Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 475
Filtrar
1.
Can J Surg ; 63(3): E226-E228, 2020 05 08.
Artigo em Inglês | MEDLINE | ID: mdl-32386471

RESUMO

Summary: The coronavirus disease 2019 (COVID-19) pandemic has had a massive impact on waits for elective operations, with tens of thousands of scheduled surgeries being cancelled or postponed across Canada. Provincial governments will likely not only reopen elective surgical capacity when it is deemed safe, but also target new funding to address the backlog of cases. There is a dearth of research on whether the provinces' approaches to managing wait lists are equitable from a patients' needs perspective or if they are associated with patients' perception of outcomes. The surgical cost models used in the past won't be useful to governments and hospital managers. New models based on hospitals' marginal costs, associated with running on weekends or off-hours and social distancing parameters, will be needed. Surgeon input, collaboration and leadership during the strategy development, implementation and management of surgical wait lists postpandemic will be imperative, as these decisions will significantly affect the health and lives of many Canadians.


Assuntos
Infecções por Coronavirus/epidemiologia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Acesso aos Serviços de Saúde/organização & administração , Pandemias , Pneumonia Viral/epidemiologia , Triagem/normas , Listas de Espera , Canadá/epidemiologia , Procedimentos Cirúrgicos Eletivos/economia , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/normas , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Triagem/organização & administração
2.
Am Surg ; 86(3): 256-260, 2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-32223807

RESUMO

Minimally invasive sigmoid colectomy via the laparoscopic approach (LA) has numerous benefits. We seek to compare outcomes between laparoscopic and robotic sigmoid colectomies. We analyzed the data using the National Inpatient Sample database between 2008 and 2014. Utilization and outcome measures were compared. The seven-year average number of patients who underwent elective sigmoid colectomy in the United States from 2008 to 2014 was estimated to be 197,053. Of these, 95.1 per cent were conducted using the LA. The mean age was 58.33 + 13.6 years and 58.23 + 12.8 years in laparoscopic and robotic approaches, respectively. No significant differences existed in respect to morbidities. Postoperative complications were comparable with respect to other complications. Length of hospital stay was statistically significantly shorter in the robot-assisted approach compared with the LA (mean 4.8 + 4 vs 5.7 + 5 days, respectively, P < 0.001). Patients who underwent robotic surgery had significantly higher total hospital charges than those who underwent laparoscopic surgery (median $45,057 vs $57,871 USD, P < 0.001). The advent of robot-assisted surgery has provided more options for patients and surgeons. Compared with laparoscopy, robot-assisted sigmoid colectomy has no clinical advantages in morbidity and mortality. However, the robotic approach has a significantly higher total charge to the patient.


Assuntos
Colectomia/métodos , Custos Hospitalares , Laparoscopia/métodos , Tempo de Internação/economia , Procedimentos Cirúrgicos Robóticos/economia , Adulto , Idoso , Colectomia/economia , Colo Sigmoide/cirurgia , Análise Custo-Benefício , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Seguimentos , Custos de Cuidados de Saúde , Humanos , Laparoscopia/economia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Retrospectivos , Medição de Risco , Procedimentos Cirúrgicos Robóticos/métodos , Estados Unidos
3.
JAMA ; 323(6): 538-547, 2020 02 11.
Artigo em Inglês | MEDLINE | ID: mdl-32044941

