFM cohort, 32.24% were in the MFM cohort, and only 24.1% were in the PFM cohort. Patients who underwent surgery for PFM had longer hospital stay (P = 0.0009), high complication rate (P = 0.0011), and less likely to be discharged home (P = 0.0013) during index hospitalization. There were no differences in overall payments at 12 months and 24 months among the cohorts. There was no significant difference in 90-day median payments among the groups ($66,212 [AFM] vs. $65,602 [MFM] and $71,837 [PFM]; P = 0.198). Male gender, commercial insurance (compared with Medicare), and higher comorbidity scores (score 3 compared with score 0) were associated with higher 90-day payments in the PFM cohort. CONCLUSIONS: Overall payments (at 12 months and 24 months) and 90-day payments were not different among the cohorts. Patients with PFM had longer hospital stay and higher complication rate and were less likely to be discharged home with higher utilization of outpatient services at 12 months and 24 months.


Assuntos
Utilização de Instalações e Serviços/economia , Tempo de Internação/estatística & dados numéricos , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Procedimentos Neurocirúrgicos/economia , Complicações Pós-Operatórias/epidemiologia , Mecanismo de Reembolso , Neoplasias da Base do Crânio/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Fossa Craniana Anterior , Fossa Craniana Média , Fossa Craniana Posterior , Estudos de Viabilidade , Feminino , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde , Complicações Pós-Operatórias/economia , Reoperação/economia , Estados Unidos , Adulto Jovem
14.
World Neurosurg ; 130: e535-e541, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31279112

RESUMO

OBJECTIVE: To understand cost distribution in a 90-day episode of care following posterior spinal fusions (PSFs) for adolescent idiopathic scoliosis (AIS). METHODS: The 2007-2016 Humana PearlDiver dataset was queried using Current Procedural Terminology codes (22800, 22802, 22804, 22842, 22843, and 22844) to identify patients with AIS, aged 10-19 years, receiving PSFs. The following categories were used to define distribution in 90-day costs: 1) facility costs, 2) surgeon costs, 3) anesthesia costs, 4) intraoperative neuromonitoring, 5) hospital services and investigations, 6) intensive care unit stay, 7) radiology, 8) physical therapy/rehabilitation, 9) office visits, and 10) readmissions. RESULTS: A total of 455 patients with AIS received PSFs, of whom 381 (83.7%) were commercial insurance beneficiaries and 74 (16.3%) were Medicaid beneficiaries. The overall average 90-day cost of surgery was $124,360 with the 90-day stipulated bundled prices being $136,302 and $62,871 for commercial and Medicaid beneficiaries, respectively. Facility costs comprised 85%-92% of the 90-day cost, followed by surgeon costs (5.2%-5.7%). Post-acute care (physical therapy/rehab and office visits) was not a major driver of the 90-day cost (0.2%-0.3%). Significant independent predictors of increased 90-day costs were-increased co-morbidity burden (+$11,284), ≥7 levels fusion (+$65,330), and length of stay (+$5298/day). Medicaid (-$81,957) payer type was associated with lower 90-day costs. CONCLUSIONS: Facility costs are a major determinant of overall 90-day costs following PSFs in AIS. Providers should aim at optimizing the co-morbidity burden and constructing accelerated care-pathways to decrease the length of stay and reduce the cost of the entire episode of care.


Assuntos
Custos de Cuidados de Saúde , Tempo de Internação/economia , Complicações Pós-Operatórias/economia , Escoliose/cirurgia , Fusão Vertebral/economia , Adolescente , Criança , Cuidado Periódico , Feminino , Humanos , Masculino , Estudos Retrospectivos , Escoliose/economia , Fusão Vertebral/métodos , Adulto Jovem
15.
Medicine (Baltimore) ; 98(27): e16054, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31277099

RESUMO

The aim of the study was to determine the financial burden of complications and examine the cost differentials between complicated and uncomplicated hospital stays, including the differences in cost due to extent of resection and operative technique.Liver resection carries a high financial cost. Despite improvements in perioperative care, postoperative morbidity remains high. The contribution of postoperative complications to the cost of liver resection is poorly quantified, and there is little data to help guide cost containment strategies.Complications for 317 consecutive adult patients undergoing liver resection were recorded using the Clavien-Dindo classification. Patients were stratified based on the grade of their worst complication to assess the contribution of morbidity to resource use of specific cost centers. Costs were calculated using an activity-based costing methodology.Complications dramatically increased median hospital cost ($22,954 vs $15,593, P < .001). Major resection cost over $10,000 more than minor resection and carried greater morbidity (82% vs 59%, P < .001). Similarly, open resection cost more than laparoscopic resection ($21,548 vs $15,235, P < .001) and carried higher rates of complications (72% vs 41.5%, P < .001). Hospital cost increased with increasing incidence and severity of complications. Complications increased costs across all cost centers. Minor complications (Clavien-Dindo Grade I and II) were shown to significantly increase costs compared with uncomplicated patients.Liver resection continues to carry a high incidence of complications, and these result in a substantial financial burden. Hospital cost and length of stay increase with greater severity and number of complications. Our findings provide an in-depth analysis by stratifying total costs by cost centers, therefore guiding future economic studies and strategies aimed at cost containment for liver resection.


