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1.
J Comp Eff Res ; 7(12): 1171-1179, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30450955

RESUMO

AIM: The effectiveness of goal-directed fluid therapy (GDFT) algorithms in improving postoperative outcomes has extensively been suggested. Nevertheless, there is a lack of strong evidence regarding both the clinical impact and the cost-effectiveness of the GDFT protocols. The aim of this study is to evaluate the costs of patients undergoing hepatobiliopancreatic surgery when a GDFT protocol is applied. Materials & methods: Consecutive ASA I-III patients undergoing hepatobiliopancreatic surgery were included in this prospective observational study. Depending on device availability, patients were handled either by fluid therapy guided by Vigileo monitor-derived hemodynamic variables (Vigileo-GDFT group) or by standard fluid treatment (standard group). Postoperative length of stay and economic costs were analyzed. RESULTS: In total, 147 patients were included (71 in the Vigileo-GDFT group and 76 in the standard group). The total hospital length of stay was 13 (median, 1st-3rd quartile, 9-20) days for the Vigileo-GDFT group and 14 (8-21) days for the standard group (p = 0.58); no statistically significant differences between the two groups emerged regarding costs and postoperative complications. In both groups, complications were the main contributor to total cost sustained. CONCLUSION: The application of a GDFT algorithm did not reduce the total length of hospital stay and the global costs, which were mainly influenced by the number of complications.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/economia , Hidratação/economia , Hidratação/métodos , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/prevenção & controle , Algoritmos , Procedimentos Cirúrgicos do Sistema Biliar/economia , Pesquisa Comparativa da Efetividade/métodos , Feminino , Objetivos , Humanos , Fígado/cirurgia , Masculino , Pessoa de Meia-Idade , Pâncreas/cirurgia , Estudos Prospectivos
2.
J Laparoendosc Adv Surg Tech A ; 28(12): 1471-1475, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29924662

RESUMO

For over two decades, enhanced recovery pathways have been implemented in many surgical disciplines, most notably in colorectal surgery. Since 2001, the Enhanced Recovery After Surgery (ERAS®) Study Group has developed a main protocol comprising 24 evidence-based core items. While these core items unite similar preoperative, intraoperative, and postoperative principles across surgical subspecialties, variations and modifications exist to these core items based on unique considerations for each surgical subspecialty. This overview will summarize overarching principles for ERAS within hepatopancreaticobiliary (HPB) surgery, first summarizing Pancreaticoduodenectomy and Hepatectomy ERAS Society Guidelines. Specifically, principles and areas of current debate regarding preoperative oral carbohydrate loading/fasting, perioperative fluid management, and analgesia will be discussed. While institutions are beginning to realize both clinical and financial benefits of ERAS within HPB surgery, enhanced recovery remains a relatively recent phenomenon within the field. The complex patient population, high morbidity, and resource-intensive care involved in HPB surgery certainly warrant special consideration. To continue to promote improved clinical outcomes in a cost-effective manner, the ERAS Society will continue to actively address concerns and ensure all recommendations are based on the most up-to-date scientific evidence within the field of HPB surgery.


Assuntos
Procedimentos Cirúrgicos do Sistema Biliar/métodos , Hepatectomia/métodos , Pancreaticoduodenectomia/métodos , Procedimentos Cirúrgicos do Sistema Biliar/economia , Hepatectomia/economia , Humanos , Assistência Perioperatória/métodos , Guias de Prática Clínica como Assunto
3.
HPB (Oxford) ; 20(9): 854-864, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29691125

RESUMO

BACKGROUND: It is unclear how either the successful or failed rescue of hepato-pancreato-biliary (HPB) patients from complications impacts costs. METHODS: A retrospective cohort study of HPB surgical patients was performed using claims data from 2013 to 2015 in the Medicare Provider Analysis and Review (MEDPAR) database. Patient demographics, characteristics, outcomes and risk-adjusted Medicare payments were compared. RESULTS: 11,596 patients were identified. Over half of the patients (n = 5,810, 50.1%) underwent liver surgery, while 42% (n = 4892) had pancreatic and 8% (n = 894) had biliary operations. The overall complication rate varied (liver: 19.6%; pancreas: 20.3%; biliary: 25.2%, p = 0.001). In general, both minor and serious complications resulted in higher Medicare payments. Failed rescue led to higher average Medicare payments during index hospitalization compared to successful rescue ($53,476 versus $44,636, p < 0.001). The reverse was true on readmission; successful rescue was associated with higher average Medicare payments ($25,746 versus $15,654, p < 0.001). Taken together (index plus readmission), total hospitalization payments were higher for failed compared to successful rescue ($66,604 versus $52,143, p < 0.001). CONCLUSION: Following HPB surgery, there is a significant cost associated with both rescue and failure-to-rescue from perioperative complications. Total hospitalization cost was highest for patients who experienced failure-to-rescue.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/economia , Custos Hospitalares , Fígado/cirurgia , Pâncreas/cirurgia , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/terapia , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos do Sistema Biliar/efeitos adversos , Procedimentos Cirúrgicos do Sistema Biliar/economia , Bases de Dados Factuais , Feminino , Humanos , Masculino , Medicare/economia , Admissão do Paciente/economia , Readmissão do Paciente/economia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Falha de Tratamento , Estados Unidos
4.
World J Surg ; 42(9): 2969-2979, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29564518