RESUMO

Importance: Privately insured patients who receive care from in-network physicians may receive unexpected out-of-network bills ("surprise bills") from out-of-network clinicians they did not choose. In elective surgery, this can occur if patients choose in-network surgeons and hospitals but receive out-of-network bills from other involved clinicians. Objective: To evaluate out-of-network billing across common elective operations performed with in-network primary surgeons and facilities. Design, Setting, and Participants: Retrospective analysis of claims data from a large US commercial insurer, representing 347 356 patients who had undergone 1 of 7 common elective operations (arthroscopic meniscal repair [116 749]; laparoscopic cholecystectomy [82 372]; hysterectomy [67 452]; total knee replacement [42 313]; breast lumpectomy [18 018]; colectomy [14 074]; coronary artery bypass graft surgery [6378]) by an in-network primary surgeon at an in-network facility between January 1, 2012, and September 30, 2017. Follow-up ended November 8, 2017. Exposure: Patient, clinician, and insurance factors potentially related to out-of-network bills. Main Outcomes and Measures: The primary outcome was the proportion of episodes with out-of-network bills. The secondary outcome was the estimated potential balance bill associated with out-of-network bills from each surgical procedure, calculated as total out-of-network charges less the typical in-network price for the same service. Results: Among 347 356 patients (mean age, 48 [SD, 11] years; 66% women) who underwent surgery with in-network primary surgeons and facilities, 20.5% of episodes (95% CI, 19.4%-21.7%) had an out-of-network bill. In these episodes, the mean potential balance bill per episode was $2011 (95% CI, $1866-$2157) when present. Out-of-network bills were associated with surgical assistants in 37% of these episodes; when present, the mean potential balance bill was $3633 (95% CI, $3384-$3883). Out-of-network bills were associated with anesthesiologists in 37% of episodes; when present, the mean potential balance bill was $1219 (95% CI, $1049-$1388). Membership in health insurance exchange plans, compared with nonexchange plans, was associated with a significantly higher risk of out-of-network bills (27% vs 20%, respectively; risk difference, 6% [95% CI, 3.9%-8.9%]; P < .001). Surgical complications were associated with a significantly higher risk of out-of-network bills, compared with episodes with no complications (28% vs 20%, respectively; risk difference, 7% [95% CI, 5.8%-8.8%]; P < .001). Among 83 021 procedures performed at ambulatory surgery centers with in-network primary surgeons, 6.7% (95% CI, 5.8%-7.7%) included an out-of-network facility bill and 17.2% (95% CI, 15.7%-18.8%) included an out-of-network professional bill. Conclusions and Relevance: In this retrospective analysis of commercially insured patients who had undergone elective surgery at in-network facilities with in-network primary surgeons, a substantial proportion of operations were associated with out-of-network bills.


Assuntos
Procedimentos Cirúrgicos Eletivos/economia , Honorários Médicos , Financiamento Pessoal/economia , Cobertura do Seguro/economia , Seguro Saúde/economia , Anestesiologistas/economia , Dedutíveis e Cosseguros , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Assistentes Médicos/economia , Estudos Retrospectivos , Cirurgiões/economia , Estados Unidos
4.
Ann R Coll Surg Engl ; 102(2): 133-140, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31508999

RESUMO

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


Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia/métodos , Doenças do Colo/cirurgia , Doenças Retais/cirurgia , Infecção da Ferida Cirúrgica/prevenção & controle , Administração Oral , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibioticoprofilaxia/economia , Doenças do Colo/economia , Análise Custo-Benefício , Procedimentos Cirúrgicos Eletivos/economia , Inglaterra , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Doenças Retais/economia , Infecção da Ferida Cirúrgica/economia , Adulto Jovem
5.
Int J Qual Health Care ; 31(Supplement_1): 14-21, 2019 Dec 22.
Artigo em Inglês | MEDLINE | ID: mdl-31867662

RESUMO

OBJECTIVE: The aim of this study is to improve rates of day of surgery admission (DOSA) for all suitable elective thoracic surgery patients. DESIGN: Lean Six Sigma (LSS) methods were used to enable improvements to both the operational process and the organizational working of the department over a period of 19 months. SETTING: A national thoracic surgery department in a large teaching hospital in Ireland. PARTICIPANTS: Thoracic surgery staff, patients and quality improvement staff at the hospital. INTERVENTION(S): LSS methods were employed to identify and remove the non-value-add in the patient's journey and achieve higher levels of DOSA. A pre-surgery checklist and Thoracic Planning Meeting were introduced to support a multidisciplinary approach to enhanced recovery after surgery (ERAS), reduce rework, improve list efficiency and optimize bed management. MAIN OUTCOME MEASURE(S): To achieve DOSA for all suitable elective thoracic surgery patients in line with the National Key Performance Indicator of 75%. A secondary outcome would be to further decrease overall length of stay by 1 day. RESULTS: Over a 19 month period, DOSA has increased from 10 to 75%. Duplication of preoperative tests reduced from 83 to <2%. Staff and patient surveys show increased satisfaction and improved understanding of ERAS. CONCLUSIONS: Using LSS methods to improve both operational process efficiency and organizational clinical processes led to the successful achievement of increasing rates of DOSA in line with national targets.