Assuntos
Hepatectomia/economia , Custos Hospitalares/estatística & dados numéricos , Tempo de Internação/economia , Complicações Pós-Operatórias/economia , Análise Custo-Benefício , Feminino , Hepatectomia/efeitos adversos , Hepatectomia/classificação , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/classificação , Período Pós-Operatório , Estudos Retrospectivos , Estatísticas não Paramétricas
16.
Chirurg ; 90(12): 1011-1018, 2019 Dec.
Artigo em Alemão | MEDLINE | ID: mdl-31359111

RESUMO

INTRODUCTION: Elective and emergency inguinal hernia surgery is a central task for general and abdominal surgeons. As a standard procedure it is regarded as having a relatively low income in the German diagnosis-related groups (DRG) system. This can lead to an economic imbalance, especially in a cost-intensive environment of a university hospital. The aim of this analysis was to investigate the influence of clinical factors on costs and the contribution margin as well as the overall economic evaluation of elective inguinal hernia surgery at a university hospital. MATERIAL AND METHODS: All patients undergoing elective inguinal hernia surgery at two locations of the Charité University Medicine Berlin in 2014 and 2015 were included in the analysis. The influence of clinical, patient and surgical factors on the economic outcome of the cases was evaluated. RESULTS: A total of 419 patients were included, mostly after a Lichtenstein operation (44.9%) and laparoscopic transabdominal preperitoneal (TAPP) surgery (53.9%). The greatest impact on the economic outcome was the occurrence of postoperative complications. Also, a patient clinical complexity level (PCCL) value of >1, more than 8 encoded secondary diagnoses and a duration of hospital stay of less than 2 days had a significantly negative impact on the contribution margin. Overall, elective inguinal hernia surgery led to a negative contribution margin of €â€¯651 per case. CONCLUSION: Elective inguinal hernia surgery in the environment of a university hospital has a high financial deficit; however, since a complete discontinuation of this treatment is not an alternative multifactorial approaches are required to improve the economic outcome.


Assuntos
Hérnia Inguinal , Laparoscopia , Complicações Pós-Operatórias/economia , Berlim , Análise Custo-Benefício , Hérnia Inguinal/economia , Hérnia Inguinal/cirurgia , Herniorrafia , Humanos , Recidiva , Telas Cirúrgicas , Resultado do Tratamento
17.
Spine (Phila Pa 1976) ; 44(13): 959-966, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31205177

RESUMO

STUDY DESIGN: The enhanced perioperative care (EPOC) program is an institutional quality improvement initiative. We used a historically controlled study design to evaluate patients who underwent major spine surgery before and after the implementation of the EPOC program. OBJECTIVE: To determine whether multidisciplinary EPOC program was associated with an improvement in clinical and financial outcomes for elective adult major spine surgery patients. SUMMARY OF BACKGROUND DATA: The enhanced recovery after surgery (ERAS) programs successfully implemented in hip and knee replacement surgeries, and improved clinical outcomes and patient satisfaction. METHODS: We compared 183 subjects in traditional care (TRDC) group to 267 intervention period (EPOC) in a single academic quaternary spine surgery referral center. One hundred eight subjects in no pathway (NOPW) care group was also examined to exclude if the observed changes between the EPOC and TRDC groups might be due to concurrent changes in practice or population over the same time period. Our primary outcome variables were hospital and intensive care unit lengths of stay and the secondary outcomes were postoperative complications, 30-day hospital readmission and cost. RESULTS: In this highly complex patient population, we observed a reduction in mean hospital length of stay (HLOS) between TRDC versus EPOC groups (8.2 vs. 6.1 d, standard deviation [SD] = 6.3 vs. 3.6, P < 0.001) and intensive care unit length of stay (ILOS) (3.1 vs. 1.9 d, SD = 4.7 vs. 1.4, P = 0.01). The number (rate) of postoperative intensive care unit (ICU) admissions was higher for the TRDC n = 109 (60%) than the EPOC n = 129 (48%) (P = 0.02). There was no difference in postoperative complications and 30-day hospital readmissions. The EPOC spine program was associated with significant average cost reduction-$62,429 to $53,355 (P < 0.00). CONCLUSION: The EPOC program has made a clinically relevant contribution to institutional efforts to improve patient outcomes and value. We observed a reduction in HLOS, ILOS, costs, and variability. LEVEL OF EVIDENCE: 3.