RESUMO

BACKGROUND: The association of hospital teaching status and overall expenditures has not been studied among patients undergoing hepato-pancreato-biliary (HPB) surgery. We sought to define the impact of hospital teaching intensity on payments and charges associated with (HPB) surgery from the payer perspective. METHODS: Surgical patients undergoing HPB procedures were identified using 2013-2015 Medicare Provider Analysis and Review (MEDPAR) data. Hospital teaching intensity was categorized based on hospital resident-to-bed ratio: non-teaching (NTH: 0), minor teaching (minor-TH: 0-0.363), and major teaching (major-TH: > 0.363). Risk-adjusted price-standardized Medicare payments were assessed and compared among HPB surgical patients at NTH versus major-TH. RESULTS: A total of 8863 patients underwent HPB (NTH: n = 1239, 14.0%; minor-TH: n = 3202, 36.1%; major-TH: n = 4422, 49.9%). Patient comorbidities did not vary across hospital according to teaching intensity (p = 0.27). Mean risk-adjusted Medicare payment at a major-TH was $29,541 versus $19,345 at a NTH (Δ-payment: + $10,195; p < 0.001). Differences in Medicare payments associated with hospital teaching status persisted when the risk-adjusted price was standardized to remove social subsidies and regional variation in costs (NTH: $19,760 vs. major-TH: $28,382; Δ-payment: + $8623). Major-TH had higher total charges submitted to Medicare versus NTH (NTH: $100,583 vs. major-TH: $120,498; Δ-charge = + $19,915), including charges for accommodations, laboratory, and blood utilization (all p < 0.05). Compared with NTH, major-TH had lower morbidity (22.6 vs. 19.0%), serious complications (13.0 vs. 10.5%) and 30-day mortality (4.8 vs. 2.3%) (all p < 0.05). CONCLUSIONS: Major-TH was associated with higher Medicare expenditures than NTH among HPB surgical patients. These differences were attributable, in part, to higher submitted charges for hospital-based services. While associated with higher payments and charges, TH did have better short-term outcomes compared with NTH.


Assuntos
Procedimentos Cirúrgicos do Sistema Biliar/economia , Honorários e Preços/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Hospitais de Ensino/estatística & dados numéricos , Medicare/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos do Sistema Biliar/efeitos adversos , Feminino , Hospitais de Ensino/classificação , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Risco Ajustado , Estados Unidos
5.
ANZ J Surg ; 88(6): 621-625, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28643856

RESUMO

BACKGROUND: Coding inaccuracies in surgery misrepresent the productivity of hospitals and outcome data of surgeons. The aim of this study was to audit the extent of coding inaccuracies in hepato-pancreato-biliary (HPB) surgery and assess the financial impact of introducing a coding proforma. METHODS: Coding of patients who underwent elective HPB surgery over a 3-month period was audited. Codes were based on International Classification of Diseases 10 and Office of Population and Census Surveys-4 codes. A coding proforma was introduced and assessed. New human resource group codes were re-assigned and new tariffs calculated. A cost analysis was also performed. RESULTS: Prior to the introduction of the coding proforma, 42.0% of patients had the incorrect diagnosis and 48.5% had missing co-morbidities. In addition, 14.5% of primary procedures were incorrect and 37.6% had additional procedures that were not coded for at all. Following the introduction of the coding proforma, there was a 27.5% improvement in the accuracy of primary diagnosis (P < 0.001) and 21% improvement in co-morbidities (P = 0.002). There was a 7.2% improvement in the accuracy of coding primary procedures (P = not significant) and a 21% improvement in the accuracy of coding of additional procedures (P < 0.001). Financial loss as a result of coding inaccuracy over our 3-month study period was £56 073 with an estimated annual loss of £228 292. CONCLUSION: Coding in HPB surgery is prone to coding inaccuracies due to the complex nature of HPB surgery and the patient case-mix. A specialized coding proforma completed 'in theatre' significantly improves the accuracy of coding and prevents loss of income.