Assuntos
Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Torácicos/métodos , Gestão da Qualidade Total , Agendamento de Consultas , Lista de Checagem , Eficiência Organizacional , Procedimentos Cirúrgicos Eletivos/economia , Hospitais de Ensino , Humanos , Irlanda , Tempo de Internação/estatística & dados numéricos , Admissão do Paciente , Satisfação do Paciente , Procedimentos Cirúrgicos Torácicos/economia
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.
Surgery ; 166(6): 1027-1032, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31472971

RESUMO

BACKGROUND: Little is known regarding the impact of minimally invasive approaches to pancreatoduodenectomy on the aggregate costs of care for patients undergoing pancreatoduodenectomy. METHODS: We queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing elective laparoscopic or open pancreatoduodenectomy between 2014 and 2016. RESULTS: In this database, 488 (10%) patients underwent elective laparoscopic; 4,544 (90%) underwent open pancreatoduodenectomy. On adjusted analysis, the risk of perioperative morbidity and overall duration of hospitalization for patients undergoing elective laparoscopic were identical to those for patients undergoing open pancreatoduodenectomy. Patients undergoing elective laparoscopic in low (+$10,399, 95% confidence interval [$3,700, $17,098]) and moderate to high (+$4,505, 95% confidence interval [$528, $8,481]) volume centers had greater costs than those undergoing open pancreatoduodenectomy in the same centers. In very high-volume centers (>127 pancreatoduodenectomies/year), aggregate costs of care for patients undergoing elective laparoscopic were essentially identical to those undergoing open pancreatoduodenectomy in the same centers (+$815, 95% confidence interval [-$1,530, $3,160]). CONCLUSION: Rates of morbidity and overall duration of hospitalization for patients undergoing elective laparoscopic are not different than those undergoing open pancreatoduodenectomy. At low to moderate and high-volume centers, elective laparoscopic is associated with greater aggregate costs of care relative to open pancreatoduodenectomy. At very high-volume centers, elective laparoscopic is cost-neutral.


Assuntos
Procedimentos Cirúrgicos Eletivos/economia , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Laparoscopia/economia , Pancreaticoduodenectomia/economia , Complicações Pós-Operatórias/economia , Idoso , Análise Custo-Benefício , Bases de Dados Factuais/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos
8.
Bone Joint J ; 101-B(9): 1081-1086, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31474135

RESUMO

AIMS: The practice of alternating operating theatres has long been used to reduce surgeon idle time between cases. However, concerns have been raised as to the safety of this practice. We assessed the payments and outcomes of total knee arthroplasty (TKA) performed during overlapping and nonoverlapping days, also comparing the total number of the surgeon's cases and the total time spent in the operating theatre per day. MATERIALS AND METHODS: A retrospective analysis was performed on the Centers for Medicare & Medicaid Services (CMS) Limited Data Set (LDS) on all primary elective TKAs performed at the New England Baptist Hospital between January 2013 and June 2016. Using theatre records, episodes were categorized into days where a surgeon performed overlapping and nonoverlapping lists. Clinical outcomes, economic outcomes, and demographic factors were calculated. A regression model controlling for the patient-specific factors was used to compare groups. Total orthopaedic cases and aggregate time spent operating (time between skin incision and closure) were also compared. RESULTS: A total of 3633 TKAs were performed (1782 on nonoverlapping days; 1851 on overlapping days). There were no differences between the two groups for length of inpatient stay, payments, mortality, emergency room visits, or readmission during the 90-day postoperative period. The overlapping group had 0.74 fewer skilled nursing days (95% confidence interval (CI) -0.26 to -1.22; p < 0.01), and 0.66 more home health visits (95% CI 0.14 to 1.18; p = 0.01) than the nonoverlapping group. On overlapping days, surgeons performed more cases per day (5.01 vs 3.76; p < 0.001) and spent more time operating (484.55 minutes vs 357.17 minutes; p < 0.001) than on nonoverlapping days. CONCLUSION: The study shows that the practice of alternating operating theatres for TKA has no adverse effect on the clinical outcome or economic utilization variables measured. Furthermore, there is opportunity to increase productivity with alternating theatres as surgeons with overlapping cases perform more cases and spend more time operating per day. Cite this article: Bone Joint J 2019;101-B:1081-1086.