Assuntos
Procedimentos Neurocirúrgicos/normas , Assistência Perioperatória/normas , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/normas , Feminino , Humanos , Tempo de Internação/economia , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/economia , Procedimentos Neurocirúrgicos/métodos , Readmissão do Paciente/economia , Readmissão do Paciente/tendências , Satisfação do Paciente , Assistência Perioperatória/economia , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/economia , Melhoria de Qualidade/normas , Resultado do Tratamento
18.
Medicine (Baltimore) ; 98(24): e16111, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31192974

RESUMO

Infected necrotizing pancreatitis (INP), the leading cause of mortality in the late phase of acute pancreatitis, nearly always requires intervention. In recent years minimal invasive surgery is becoming more and more popular for the management of INP, but few studies compared different minimally invasive strategies. The objective of this observation study was to evaluate the safety and effectiveness with several minimal invasive treatment.We retrospectively reviewed cases of percutaneous catheter drainage (PCD), minimal access retroperitoneal pancreatic necrosectomy (MARPN), small incision pancreatic necrosectom (SIPN), single-incision access port retroperitoneoscopic debridement (SIAPRD) for INP between January 2013 and October 2018. Data were analyzed for the primary endpoints as well as secondary endpoints.Eighty-one patients with INP were treated by minimally invasive procedures including PCD (n = 32), MARPN (n = 18), SIPN (n = 16), and SIAPRD (n = 15). Overall mortality was greatest after PCD 34% (MARPN 11% vs SIPN 6% vs SIRLD6%). Problems after initial surgery were ongoing sepsis (PCD 56% vs MARPN 50% vs SIPN 31% vs SIAPRD13%; P < .05). There was a significant difference in number of interventions (median, 6 vs 5 vs 3 vs 2; P < .05). Time from onset of symptoms to recovery was less for SIAPRD than for PCD, MARPN, or SIPN (median, 45 vs 102 vs 80 vs 67 days; P < .05).SIAPRD remedy evidently improved outcomes, including systemic inflammatory response syndrome, number of interventions, length of hospital stay and overall cost. It is technically feasible, safe, and effective for INP, in contrast to others, and can achieve the best clinical results with the least cost. Furthermore, relevant multicentre randomized controlled trials are eager to prove these findings.


Assuntos
Procedimentos Cirúrgicos Minimamente Invasivos , Pancreatite Necrosante Aguda/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Pancreatite Necrosante Aguda/economia , Pancreatite Necrosante Aguda/epidemiologia , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
19.
Urology ; 133: 11-15, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31229516

RESUMO

Sepsis following transrectal prostate biopsy occurs in 2%-5% of cases and the risk is increasing. We performed a comprehensive literature search for the cost of post-prostate biopsy sepsis to define the potential cost savings of reducing infectious complications. Reporting of cost is varied and presents a challenge to interpretation. Length of hospitalization ranged from 1.1 to 14 days and the percent admitted to an ICU ranged from 1.1% to 25%. The estimated cost of sepsis post-prostate biopsy, adjusted for inflation, ranged from $8,672 to $19,100. Healthcare costs of treating post-biopsy infection are substantial. Our findings should guide payers and policymakers, especially in value-based care models.


Assuntos
Custos de Cuidados de Saúde , Complicações Pós-Operatórias/economia , Próstata/patologia , Sepse/economia , Biópsia , Humanos , Masculino
20.
Medicine (Baltimore) ; 98(25): e15986, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31232931

RESUMO

This study assessed the impact of intraoperative and early postoperative periprosthetic hip fractures (PPHFx) after primary total hip arthroplasty (THA) on health care resource utilization and costs in the Medicare population.This retrospective observational cohort study used health care claims from the United States Centers for Medicare and Medicaid Standard Analytic File (100%) sample. Patients aged 65+ with primary THA between 2010 and 2016 were identified and divided into 3 groups - patients with intraoperative PPHFx, patients with postoperative PPHFx within 90 days of THA, and patients without PPHFx. A multi-level matching technique, using direct and propensity score matching was used. The proportion of patients admitted at least once to skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), and readmission during the 0 to 90 or 0 to 365 day period after THA as well as the total all-cause payments during those periods were compared between patients in PPHFx groups and patients without PPHFx.After dual matching, a total 4460 patients for intraoperative and 2658 patients for postoperative PPHFx analyses were included. Utilization of any 90-day post-acute services was statistically significantly higher among patients in both PPHFx groups versus those without PPHFx: for intraoperative analysis, SNF (41.7% vs 30.8%), IRF (17.7% vs 10.1%), and readmissions (17.6% vs 11.5%); for postoperative analysis, SNF (64.5% vs 28.7%), IRF (22.6% vs 7.2%), and readmissions (92.8% vs 8.8%) (all P < .0001). The mean 90-day total all-cause payments were significantly higher in both intraoperative ($30,114 vs $21,229) and postoperative ($53,669 vs $ 19,817, P < .0001) PPHFx groups versus those without PPHFx. All trends were similar in the 365-day follow up.Patients with intraoperative and early postoperative PPHFx had statistically significantly higher resource utilization and payments than patients without PPHFx after primary THA. The differences observed during the 90-day follow up were continued over the 1-year period as well.


Assuntos
Artroplastia de Quadril/efeitos adversos , Revisão da Utilização de Seguros/estatística & dados numéricos , Fraturas Periprotéticas/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Custos de Cuidados de Saúde , Humanos , Revisão da Utilização de Seguros/economia , Estudos Longitudinais , Masculino , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Fraturas Periprotéticas/economia , Fraturas Periprotéticas/etiologia , Fraturas Periprotéticas/reabilitação , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/reabilitação , Estudos Retrospectivos , Estados Unidos/epidemiologia
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