Assuntos
Procedimentos Cirúrgicos do Sistema Biliar/normas , Codificação Clínica/normas , Procedimentos Cirúrgicos Eletivos/classificação , Custos Hospitalares , Pancreatectomia/normas , Procedimentos Cirúrgicos do Sistema Biliar/economia , Codificação Clínica/economia , Estudos de Coortes , Redução de Custos , Procedimentos Cirúrgicos Eletivos/economia , Feminino , Humanos , Masculino , Pancreatectomia/economia , Medição de Risco , Reino Unido
6.
J Surg Res ; 220: 25-29, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29180188

RESUMO

BACKGROUND: The acute care surgery (ACS) model has been widely implemented with single institution studies demonstrating improved outcomes. Recent multicenter studies have raised questions about the economics and efficacy of ACS. This study compares traditional and ACS outcomes across an entire state. METHODS: A retrospective review of Virginia's Health Information administrative database was completed. Adults admitted with appendicitis or cholecystitis between 2008 and 2014 were included. Hospital administration was contacted to determine surgical model. To compare patient characteristics, t-test and chi-square analyses were used. Total charges and length of stay (LOS) differences between ACS and traditional were examined using generalized linear models, whereas logistic regression was used for the presence of complications and 30-day mortality. RESULTS: Overall, the ACS model showed an increased proportion of uninsured patients with a higher rate of comorbidities. In the appendicitis subgroup, (n = 22,011; ACS n = 1993), ACS patients had higher total charges ($30,060 versus $28,460, P = 0.013), longer LOS (3.31 versus 2.92 d, P < 0.001), and higher chance of complications (odds ratio [OR] = 1.2, P = 0.016) and mortality (OR = 2.4, P = 0.029). After adjustment for comorbidities and insurance, mortality was no longer significantly different. In the cholecystitis group (n = 6936; ACS n = 777), ACS patients had a longer LOS (4.55 versus 4.13 d; P = 0.009) without significant differences in mortality, complications, or cost. There were no significant differences after adjustment for patient characteristics. CONCLUSIONS: ACS patients in Virginia have a higher rate of medical comorbidities and uninsured status, with slightly worse outcomes than the traditional model for appendicitis. Further studies to determine which patients benefit the most from ACS are warranted.


Assuntos
Apendicite/cirurgia , Colecistite/cirurgia , Cuidados Críticos/economia , Cuidados Críticos/métodos , Complicações Pós-Operatórias/epidemiologia , Doença Aguda , Adulto , Idoso , Apendicectomia/efeitos adversos , Apendicectomia/economia , Apendicite/complicações , Apendicite/mortalidade , Procedimentos Cirúrgicos do Sistema Biliar/efeitos adversos , Procedimentos Cirúrgicos do Sistema Biliar/economia , Colecistite/complicações , Colecistite/mortalidade , Comorbidade , Cuidados Críticos/organização & administração , Custos de Cuidados de Saúde , Humanos , Tempo de Internação , Pessoas sem Cobertura de Seguro de Saúde , Pessoa de Meia-Idade , Modelos Teóricos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Virginia
7.
J Laparoendosc Adv Surg Tech A ; 26(12): 985-991, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27828723

RESUMO

INTRODUCTION: The aim of the present study was to compare the outcomes of secondary laparoscopic CBD exploration (LCBDE) following failed endoscopic retrograde cholangiopancreatography (ERCP) and primary laparoscopic common bile duct (CBD) exploration. MATERIALS AND METHODS: One hundred eighty-five patients undergoing LCBDE were divided into Group I consisting of patients undergoing a primary LCBDE (n = 102) and Group II consisting of patients undergoing LCBDE after failure of ERCP to clear the CBD stones (n = 83). Primary outcome measure was successful laparoscopic CBD clearance. The secondary outcome measures were degree of difficulty, operative time, complications, hospital stay, and the cost of treatment. RESULTS: Success rate was similar in both groups (85.3% versus 80.7%). Mean operative time, degree of difficulty, hospital stay, and cost of procedure were significantly higher in Group II (P value <.05). CONCLUSION: It may be prudent to consider ERCP failure patients for primary LCBDE than risk the complications of ERCP if they are suitable for primary surgery.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia Laparoscópica/métodos , Coledocolitíase/cirurgia , Ducto Colédoco/cirurgia , Cálculos Biliares/cirurgia , Adolescente , Adulto , Idoso , Procedimentos Cirúrgicos do Sistema Biliar/economia , Procedimentos Cirúrgicos do Sistema Biliar/métodos , Criança , Colecistectomia Laparoscópica/economia , Coledocolitíase/complicações , Custos e Análise de Custo , Feminino , Cálculos Biliares/complicações , Humanos , Laparoscopia/economia , Laparoscopia/métodos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Prospectivos , Falha de Tratamento , Resultado do Tratamento , Adulto Jovem
8.
HPB (Oxford) ; 18(9): 712-7, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27593587

RESUMO

BACKGROUND: This project aimed to study resource utilization and surgical outcomes after hepaticojejunostomy (HJ) for biliary injuries utilizing data from ACS NSQIP. METHODS: Data from the Participant Use Data File containing surgical patients submitted to the ACS NSQIP during the period of 1/1/2005-12/31/2014 were analyzed. RESULTS: During the study period, 320 patients underwent HJ. Mean age was 50 years, and 109 (34%) were male. Forty-four percent of patients met criteria for ASA class III-V. Forty patients (12.5%) developed one or more critical care complications (CCC). Eighty-one patients (25%) experienced morbidity with a perioperative mortality rate of 1.9%. The mean age of these patients was 52 years, and 62% were male. Age and preoperative elevated alkaline phosphatase were independent predictors of CCC (p < 0.001 and 0.042, OR 1.035, OR 4.337, respectively). Patients ASA class III, age, and preoperative hypoalbuminemia were found to increase risk for prolonged LOS (OR 1.87, p = 0.041, OR 1.02, p = 0.049, OR 2.63, p = 0.001). DISCUSSION: The most significant predictors of morbidity and increased resource utilization after HJ include increasing age, ASA class III or above, and preoperative hypoalbuminemia. Age and ASA class are the strongest predictors of CCC in these patients.


Assuntos
Procedimentos Cirúrgicos do Sistema Biliar/economia , Sistema Biliar/lesões , Cuidados Críticos/economia , Recursos em Saúde/economia , Custos Hospitalares , Jejunostomia/economia , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/terapia , Avaliação de Processos em Cuidados de Saúde/economia , Ferimentos e Lesões/economia , Ferimentos e Lesões/cirurgia , Adulto , Fatores Etários , Idoso , Procedimentos Cirúrgicos do Sistema Biliar/efeitos adversos , Procedimentos Cirúrgicos do Sistema Biliar/mortalidade , Bases de Dados Factuais , Feminino , Recursos em Saúde/estatística & dados numéricos , Humanos , Hipoalbuminemia/complicações , Hipoalbuminemia/economia , Hipoalbuminemia/terapia , Doença Iatrogênica/economia , Jejunostomia/efeitos adversos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Readmissão do Paciente/economia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/mortalidade , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidade
9.
World J Gastroenterol ; 22(11): 3234-41, 2016 Mar 21.
Artigo em Inglês | MEDLINE | ID: mdl-27004001

RESUMO

AIM: To evaluate short-term outcomes following intraoperative biliary lavage for hepatolithiasis. METHODS: A total of 932 patients who were admitted to the West China Medical Center of Sichuan University between January 2010 and January 2014 and underwent bile duct exploration and lithotomy were retrospectively included in our study. The patients were divided into the lavage group and the control group. Related pre-, intra-, and postoperative factors were recorded, analyzed, and compared between the two groups in order to verify the effects of biliary lavage on the short-term outcome of patients with hepatolithiasis. RESULTS: Amongst the patients who were included, 678 patients with hepatolithiasis were included in the lavage group, and the other 254 patients were enrolled in the control group. Data analyses revealed that preoperative baseline and related intraoperative variables were not significantly different. However, patients who underwent intraoperative biliary lavage had prolonged postoperative hospital stays (6.67 d vs 7.82 d, P = 0.024), higher hospitalization fees (RMB 28437.1 vs RMB 32264.2, P = 0.043), higher positive rates of bacterial cultures from blood (13.3% vs 25.8%, P = 0.001) and bile (23.6% vs 40.7%, P = 0.001) samples, and increased usage of advanced antibiotics (26.3% vs 38.2%, P = 0.001). In addition, in the lavage group, more patients had fever (> 37.5 °C, 81.4% vs 91.1%, P = 0.001) and hyperthermia (> 38.5°C, 39.7% vs 54.9%, P = 0.001), and higher white blood cell counts within 7 d after the operation compared to the control group. CONCLUSION: Intraoperative biliary lavage might increase the risk of postoperative infection, while not significantly increasing gallstone removal rate.


Assuntos
Infecções Bacterianas/microbiologia , Procedimentos Cirúrgicos do Sistema Biliar , Cálculos Biliares/terapia , Irrigação Terapêutica/efeitos adversos , Adulto , Idoso , Antibacterianos/uso terapêutico , Infecções Bacterianas/diagnóstico , Infecções Bacterianas/tratamento farmacológico , Infecções Bacterianas/economia , Procedimentos Cirúrgicos do Sistema Biliar/efeitos adversos , Procedimentos Cirúrgicos do Sistema Biliar/economia , China , Feminino , Cálculos Biliares/diagnóstico , Cálculos Biliares/economia , Cálculos Biliares/cirurgia , Custos Hospitalares , Humanos , Cuidados Intraoperatórios , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Irrigação Terapêutica/economia , Irrigação Terapêutica/métodos , Fatores de Tempo , Resultado do Tratamento
10.
Orv Hetil ; 157(7): 268-74, 2016 Feb 14.
Artigo em Húngaro | MEDLINE | ID: mdl-26853728

RESUMO

INTRODUCTION: Self-expandable metal and plastic stents can be applied in the palliative endoscopic treatment of patients with unresectable malignant biliary obstruction. The use of metal stentsis recommended if the patient's life expectancy is more than four months. AIM: To compare the therapeutic efficacy and cost-effectiveness of metal and plastic stents in the treatment of malignant biliary obstruction. METHOD: The authors retrospectively enrolled patients who received metal (37 patients) or plastic stent (37 patients). The complication rate, stent patency and cumulative cost of treatment were assessed in the two groups. RESULTS: The complication rate of metal stents was lower (37.84% vs. 56.76%), but the stent patency was higher compared with plastic stents (19.11 vs. 8.29 weeks; p = 0.0041). In the plastic stent group the frequency of hospitalization of patients in context with stent complications (1.18 vs. 2.32; p = 0.05) and the necessity of reintervention for stent dysfunction (17 vs. 27; p = 0.033) were substantially higher. In this group multiple stent implantation raised the stent patency from 7.68 to 10.75 weeks. There was no difference in the total cost of treatment of malignant biliary obstruction between the two groups (p = 0.848). CONCLUSIONS: Considering the cost of treatment and the burden of patients the authors recommend self-expandable metal sten timplantation if the life expectancy of patients is more than two months. In short survival cases multiple plastic stent implantation is recommended.


Assuntos
Neoplasias do Sistema Biliar/complicações , Procedimentos Cirúrgicos do Sistema Biliar/economia , Procedimentos Cirúrgicos do Sistema Biliar/métodos , Colestase/etiologia , Stents Metálicos Autoexpansíveis/economia , Stents/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Colangiopancreatografia Retrógrada Endoscópica , Colestase/diagnóstico por imagem , Análise Custo-Benefício , Feminino , Humanos , Hungria , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos/economia , Cuidados Paliativos/métodos , Plásticos , Estudos Retrospectivos
11.
World J Gastroenterol ; 22(2): 736-47, 2016 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-26811621

RESUMO

Single-incision laparoscopic surgery (SILS), or laparoendoscopic single-site surgery, has been employed in various fields to minimize traumatic effects over the last two decades. Single-incision laparoscopic cholecystectomy (SILC) has been the most frequently studied SILS to date. Hundreds of studies on SILC have failed to present conclusive results. Most randomized controlled trials (RCTs) have been small in scale and have been conducted under ideal operative conditions. The role of SILC in complicated scenarios remains uncertain. As common bile duct exploration (CBDE) methods have been used for more than one hundred years, laparoscopic CBDE (LCBDE) has emerged as an effective, demanding, and infrequent technique employed during the laparoscopic era. Likewise, laparoscopic biliary-enteric anastomosis is difficult to carry out, with only a few studies have been published on the approach. The application of SILS to CBDE and biliary-enteric anastomosis is extremely rare, and such innovative procedures are only carried out by a number of specialized groups across the globe. Herein we present a thorough and detailed analysis of SILC in terms of operative techniques, training and learning curves, safety and efficacy levels, recovery trends, and costs by reviewing RCTs conducted over the past three years and two recently updated meta-analyses. All existing literature on single-incision LCBDE and single-incision laparoscopic hepaticojejunostomy has been reviewed to describe these two demanding techniques.


Assuntos
Doenças Biliares/cirurgia , Procedimentos Cirúrgicos do Sistema Biliar/métodos , Laparoscopia , Doenças Biliares/diagnóstico , Doenças Biliares/economia , Procedimentos Cirúrgicos do Sistema Biliar/efeitos adversos , Procedimentos Cirúrgicos do Sistema Biliar/economia , Colecistectomia Laparoscópica , Competência Clínica , Análise Custo-Benefício , Custos de Cuidados de Saúde , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/economia , Curva de Aprendizado , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Resultado do Tratamento
12.
JOP ; 15(2): 128-31, 2014 Mar 10.
Artigo em Inglês | MEDLINE | ID: mdl-24618435

RESUMO

Pancreatic cancer is one of the leading causes of cancer deaths worldwide and constitutes a major public health problem. One of the most common symptoms associated with pancreatic adenocarcinoma is jaundice, caused by the obstruction of common bile duct. Endobiliary stenting is used to relief these patients either preoperatively or merely for palliation and plastic or metal stents are usually endoscopically or percutaneously placed. Two interesting studies were presented at the 2014 ASCO Gastrointestinal Cancers Symposium. Strom et al. sought to investigate the effect of preoperative biliary drainage on recurrence and survival and they concluded that percutaneous biliary decompression was an independent predictor of worse overall survival and was associated with non-significant increase in hepatic recurrence (Abstract #314). Montero et al. presented the results of their study regarding the cost-effectiveness of metal stents in patients with inoperable pancreatic cancer and they concluded that placement of metal biliary stents is cost saving, improves overall survival and quality-adjusted survival compared with plastic stents (Abstract #260). Both studies concluded to useful results that along with the existing literature and formulated guidelines may help the provision of more effective, higher quality management of these patients.


Assuntos
Adenocarcinoma/terapia , Procedimentos Cirúrgicos do Sistema Biliar/métodos , Drenagem/métodos , Neoplasias Pancreáticas/terapia , Adenocarcinoma/mortalidade , Procedimentos Cirúrgicos do Sistema Biliar/economia , Análise Custo-Benefício , Drenagem/economia , Humanos , Neoplasias Pancreáticas/mortalidade , Stents , Taxa de Sobrevida , Resultado do Tratamento
13.
J Trauma Acute Care Surg ; 76(1): 84-92; discussion 92-4, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-24368361

RESUMO

BACKGROUND: Studies have demonstrated that relative value units (RVUs) do not appropriately reflect cognitive effort or time spent in patient care, but RVU continues to be used as a standardized system to track productivity. It is unknown how well RVU reflects the effort of acute care surgeons. Our objective was to determine if RVUs adequately reflect increased surgeon effort required to treat emergent versus elective patients receiving similar procedures. METHODS: A retrospective analysis using The American College of Surgeons' National Surgical Quality Improvement Program 2011 data set was conducted. The control group consisted of patients undergoing elective colectomy, hernia repair, or biliary procedures as identified by Current Procedural Terminology. Comparison was made to emergent cases after being stratified to laparoscopic or open technique. Generalized linear models and logistic regression were used to assess specific outcomes, controlling for demographics and comorbidities of interest. The RVUs, operative time, and length of stay (LOS) were primary variables, with major/minor complications, mortality, and readmissions being evaluated as the relevant outcomes. RESULTS: A total of 442,149 patients in the National Surgical Quality Improvement Program underwent one of the operative procedures of interest; 27,636 biliary (91% laparoscopic; 8.5% open), 28,722 colorectal (40.3% laparoscopic, 59.7% open), and 31,090 hernia (26.6% laparoscopic, 73.4% open) operations. Emergent procedures were found to have average RVU values that were identical to their elective case counterparts. Complication rates were higher and LOS were increased in emergent cases. Odds ratios for complications and readmissions in emergent cases were twice those of elective procedures. Mortality was skewed toward emergent cases. CONCLUSION: Our data indicate that the emergent operative management for various procedures is similarly valued despite increased LOS, more complications, higher mortality risk, and subsequently increased physician attention. Our findings suggest that the RVU system for acute care surgeons may need to be reevaluated to better capture the additional work involved in emergent patient care.


Assuntos
Escalas de Valor Relativo , Especialidades Cirúrgicas/economia , Procedimentos Cirúrgicos do Sistema Biliar/economia , Procedimentos Cirúrgicos do Sistema Biliar/estatística & dados numéricos , Colectomia/economia , Colectomia/estatística & dados numéricos , Feminino , Herniorrafia/economia , Herniorrafia/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Especialidades Cirúrgicas/organização & administração , Especialidades Cirúrgicas/estatística & dados numéricos , Fatores de Tempo , Estados Unidos
14.
Hepatogastroenterology ; 60(121): 42-5, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-22641110

RESUMO

BACKGROUND/AIMS: This study aims to compare the clinical outcomes and costs between percutaneous transhepatic biliary stenting (PTBS) and surgical bypass. METHODOLOGY: We randomly assigned 142 patients with unresectable malignant biliary obstruction between 2005 and 2010 to receive PTBS or surgical bypass as palliative treatment. PTBS was successfully performed in 70 patients who formed the PTBS group (failed in 7 patients). Sixty five patients underwent surgical bypass treatment. Additional gastrojejunostomy was performed in five patients. The effectiveness of biliary drainage, hospital stay, complications, cost, survival time and mortality were compared. RESULTS: Patients in PTBS group had shorter hospital stay and lower initial and overall expense than the surgical group (p<0.05). There was no significant difference in effectiveness of biliary drainage (p=0.9307) or survival time between two groups (p=0.4826). Early complications of PTBS group was significantly lower than surgical group (3/75 vs. 11/65, p=0.0342). Late complication in PTBS group did not differ significantly from surgical group (9/70 vs. 6/65, p=0.6823). The survival curves in the two groups showed no significant difference (p=0.1032). CONCLUSIONS: PTBD is a better palliative treatment than surgical bypass for unresectable malignant biliary obstruction for its high effectiveness of biliary drainage and acceptable expense and complication.


Assuntos
Colestase/terapia , Neoplasias/complicações , Stents , Adulto , Idoso , Procedimentos Cirúrgicos do Sistema Biliar/economia , Análise Custo-Benefício , Drenagem , Feminino , Derivação Gástrica/economia , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos
15.
J Am Coll Surg ; 214(6): 919-27, 2012 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22495064

RESUMO

BACKGROUND: Controversy exists regarding the optimal timing of repair after iatrogenic bile duct injuries (BDI). Several studies advocate late repair (≥6 weeks after injury) with mandatory drainage and resolution of inflammation. Others indicate that early repair (<6 weeks after injury) produces comparable or superior clinical outcomes. Additionally, although most studies have reported inferior outcomes with primary surgeon repair, this practice continues. With disparate published recommendations and rising health care costs, decision analysis was used to examine the cost-effectiveness of BDI repair. STUDY DESIGN: A Markov model was developed to evaluate primary surgeon repair (PSR), late repair by a hepatobiliary surgeon (LHBS), and early repair by a hepatobiliary surgeon (EHBS). Baseline values and ranges were collected from the literature. Sensitivity analsyses were conducted to test the strength of the model and variability of parameters. RESULTS: The model demonstrated that EHBS was associated with lower costs, earlier return to normal activity, and better quality of life. Specifically, 1 year after repair, PSR yielded 0.53 quality adjusted life years (QALYs) ($120,000/QALY) and LHBS yielded 0.74 QALYs ($74,000/QALY); EHBS yielded 0.82 QALYs ($48,000/QALY). Sensitivity analyses supported these findings at clinically meaningful probabilities. CONCLUSIONS: This cost-effectiveness model demonstrates that early repair by a hepatobiliary surgeon is the superior strategy for the treatment of BDI in properly selected patients. Although there is little clinical difference between early and late repair, there is a great difference in cost and quality of life. Ideally, costs and quality of life should be considered in decisions regarding strategies of repair of injured bile ducts.


Assuntos
Doenças dos Ductos Biliares/cirurgia , Ductos Biliares/lesões , Procedimentos Cirúrgicos do Sistema Biliar/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Doença Iatrogênica/economia , Modelos Econômicos , Procedimentos Cirúrgicos Reconstrutivos/economia , Doenças dos Ductos Biliares/economia , Doenças dos Ductos Biliares/etiologia , Ductos Biliares/cirurgia , Procedimentos Cirúrgicos do Sistema Biliar/métodos , Análise Custo-Benefício , Humanos , Complicações Pós-Operatórias , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Procedimentos Cirúrgicos Reconstrutivos/métodos , Fatores de Tempo , Resultado do Tratamento
16.
Appl Health Econ Health Policy ; 10(1): 15-29, 2012 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-22077427

RESUMO

BACKGROUND: Patients with gallbladder and common bile duct stones are generally treated by pre-operative endoscopic sphincterotomy (ES) followed by laparoscopic cholecystectomy (POES). Recently, a meta-analysis has shown that intra-operative ES during laparoscopic cholecystectomy (IOES) results in fewer complications than POES, with similar efficacy. The cost effectiveness of IOES versus POES is unknown. OBJECTIVE: The objective of this study was to compare the cost effectiveness of IOES versus POES from the UK NHS perspective. METHODS: A decision-tree model estimating and comparing costs to the UK NHS and QALYs gained following a policy of either IOES or POES was developed with a time horizon of 3 years. Uncertainty was investigated with probabilistic sensitivity analysis, and the expected value of perfect information (EVPI) and partial information (EVPPI) were also calculated. RESULTS: IOES was less costly than POES (approximately -£623 per patient [year 2008 values]) and resulted in similar quality of life (+0.008 QALYs per patient) as POES. Given a willingness-to-pay threshold of £20 000 per QALY gained, there was a 92.9% probability that IOES is cost effective compared with POES. Full implementation of IOES could save the NHS £2.8 million per annum. At a willingness to pay of £20 000 per QALY gained, the 10-year population EVPI was estimated at £0.6 million. CONCLUSIONS: IOES appears to be cost effective compared with POES.


Assuntos
Procedimentos Cirúrgicos do Sistema Biliar , Sistema Biliar/fisiopatologia , Cálculos Biliares/cirurgia , Cuidados Intraoperatórios , Cuidados Pré-Operatórios , Esfinterotomia Endoscópica/economia , Procedimentos Cirúrgicos do Sistema Biliar/economia , Análise Custo-Benefício , Humanos , Qualidade de Vida , Medicina Estatal , Reino Unido
18.
Magy Seb ; 60(5): 239-42, 2007 Oct.
Artigo em Húngaro | MEDLINE | ID: mdl-17984013

RESUMO

This review summarises the data of current meta-analyses on the outcome of endoscopic and surgical biliary bypass procedures applied for inoperable pancreatic tumours. The authors suggest that plastic biliary stents should be used in cases only with short survival (less than six months). In patients with a prognosis of longer than six month, self-expandable metal stents are more cost-effective. This latter technique is as efficient as the traditional surgical bypass procedures. However, surgical bypass is preferable in cases if tumour resection is questionable after staging or in patients with gastric emptying problems.Furthermore, application of duodenal stents is suggested in selected cases only due to relatively frequent late complications (stent migration, perforation, obstruction). Duodenal stents can be used in patients with advanced stage disease or very high operative risk.


Assuntos
Procedimentos Cirúrgicos do Sistema Biliar/métodos , Endoscopia do Sistema Digestório , Intestinos/cirurgia , Cuidados Paliativos/métodos , Neoplasias Pancreáticas/cirurgia , Stents , Anastomose Cirúrgica , Procedimentos Cirúrgicos do Sistema Biliar/efeitos adversos , Procedimentos Cirúrgicos do Sistema Biliar/economia , Procedimentos Cirúrgicos do Sistema Biliar/instrumentação , Procedimentos Cirúrgicos do Sistema Biliar/mortalidade , Endoscopia do Sistema Digestório/efeitos adversos , Endoscopia do Sistema Digestório/economia , Endoscopia do Sistema Digestório/mortalidade , Medicina Baseada em Evidências , Humanos , Estadiamento de Neoplasias , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Stents/economia
19.
J Am Coll Surg ; 196(3): 385-93, 2003 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-12648690

RESUMO

BACKGROUND: Recent population-based studies have demonstrated that the use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is associated with a decrease in the rate of common bile duct (CBD) injury. The cost implications of a management strategy involving routine IOC use have not been adequately evaluated. STUDY DESIGN: Decision analytic models were developed to analyze costs and benefits of routine IOC use during LC. The models were used to calculate the cost per life saved, cost per CBD injury avoided, and incremental cost of IOC when used routinely. Transition probabilities, costs, and outcomes were derived from published sources. Sensitivity analyses were used to account for uncertainty in these estimates. RESULTS: Using base-case estimates, management of patients undergoing LC with routine IOC would cost 100 dollars more per LC. Routine IOC would prevent 2.5 deaths for every 10,000 patients at a cost of 390,000 dollars per life saved (13,900 dollars per life year saved). The cost per CBD injury avoided with IOC use is 87,143 dollars. The cost per CBD injury avoided is less for procedures done in high-risk patients (approximately 8,000 dollars) or by less experienced surgeons (approximately 61,000 dollars). CONCLUSIONS: These models describe settings where the cost of IOC and the reduction in CBD injury rates make routine IOC use cost effective. Routine IOC use among less experienced surgeons and in high-risk operations is the most cost effective, but the cost implications of routine use for the general population should also be considered cost effective.


Assuntos
Doenças dos Ductos Biliares/prevenção & controle , Colangiografia/economia , Colecistectomia Laparoscópica/efeitos adversos , Ducto Colédoco/lesões , Ducto Colédoco/cirurgia , Monitorização Intraoperatória/economia , Doenças dos Ductos Biliares/economia , Doenças dos Ductos Biliares/etiologia , Doenças dos Ductos Biliares/mortalidade , Procedimentos Cirúrgicos do Sistema Biliar/economia , Análise Custo-Benefício , Humanos , Monitorização Intraoperatória/métodos , Avaliação de Resultados em Cuidados de Saúde , Estados Unidos
20.
Am J Gastroenterol ; 97(4): 898-904, 2002 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-12003425

RESUMO

OBJECTIVES: Obstructive jaundice frequently complicates pancreatic carcinoma and is associated with complications such as malabsorption, coagulopathy, progressive hepatocellular dysfunction, and cholangitis in addition to disabling pruritus, which greatly interferes with terminal patients' quality of life. Endoscopic placement of biliary stents decreases the risk of these complications and is considered the procedure of choice for palliation for patients with unresectable tumors. We used decision analysis with Markov modeling to compare the cost-effectivenesses of plastic stents and metal stents in patients with unresectable pancreatic carcinoma. METHODS: A model of the natural history of unresectable pancreatic carcinoma was constructed using probabilities derived from the literature. Cost estimates were obtained from Medicare reimbursement rates and supplemented by the literature. Two strategies were evaluated: 1) initial endoscopic plastic stent placement and 2) initial endoscopic metal stent placement. We compared total costs and performed cost-effectiveness analysis in these strategies. The outcome measures were quality-adjusted life months. Sensitivity analyses were performed on selected variables. RESULTS: Our baseline analysis showed that initial plastic stent placement was associated with a total cost of $13,879/patient and 1.799 quality-adjusted life months. Initial placement of a metal stent cost $13,466/patient and conferred 1.832 quality-adjusted life months. Among the variables examined, expected patient survival was demonstrated by sensitivity analyses to have the most influence on the results of the model. CONCLUSION: Initial endoscopic placement of a metal stent is a cost-saving strategy compared to initial plastic stent placement, particularly in patients expected to survive longer than 6 months.


Assuntos
Procedimentos Cirúrgicos do Sistema Biliar/economia , Carcinoma/complicações , Carcinoma/cirurgia , Colestase/etiologia , Colestase/cirurgia , Técnicas de Apoio para a Decisão , Modelos Estatísticos , Neoplasias Pancreáticas/complicações , Neoplasias Pancreáticas/cirurgia , Stents/economia , Carcinoma/economia , Colestase/economia , Análise Custo-Benefício/economia , Humanos , Cadeias de Markov , Metais/economia , Neoplasias Pancreáticas/economia , Plásticos/economia , Anos de Vida Ajustados por Qualidade de Vida
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