Assuntos
Artroplastia do Joelho/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Salas Cirúrgicas/estatística & dados numéricos , Duração da Cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia do Joelho/economia , Boston/epidemiologia , Bases de Dados Factuais/estatística & dados numéricos , Eficiência Organizacional/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/economia , Feminino , Humanos , Tempo de Internação , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Salas Cirúrgicas/organização & administração , Estudos Retrospectivos , Fatores de Tempo , Estados Unidos/epidemiologia
9.
Rev Col Bras Cir ; 46(3): e20192175, 2019 Aug 05.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31389524

RESUMO

OBJECTIVE: to evaluate the feasibility of abbreviated fasting in oncologic colorectal surgeries, as well as the impact on the surgical outcome of the patients. METHODS: prospective randomized comparative study with patients undergoing elective colorectal cancer surgeries from May to September 2017. Patients were randomized electronically into two groups according to the preoperative fast to be adopted: conventional or abbreviated. RESULTS: of the 33 patients included, 15 followed the abbreviated fasting protocol and 18 the conventional fasting. Both groups had comparable profiles. No patient underwent mechanical preparation of the colon. In 69.7% of the cases, surgery involved low rectal dissection. The procedures were equivalent in relation to intraoperative variables and severe complications. The time to achieve complete oral intake was shorter for abbreviated fasting (10 versus 16 days, p=0.001), as well as the length of inhospital stay (2 versus 4 days, p=0.009). Hospital costs were lower in the abbreviated fasting (331 versus 682 reais, p<0.001). The univariable analysis revealed a correlation between complete oral intake and abbreviated fasting [HR 0.29 (IC95%: 0.12-0.68] and abdominal distension [HR 0.12 (IC95% 0.01-0.94)]. After multivariable analysis, abbreviated fasting presented a lower time for complete oral intake [HR 0.39 (IC95%: 0.16-0.92]. CONCLUSION: the abbreviated preoperative fasting favors the metabolic-nutritional recovery, reducing the time for complete oral intake. The implementation of the abbreviation protocol reduces hospital admission costs.


Assuntos
Neoplasias Colorretais/cirurgia , Procedimentos Cirúrgicos Eletivos/economia , Jejum , Cuidados Pré-Operatórios/métodos , Idoso , Neoplasias Colorretais/economia , Método Duplo-Cego , Feminino , Custos Hospitalares , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Prospectivos
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.
Surgery ; 166(4): 483-488, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31345565

RESUMO

BACKGROUND: Alvimopan has been shown to reduce length of stay after bowel resection. Use remains variable among institutions due to cost and efficacy concerns in laparoscopic surgery. Additionally, alvimopan's effects have not been isolated from other medications within enhanced recovery protocols. The aim of this study was to distinguish the relationship between alvimopan use, length of stay, and cost in both open and laparoscopic segmental colectomies. METHODS: The Vizient dataset was queried to identify patients undergoing open and laparoscopic colectomies from 2015 to 2017. Patient demographics and treatment details were collected. Primary outcomes of interest included duration of stay and total direct costs. RESULTS: In the study, 12,727 patients met inclusion criteria and 3,358 (26.4%) received alvimopan. For both open and laparoscopic groups, alvimopan was associated with decreased length of stay in unadjusted (4.0 vs 6.0 days, P < .01 and 3.0 vs 4.0 days, P < .01, respectively) and adjusted analysis (effect ratio 0.79, P < .01 and 0.85, P < .01, respectively). Alvimopan was associated with a 7% decrease in direct cost after adjustment (effect ratio 0.93, P = .04), with no cost difference in laparoscopic procedures (effect ratio 0.99, P = .71). CONCLUSION: Alvimopan use is associated with decreased length of stay for both open and laparoscopic colon resections, decreased cost in open procedures, and no cost difference for laparoscopic procedures.


Assuntos
Colectomia/métodos , Redução de Custos , Laparoscopia/economia , Laparotomia/economia , Tempo de Internação/economia , Piperidinas/uso terapêutico , Idoso , Estudos de Coortes , Colectomia/economia , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Fármacos Gastrointestinais/uso terapêutico , Custos de Cuidados de Saúde , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Laparotomia/efeitos adversos , Laparotomia/métodos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Estados Unidos
12.
Int J Health Care Qual Assur ; 32(6): 1013-1021, 2019 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-31282259

RESUMO

PURPOSE: The purpose of this paper is to examine from the viewpoint of resource utilization the Japanese surgical payment system which was revised in April 2016. DESIGN/METHODOLOGY/APPROACH: The authors collected data from surgical records in the Teikyo University electronic medical record system from April 1 till September 30, 2016. The authors defined the decision-making unit as a surgeon with the highest academic rank in the surgery. Inputs were defined as the number of medical doctors who assisted surgery, and the time of operation from skin incision to closure. An output was defined as the surgical fee. The authors calculated each surgeon's efficiency score using output-oriented Charnes-Cooper-Rhodes model of data envelopment analysis. The authors compared the efficiency scores of each surgical specialty using the Kruskal-Wallis and the Steel method. FINDINGS: The authors analyzed 2,558 surgical procedures performed by 109 surgeons. The difference in efficiency scores was significant (p = 0.000). The efficiency score of neurosurgery was significantly greater than obstetrics and gynecology, general surgery, orthopedics, emergency surgery, urology, otolaryngology and plastic surgery (p<0.05). ORIGINALITY/VALUE: The authors demonstrated that the surgeons' efficiency was significantly different among their specialties. This suggests that the Japanese surgical reimbursement scales fail to reflect resource utilization despite the revision in 2016.


Assuntos
Recursos em Saúde/economia , Custos Hospitalares , Salas Cirúrgicas/economia , Procedimentos Cirúrgicos Operatórios/economia , Bases de Dados Factuais , Eficiência Organizacional , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Emergências/economia , Feminino , Custos de Cuidados de Saúde , Hospitais Universitários/economia , Humanos , Japão , Masculino , Salas Cirúrgicas/estatística & dados numéricos , Inovação Organizacional , Sistema de Pagamento Prospectivo , Estudos Retrospectivos , Estatísticas não Paramétricas , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos
13.
J Surg Res ; 244: 153-159, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31288184

RESUMO

BACKGROUND: Repair of ventral and incisional hernias remains a costly challenge for health care systems. In a previous study of a single surgeon's elective open ventral hernia repair (VHR) practice, a cost model was developed, which predicted over 70% of hospital cost variation. The purpose of the present study was to evaluate the ventral hernia cost model with multiple surgeons' elective open VHR cases and extending to include nonelective and laparoscopic VHR. MATERIALS AND METHODS: With the University of Kentucky Institutional Review Board approval, elective and emergent cases of open and laparoscopic VHR performed by multiple surgeons over 3 y were identified. Perioperative variables were obtained from the local American College of Surgeons National Surgery Quality Improvement Program database and electronic medical record review. Hospital cost data were obtained from the hospital cost accounting system. Forward multivariable regression of log-transformed costs identified independent cost drivers (P for entry < 0.05, and P for exit > 0.10). RESULTS: Of the 387 VHRs, 74% were open repairs; mean age was 55 y, and 52% of patients were female. For open, elective cases (n = 211; mean cost of $19,145), the previously reported six-factor cost model predicted 45% of the total cost variation. With all VHRs included, additional variables were found to independently drive costs, predicting 59% of the total cost variation from the base cost. The biggest cost drivers were inpatient status (+$1013), use of biologic mesh (+$1131), preoperative systemic inflammatory response syndrome/sepsis (+$894), and preoperative open wound (+$786). CONCLUSIONS: Ventral hernia repair cost variability is predictable. Understanding the independent drivers of cost may be helpful in controlling costs and in negotiating appropriate reimbursement with payers.


Assuntos
Procedimentos Cirúrgicos Eletivos/economia , Hérnia Ventral/cirurgia , Herniorrafia/economia , Laparoscopia/economia , Modelos Econômicos , Adulto , Idoso , Custos e Análise de Custo/métodos , Custos e Análise de Custo/estatística & dados numéricos , Feminino , Previsões/métodos , Hérnia Ventral/economia , Custos Hospitalares/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Mecanismo de Reembolso , Estudos Retrospectivos
14.
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
15.
Surgery ; 166(2): 166-171, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31160061

RESUMO

BACKGROUND: Little is known regarding the impact of the minimally invasive approach to distal pancreatectomy on the aggregate costs of care for patients undergoing distal pancreatectomy. METHODS: We queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing elective laparoscopic distal pancreatectomy or open distal pancreatectomy between 2012 and 2014. Multivariable regression was used to evaluate postoperative outcomes including readmissions to 90 days after distal pancreatectomy. RESULTS: A total of 267 (11%) patients underwent laparoscopic distal pancreatectomy, and a total of 2,214 (89%) underwent open distal pancreatectomy. On multivariable regression, patients undergoing laparoscopic distal pancreatectomy had a decreased odds risk of having any severe adverse outcome (odds ratio 0.73, 95% confidence interval [0.54-0.97]), prolonged length of stay (odds ratio 0.49, 95% confidence interval [0.30-0.79]), and of being in the highest quartile for aggregate costs of care (odds ratio 0.46, 95% confidence interval [0.32-0.66]) relative to those undergoing open distal pancreatectomy. Patients undergoing laparoscopic distal pancreatectomy had a lower average 90-day aggregate cost of care than those undergoing open distal pancreatectomy when procedures were performed in high-volume (-$16,153, 95% CI: [-$23,342 to -$8,964]) centers. CONCLUSION: Patients undergoing laparoscopic distal pancreatectomy have a lower risk of severe adverse outcomes, prolonged overall length of stay, and lower associated costs of care relative to those undergoing open distal pancreatectomy. This association is independent of hospital volume.


Assuntos
Procedimentos Cirúrgicos Eletivos/economia , Custos de Cuidados de Saúde , Laparoscopia/economia , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Adulto , Idoso , Estudos de Coortes , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Laparoscopia/métodos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Pancreatectomia/efeitos adversos , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Prognóstico , Análise de Regressão , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Estados Unidos
16.
J Surg Res ; 240: 124-129, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30928769

RESUMO

BACKGROUND: The objective of this study was to assess cost differences between patients who underwent percutaneous endovascular aortic repair (PEVAR) and open surgical femoral exposure in elective endovascular aortic repair (EVAR) of abdominal aortic aneurysms. MATERIALS AND METHODS: An IRB-approved single center retrospective analysis of patients who underwent elective EVAR for abdominal aortic aneurysms from 2009 to 2016 was performed. One hundred patients were selected with 50 patients who underwent PEVAR and 50 patients who underwent open surgical femoral exposure. Patient demographics, procedural variables, and hospital outcomes were collected and compared. Primary outcomes assessed used in cost calculations included operating time (OR time), hospital length of stay (LOS), and intensive care unit stay (ICU LOS). Extrapolated cost differences were based on known, published cost multipliers for the primary outcomes observed. RESULTS: Patients undergoing PEVAR had significant reduction in mean OR time (113.9 min versus 144.9 min, P < 0.001), mean ICU LOS (19.7 h versus 28.9 h, P = 0.094), and overall LOS (28.3 h versus 33.1 h, P = 0.020). There was no statistically significant difference in access related complications, although there was a trend toward less complication rates with PEVAR (0% versus 5%, P = 0.056). Calculated cost of procedures based on mean ICU LOS, hospital LOS, and OR time, showed significant reduction in mean hospital costs with PEVAR ($16,628.5 versus $21,705.8, P < 0.001). Multiple linear regression analysis demonstrated an overall 23% cost reduction with PEVAR. CONCLUSIONS: Prior reports comparing PEVAR versus EVAR with open femoral exposures have shown improvement in overall patient time to ambulation and other hospital metrics such as LOS with PEVAR. There is, however, a paucity of overall cost comparison data regarding PEVAR. In this study, adoption of PEVAR was seen to significantly reduce OR times (19%) and overall hospital LOS (50%). The outcomes observed ultimately translated into significant reduction in hospital costs.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Análise Custo-Benefício , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Endovasculares/economia , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/economia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Feminino , Artéria Femoral/cirurgia , Custos Hospitalares/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/economia , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Dispositivos de Oclusão Vascular/economia
17.
J Cardiovasc Surg (Torino) ; 60(4): 460-467, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30994308

RESUMO

INTRODUCTION: Short stay endovascular aneurysm repair pathways (SS-EVAR) provide potential advantages to both healthcare providers and patients. However, these benefits must be carefully balanced against the inherent risks to patient safety and tariff penalties associated with unplanned readmissions. EVIDENCE ACQUISITION: A literature review was performed using the databases MEDLINE, Embase and Cochrane Library up until March 2019. Search terms used included "endovascular aneurysm repair," "aneurysm repair," "EVAR," "abdominal aortic aneurysm," "day case," "short stay," "fast track," and "ambulatory." EVIDENCE SYNTHESIS: Nine relevant articles (including one prior review on the topic) were identified. This early data suggests that SS-EVAR is associated with good patient satisfaction and modest cost savings for healthcare providers. Patient selection, preoperative preparation and supported discharge with early follow-up are essential components of a SS-EVAR pathway. Increasingly, SS-EVAR tends to be delivered via bilateral percutaneous access and loco-regional anesthesia. Over 70% of patients enrolled onto SS-EVAR pathways successfully complete them. Long procedures with excessive blood loss are associated with pathway non-completion. All serious complications occur within 6 hours of the procedure and the mortality (0-1%), morbidity (8-58%) and readmission rates (0-6%) associated with SS-EVAR remains acceptably low. SS-EVAR pathways can be safely and effectively implemented in both teaching and non-teaching hospitals. CONCLUSIONS: Short-stay EVAR pathways are safe and acceptable to patients. With appropriate selection of motivated patients, successful expedited discharge can be achieved with limited readmissions, thus facilitating increased resource efficiency and cost savings for healthcare providers.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Endovasculares , Redução de Custos , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/economia , Humanos , Tempo de Internação , Readmissão do Paciente/estatística & dados numéricos , Seleção de Pacientes , Complicações Pós-Operatórias/epidemiologia
18.
J Ayub Med Coll Abbottabad ; 31(1): 3-7, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30868773

RESUMO

Background: Acute presentation of gall stone disease is a common emergency. Resource limitation often results in unnecessary long waiting times and repeat hospital admissions. The aim of this study was to investigate if funding a dedicated hot gall bladder list is justified. Methods: Patients with acute gall stone related complications between 1st January 2016 and 31st December 2017 were studied. Outcome measures included the number of acute admissions, length of hospital stay (LOS), approximate cost per patient. The length of stay was identified as a critical outcome measure. Results: Fourteen hundred and ninety-five (11%) out of 14189 acute surgical admissions were related to gall stone complications. These included acute cholecystitis 576 (39%), biliary colic 485 (32%), pancreatitis 405 (27%) and jaundice 34 (2%). Twelve hundred and twenty-two patients accounted for 1461 admissions. 182 (15%) patients had recurrent admissions (35%) and on average stayed 11.2 days in the hospital compared to 5.8 days for that of single presentation. The cost of emergency LC (£2053) was less than half of elective LC following single emergency admission (£5661) and less than one third of Elective LC following recurrent admissions (£7453). A trust can save £1,891,784 per year by achieving 80% target. The savings can be used to fund a dedicated hot gall bladder list, releasing hospital beds and additional benefit of reducing the workforce days lost to sickness in general. Conclusions: Emergency LC is cost effective and savings made for such a service is sufficient to fund a dedicated hot gall bladder list..


Assuntos
Colecistectomia Laparoscópica/economia , Cálculos Biliares/complicações , Cálculos Biliares/cirurgia , Custos Hospitalares/estatística & dados numéricos , Redução de Custos , Análise Custo-Benefício , Procedimentos Cirúrgicos Eletivos/economia , Emergências/economia , Feminino , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/economia , Admissão do Paciente/estatística & dados numéricos
19.
J Arthroplasty ; 34(5): 834-838, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30777622

RESUMO

BACKGROUND: The Comprehensive Care for Joint Replacement model is the newest iteration of the bundled payment methodology introduced by the Centers for Medicare and Medicaid Services. Comprehensive Care for Joint Replacement model, while incentivizing providers to deliver care at a lower cost, does not incorporate any patient-level risk stratification. Our study evaluated the impact of specific medical co-morbidities on the cost of care in total joint arthroplasty (TJA) patients. METHODS: A retrospective study was conducted on 1258 Medicare patients who underwent primary elective TJA between January 2015 and July 2016 at a single institution. There were 488 males, 552 hips, and the mean age was 71 years. Cost data were obtained from the Centers for Medicare and Medicaid Services. Co-morbidity information was obtained from a manual review of patient records. Fourteen co-morbidities were included in our final multiple linear regression models. RESULTS: The regression models significantly predicted cost variation (P < .001). For index hospital costs, a history of cardiac arrhythmias (P < .001), valvular heart disease (P = .014), and anemia (P = .020) significantly increased costs. For post-acute care costs, a history of neurological conditions like Parkinson's disease or seizures (P < .001), malignancy (P = .001), hypertension (P = .012), depression (P = .014), and hypothyroidism (P = .044) were associated with increases in cost. Similarly, for total episode cost, a history of neurological conditions (P < .001), hypertension (P = .012), malignancy (P = .023), and diabetes (P = .029) were predictors for increased costs. CONCLUSION: The cost of care in primary elective TJA increases with greater patient co-morbidity. Our data provide insight into the relative impact of specific medical conditions on cost of care and may be used in risk stratification in future reimbursement methodologies.


Assuntos
Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , Custos Hospitalares/estatística & dados numéricos , Osteoartrite/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Procedimentos Cirúrgicos Eletivos/economia , Feminino , Hospitais , Humanos , Masculino , Medicare/economia , Pessoa de Meia-Idade , Osteoartrite/economia , Osteoartrite/epidemiologia , Osteoartrite/cirurgia , Pacotes de Assistência ao Paciente/economia , Estudos Retrospectivos , Cuidados Semi-Intensivos , Estados Unidos
20.
J Vasc Surg ; 70(2): 485-496, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30777686

RESUMO

OBJECTIVE: Endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) is the standard treatment for anatomically suitable patients. EVAR has been associated with a lower perioperative morbidity and mortality compared with open surgical repair (OSR) at the expense of increased reinterventions and costs. We aimed to compare the outcomes of EVAR and OSR for elective AAA repair. The primary end point was cost per QALY at 3 years. Secondary end points were perioperative morbidity and mortality; freedom from reintervention; length of hospital, high-dependency unit, and intensive care unit stay; and freedom from all-cause mortality. METHODS: The project was approved by the Galway Clinical Research Ethics Committee. This project followed the Declaration of Helsinki. This was an audit of interventions that had already taken place. No active clinical intervention was undertaken, and patients' anonymity was preserved; thus, individual patient consent was not obtained. Data on all elective AAA repairs at a tertiary referral vascular center were collected from 2002 to 2015. Demographics and outcomes were reported according to the Society for Vascular Surgery guidelines. QALY was measured on the basis of a quality-adjusted time without symptoms or toxicity assessment. Data were analyzed using parametric and nonparametric tests. RESULTS: Between 2002 and 2015, a total of 494 patients required elective AAA surgery; 401 underwent EVAR and 93 underwent OSR. Demographics and vascular-related risk factors were similar in both groups. Median (interquartile range) cost per QALY at 3 years was €5776 (€5541-€6481) for EVAR vs €7101 (€5812-€8952) for OSR (P < .001). EVAR was associated with reduced perioperative morbidity (12.2% vs 50%; P < .001). There was no significant association between procedure and perioperative mortality (EVAR, 1.7%; OSR, 4.3%; P = .130). There was no significant association found between the procedure and reintervention (P = .502). Our subgroup analysis found no association between procedure and improvement in all-cause mortality, QALYs, costs, or cost per QALY. CONCLUSIONS: EVAR is cost-effective with improved cost per QALY compared with OSR.


Assuntos
Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/economia , Procedimentos Endovasculares/economia , Custos Hospitalares , Hospitais com Alto Volume de Atendimentos , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Redução de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/terapia , Intervalo Livre de Progressão , Anos de Vida Ajustados por Qualidade de Vida , Retratamento/economia , Estudos Retrospectivos , Fatores de Tempo
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA