RESUMEN
BACKGROUND: Operating rooms contribute to over 40% of hospital expenses, with a portion attributed to waste from single-use, sterile surgical supplies (SUSSS). This research aimed to determine the amount of cost wastage due to not using SUSSS during laparotomy procedures. METHODS: A descriptive-analytical investigation was conducted in two prominent teaching hospitals in Mashhad, Iran 2018. Seventy-seven laparotomy surgeries were scrutinized, documenting both used and unused disposable devices, with their respective costs being assessed. Data analysis was performed using SPSS version 16 software. RESULTS: The study revealed that during surgery in the operating rooms, waste of SUSSS averaged 5.9%. Betadine solution and sterile Gauze types were the top two contributors to resource wastage. Sterile Gauze types incurred the highest cost loss. The study found a significant correlation between cost wastage and surgeon experience (r = 0.296, P < 0.001) as well as surgery duration (r = 0.439, P < 0.001). CONCLUSION: Inadequate management of available and commonly used disposable supplies leads to increased hospital expenses. Enhancing the surgical team's knowledge of sterile surgical supplies usage and making thoughtful selections can play a vital role in curbing health costs by minimizing waste of SUSSS in the operating rooms.
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Laparotomía , Quirófanos , Humanos , Laparotomía/economía , Quirófanos/economía , Quirófanos/organización & administración , Irán , Hospitales de Enseñanza , Esterilización/economía , Residuos Sanitarios/economía , Residuos Sanitarios/estadística & datos numéricos , Equipos Desechables/economía , Equipos Desechables/provisión & distribución , Equipos Desechables/estadística & datos numéricosRESUMEN
BACKGROUND: Single-use materials and equipment are regularly opened by the surgical team during procedures but left unused, potentially resulting in superfluous costs and excess environmental waste. OBJECTIVE: This study aimed to estimate the excess use of surgical supplies in minimally invasive benign gynecologic surgeries. STUDY DESIGN: This is a prospective observational study conducted at a university-affiliated single tertiary medical center. Designated study personnel were assigned to observe surgical procedures performed during July to September 2022. Surgical teams were observed while performing surgeries for benign indications. The teams were not informed of the purpose of the observation to avoid potential bias. Disposable materials and equipment opened during the procedure were documented. Excess supplies were defined as those opened but left unused before being discarded. Costs per item of the excess supplies were estimated on the basis of material and equipment costs provided by the hospital. RESULTS: A total of 99 surgeries were observed, including laparoscopic (32%), robotic (39%), hysteroscopic (14%), vaginal (11%), and laparotomy procedures (3%). Excess use of surgical supplies was documented in all but one procedure. The total cost across all surgeries reached $6357. The contained tissue extraction bag was the most expensive item not used (Applied Medical, Rancho Santa Margarita, CA; $390 per unit) in 4 procedures, contributing 25.54% to the total cost. Raytec was the most common surgical waste, with a total of n=583 opened but unused (average n=5.95 per surgery). A significant difference was found in the rate of excess supplies across the surgical approaches, with robotic surgery contributing 52.19% of the total cost (P=.01). CONCLUSION: Excess use of disposable materials and equipment is common in minimally invasive benign gynecologic surgeries and contributes to superfluous costs and excess environmental waste. It is predominantly attributed to the opening of inexpensive materials that are left unused during the procedure. Increased awareness of costs and generated waste may reduce excess use of surgical supplies and should be further explored in future research.
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Procedimientos Quirúrgicos Ginecológicos , Procedimientos Quirúrgicos Robotizados , Humanos , Femenino , Procedimientos Quirúrgicos Ginecológicos/instrumentación , Procedimientos Quirúrgicos Ginecológicos/economía , Procedimientos Quirúrgicos Ginecológicos/estadística & datos numéricos , Estudios Prospectivos , Procedimientos Quirúrgicos Robotizados/economía , Procedimientos Quirúrgicos Robotizados/estadística & datos numéricos , Procedimientos Quirúrgicos Robotizados/instrumentación , Procedimientos Quirúrgicos Mínimamente Invasivos/economía , Procedimientos Quirúrgicos Mínimamente Invasivos/instrumentación , Laparoscopía/economía , Laparoscopía/estadística & datos numéricos , Laparoscopía/instrumentación , Histeroscopía/economía , Histeroscopía/estadística & datos numéricos , Equipos Desechables/economía , Equipos Desechables/provisión & distribución , Laparotomía/economía , Adulto , Persona de Mediana EdadRESUMEN
BACKGROUND: Open Abdomen (OA) cases represent a significant surgical and resource challenge. AbClo is a novel non-invasive abdominal fascial closure device that engages lateral components of the abdominal wall muscles to support gradual approximation of the fascia and reduce the fascial gap. The study objective was to assess the economic implications of AbClo compared to negative pressure wound therapy (NPWT) alone on OA management. METHODS: We conducted a cost-minimization analysis using a decision tree comparing the use of the AbClo device to NPWT alone among patients with midline laparotomy for trauma or acute abdominal surgery who were ineligible for primary fascial closure. The time horizon was limited to the length of the inpatient hospital stay, and costs were considered from the perspective of the US Medicare payer. Clinical effectiveness data for AbClo was obtained from a randomized clinical trial. Cost data was obtained from the published literature. Probabilistic and deterministic sensitivity analyses were performed. The primary outcome was incremental cost. RESULTS: The mean cumulative costs per patient were $76 582 for those treated with NPWT alone and $70,582 for those in the group treated with the AbClo device. Compared to NPWT alone, AbClo was associated with lower incremental costs of -$6012 (95% CI -$19 449 to +$1996). The probability that AbClo was cost-savings compared to NPWT alone was 94%. CONCLUSIONS: The use of AbClo is an economically attractive strategy for management of OA in in patients with midline laparotomy for trauma or acute abdominal surgery who were ineligible for primary fascial closure.
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Técnicas de Cierre de Herida Abdominal , Terapia de Presión Negativa para Heridas , Humanos , Terapia de Presión Negativa para Heridas/economía , Terapia de Presión Negativa para Heridas/métodos , Terapia de Presión Negativa para Heridas/instrumentación , Técnicas de Cierre de Herida Abdominal/economía , Técnicas de Cierre de Herida Abdominal/instrumentación , Fasciotomía/economía , Traumatismos Abdominales/cirugía , Traumatismos Abdominales/economía , Análisis Costo-Beneficio , Estados Unidos , Laparotomía/economía , Técnicas de Abdomen Abierto/economíaRESUMEN
BACKGROUND: Despite its increasing popularity, laparoscopy is not the option for bariatric surgeries performed in the Brazilian public health system. AIMS: To compare laparotomy and laparoscopic access in bariatric surgery, considering aspects such as morbidity, mortality, costs, and length of stay. METHODS: The study included 80 patients who were randomly assigned to perform a Roux-en-Y gastric bypass. They were equally divided in two groups, laparoscopic and laparotomy. The results obtained in the postoperative period were evaluated and compared according to the Ministry of Health protocol, and later, in their outpatient returns. RESULTS: The surgical time was similar in both groups (p=0.240). The costs of laparoscopic surgery proved to be higher, mainly due to staplers and staples. The patients included in the laparotomy group presented higher rates of severe complications, such as incisional hernia (p<0.001). Costs related to social security and management of postoperative complications were higher in the open surgery group (R$ 1,876.00 vs R$ 34,268.91). CONCLUSIONS: The costs related to social security and treatment of complications were substantially lower in laparoscopic access when compared to laparotomy. However, considering the operative procedure itself, the laparotomy remained cheaper. Finally, the length of stay, the rate of complications, and return to labor had more favorable results in the laparoscopic route.
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Cirugía Bariátrica , Laparoscopía , Obesidad Mórbida , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cirugía Bariátrica/efectos adversos , Cirugía Bariátrica/economía , Costos y Análisis de Costo , Derivación Gástrica/efectos adversos , Derivación Gástrica/economía , Laparoscopía/efectos adversos , Laparoscopía/economía , Laparotomía/efectos adversos , Laparotomía/economía , Obesidad Mórbida/cirugía , Complicaciones Posoperatorias , Resultado del Tratamiento , Estudios Retrospectivos , Brasil , Hospitales PúblicosRESUMEN
BACKGROUND: Older adults (OAs) ≥ 65 years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures (EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA compared to their younger counterparts in the state of Maryland. METHODS: A retrospective review of the Maryland Health Services Cost Review Commission from 2009 to 2018 was undertaken. Patients undergoing urgent or emergent ESGP were divided into 2 groups (18-64 years and ≥65 years). Data collected included demographics, APR-severity of illness (SOI), APR-risk of mortality (ROM), the EGSP (partial colectomy [PC], small bowel resection [SBR], cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and laparotomy), length of stay (LOS), and hospital charges. P-values (P < .05) were significant. RESULTS: Of the 181,283 patients included in the study, 55,401 (38.1%) were ≥65 years of age. Older adults presented with greater APR-SOI (major 37.7% vs 21.3%, extreme 5.2% vs 9.3%), greater APR-ROM (major 25.3% vs 8.7%, extreme 22.3% vs 5.3%), underwent PC (24.5% vs 10.9%) and SBR (12.8% vs 7.0%) more frequently, and incurred significantly higher median hospital charges for every EGSP, consistently between 2009 and 2018 due to increased LOS and complications when compared to those ≤65 years of age. CONCLUSION: These findings stress the need for validated frailty indices and quality improvement initiatives focused on the care of OAs in emergency general surgery to maximize outcomes and optimize cost.
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Procedimientos Quirúrgicos Operativos/economía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Apendicectomía/economía , Apendicectomía/estadística & datos numéricos , Colecistectomía/economía , Colecistectomía/estadística & datos numéricos , Colectomía/métodos , Urgencias Médicas/economía , Urgencias Médicas/epidemiología , Femenino , Costos de la Atención en Salud , Precios de Hospital , Humanos , Intestino Delgado/cirugía , Laparotomía/economía , Laparotomía/estadística & datos numéricos , Tiempo de Internación/economía , Masculino , Maryland/epidemiología , Persona de Mediana Edad , Úlcera Péptica/cirugía , Complicaciones Posoperatorias , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Adherencias Tisulares/cirugía , Adulto JovenRESUMEN
BACKGROUND AND OBJECTIVES: To compare the immediate operating room (OR), inpatient, and overall costs between three surgical modalities among women with endometrial cancer (EC) and Class III obesity or higher. METHODS: A multicentre prospective observational study examined outcomes of women, with early stage EC, treated surgically. Resource use was collected for OR costs including OR time, equipment, and inpatient costs. Median OR, inpatient, and overall costs across surgical modalities were analyzed using an Independent-Samples Kruskal-Wallis Test among patients with BMI ≥ 40. RESULTS: Out of 520 women, 103 had a BMI ≥ 40. Among women with BMI ≥ 40: median OR costs were $4197.02 for laparotomy, $5524.63 for non-robotic assisted laparoscopy, and $7225.16 for robotic-assisted laparoscopy (p < 0.001) and median inpatient costs were $5584.28 for laparotomy, $3042.07 for non-robotic assisted laparoscopy, and $1794.51 for robotic-assisted laparoscopy (p < 0.001). There were no statistically significant differences in the median overall costs: $10 291.50 for laparotomy, $8412.63 for non-robotic assisted laparoscopy, and $9002.48 for robotic-assisted laparoscopy (p = 0.185). CONCLUSION: There was no difference in overall costs between the three surgical modalities in patient with BMI ≥ 40. Given the similar costs, any form of minimally invasive surgery should be promoted in this population.
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Análisis Costo-Beneficio , Neoplasias Endometriales/economía , Histerectomía/economía , Laparoscopía/economía , Laparotomía/economía , Obesidad/fisiopatología , Procedimientos Quirúrgicos Robotizados/economía , Neoplasias Endometriales/patología , Neoplasias Endometriales/cirugía , Femenino , Estudios de Seguimiento , Humanos , Histerectomía/métodos , Laparoscopía/métodos , Laparotomía/métodos , Tiempo de Internación , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/economía , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Pronóstico , Estudios Prospectivos , Procedimientos Quirúrgicos Robotizados/métodosRESUMEN
OBJECTIVE: Evaluate the cost-effectiveness of open, laparoscopic, and robotic colectomy. BACKGROUND: The use of robotic-assisted colon surgery is increasing. Robotic technology is more expensive and whether a robotically assisted approach is cost-effective remains to be determined. METHODS: A decision-analytic model was constructed to evaluate the 1-year costs and quality-adjusted time between robotic, laparoscopic, and open colectomy. Model inputs were derived from available literature for costs, quality of life (QOL), and outcomes. Results are presented as incremental cost-effectiveness ratios (ICERs), defined as incremental costs per quality-adjusted life year (QALY) gained. One-way and probabilistic sensitivity analyses were performed to test the effect of clinically reasonable variations in the inputs on our results. RESULTS: Open colectomy cost more and achieved lower QOL than robotic and laparoscopic approaches. From the societal perspective, robotic colectomy costs $745 more per case than laparoscopy, resulting in an ICER of $2,322,715/QALY because of minimal differences in QOL. From the healthcare sector perspective, robotics cost $1339 more per case with an ICER of $4,174,849/QALY. In both models, laparoscopic colectomy was more frequently cost-effective across a wide range of willingness-to-pay thresholds. Sensitivity analyses suggest robotic colectomy becomes cost-effective at $100,000/QALY if robotic disposable instrument costs decrease below $1341 per case, robotic operating room time falls below 172 minutes, or robotic hernia rate is less than 5%. CONCLUSIONS: Laparoscopic and robotic colectomy are more cost-effective than open resection. Robotics can surpass laparoscopy in cost-effectiveness by achieving certain thresholds in QOL, instrument costs, and postoperative outcomes. With increased use of robotic technology in colorectal surgery, there is a burden to demonstrate these benefits.
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Colectomía/economía , Colectomía/métodos , Análisis Costo-Beneficio , Laparoscopía/economía , Procedimientos Quirúrgicos Robotizados/economía , Estudios de Cohortes , Técnicas de Apoyo para la Decisión , Femenino , Humanos , Laparoscopía/métodos , Laparotomía/economía , Laparotomía/métodos , Masculino , Calidad de Vida , Años de Vida Ajustados por Calidad de Vida , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/métodos , Resultado del TratamientoRESUMEN
Background: Out-of-pocket payments and catastrophic healthcare expenditures (CHE) are important barriers to achieving equity and access to emergency and essential surgical care in low- and middle-income countries (LMICs), with important implications for universal health coverage (UHC). However, data on CHE for surgical care in these settings are limited, especially with regard to infections. Methods: We performed a retrospective review of 32 children receiving laparotomy for typhoid intestinal perforation in a four-year period. Data on medical costs were reviewed. Because of the lack of reliable data on household incomes and average national incomes for Nigeria, gross domestic product per capita was used to calculate CHE. The GDP per capita for the country during the study period was $2,028.182. Expenditure >10% GDP per capita (or > $202.82) was considered CHE. Results: There were 15 boys and 17 girls aged 2-15 years (mean 7.72 years). Seventeen patients (53%) were referred from district/general hospitals or mission hospitals. After surgical treatment, 16 patients (50%) developed complications (intra-abdominal abscesses and incision complications), and nine (28.1%) required re-operation. Seven patients (21.9%) required intensive care (ICU) treatment and three (9.4%) died from overwhelming infection. The hospital stay was 3-93 days (mean 23 days). The average total medical cost was $452 (range $236-$1,700). The total medical costs exceeded 10% of GDP ($202.82) for all patients. Total expenditure for four patients requiring intensive care exceeded $202.82 for the ICU care alone. Conclusion: Surgical treatment of typhoid intestinal perforation in children is associated with a high rate of CHE if care is provided at tertiary hospitals. Investments in prevention and control of this and other surgical infections as well as scale up of capacity at district hospitals to provide such care are important in preventing CHE.
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Financiación Personal/estadística & datos numéricos , Gastos en Salud/estadística & datos numéricos , Perforación Intestinal/etiología , Perforación Intestinal/cirugía , Laparotomía/economía , Fiebre Tifoidea/complicaciones , Adolescente , Niño , Preescolar , Femenino , Humanos , Masculino , Nigeria , Estudios RetrospectivosRESUMEN
BACKGROUND: Laparoscopy for ventriculoperitoneal shunt creation might offer smaller incisions and more reliable placement. We assessed the reliability and cost-effectiveness of this technique compared with mini-laparotomy shunt placement. METHODS: All patients undergoing ventriculoperitoneal shunt creation between November 2013 and September 2017 at a single academic institution were evaluated. Individual cases were assessed for the use of laparoscopy for peritoneal shunt placement (laparoscopy) versus mini-laparotomy for peritoneal shunt placement (open). The direct hospital costs for the laparoscopy and open groups were compared for elective shunt placement from the Vizient database. These direct costs were the proportion of the admission cost attributed to surgery. The primary endpoints included costs and revision of the peritoneal catheter within 12 months of the index procedure. RESULTS: A total of 68 patients met the inclusion criteria. Most cases (n = 40; 58.8%) had been performed with laparoscopy, with 28 performed using an open peritoneal approach. Three patients had required ≥1 distal shunt revision: 2 laparoscopy patients (5.0%; 1 had required a second revision) and 1 open patient (3.6%). No statistically significant differences were found for the patients requiring distal shunt revision between the 2 groups (P = 1.000; Fisher's exact test). The direct cost ($9461) of ventriculoperitoneal shunt creation with laparoscopy was greater than that with an open approach ($8247; P = 0.033). CONCLUSIONS: Both laparoscopy and open peritoneal shunt creation are safe procedures, with a 12-month distal revision rate in the present series of ~4%. Laparoscopy provided no relative improvement in safety or complication avoidance but had resulted in a mean increase in costs of >$1200 per patient.
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Análisis Costo-Beneficio , Laparoscopía , Laparotomía , Derivación Ventriculoperitoneal/métodos , Adulto , Anciano , Falla de Equipo/estadística & datos numéricos , Femenino , Humanos , Hidrocefalia/cirugía , Laparoscopía/efectos adversos , Laparoscopía/economía , Laparoscopía/métodos , Laparotomía/efectos adversos , Laparotomía/economía , Laparotomía/métodos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Reoperación/estadística & datos numéricosRESUMEN
BACKGROUND: The risk of death in severe complicated intra-abdominal sepsis (SCIAS) remains high despite decades of surgical and antimicrobial research. New management strategies are required to improve outcomes. The Closed Or Open after Laparotomy (COOL) trial investigates an open-abdomen (OA) approach with active negative pressure peritoneal therapy. This therapy is hypothesized to better manage peritoneal bacterial contamination, drain inflammatory ascites, and reduce the risk of intra-abdominal hypertension leading to improved survival and decreased complications. The total costs and cost-effectiveness of this therapy (as compared with standard fascial closure) are unknown. METHODS: We propose a parallel cost-utility analysis of this intervention to be conducted alongside the 1-year trial, extrapolating beyond that using decision analysis. Using resource use metrics (e.g., length of stay, re-admissions) from patients at all study sites and microcosting data from patients enrolled in Calgary, Alberta, the mean cost difference between treatment arms will be established from a publicly-funded health care payer perspective. Quality of life will be measured at 6 months and 1 year postoperatively with the Euroqol EQ-5D-5 L and SF-36 surveys. A within-trial analysis will establish cost and utility at 1 year, using a bootstrapping approach to provide confidence intervals around an estimated incremental cost-effectiveness ratio. If neither operative strategy is economically dominant, Markov modeling will be used to extrapolate the cost per quality-adjusted life years gained to 2-, 5-, 10-year, and lifetime horizons. Future costs and benefits will be discounted at 1.5% per annum. A cost-effectiveness acceptability curve will be generated using Monte Carlo simulation. If all trial outcomes are similar, the primary analysis will default to a cost-minimization approach. Subgroup analysis will be carried out for patients with and without septic shock at presentation, and for patients whose initial APACHE II scores are > 20 versus ≤ 20. DISCUSSION: In addition to an estimate of the clinical effectiveness of an OA approach for SCIAS, an understanding of its cost effectiveness will be required prior to its adoption in any resource-constrained environment. We will estimate this key parameter for use by clinicians and policymakers. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03163095, registered May 22, 2017.
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Análisis Costo-Beneficio , Infecciones Intraabdominales/cirugía , Terapia de Presión Negativa para Heridas/economía , Sepsis/cirugía , Humanos , Infecciones Intraabdominales/complicaciones , Laparotomía/economía , Sepsis/complicacionesRESUMEN
BACKGROUND: Surgical disease increasingly contributes to global mortality and morbidity. The Lancet Commission on Global Surgery found that global cost-effectiveness data are lacking for a wide range of essential surgical procedures. This study helps to address this gap by defining the cost-effectiveness of exploratory laparotomies in a regional referral hospital in Uganda. MATERIALS AND METHODS: A time-and-motion analysis was utilized to calculate operating theater personnel costs per case. Ward personnel, administrative, medication, and supply costs were recorded and calculated using a microcosting approach. The cost in 2018 US Dollars (USD, $) per disability-adjusted life year (DALY) averted was calculated based on age-specific life expectancies for otherwise fatal cases. RESULTS: Data for 103 surgical patients requiring exploratory laparotomy at the Soroti Regional Referral Hospital were collected over 8 mo. The most common cause for laparotomy was small bowel obstruction (32% of total cases). The average cost per patient was $75.50. The postoperative mortality was 11.7%, and 7.8% of patients had complications. The average number of DALYs averted per patient was 18.51. The cost in USD per DALY averted was $4.08. CONCLUSIONS: This investigation provides evidence that exploratory laparotomy is cost-effective compared with other public health interventions. Relative cost-effectiveness includes a comparison with bed nets for malaria prevention ($6.48-22.04/DALY averted), tuberculosis, tetanus, measles, and polio vaccines ($12.96-25.93/DALY averted), and HIV treatment with multidrug antiretroviral therapy ($453.74-648.20/DALY averted). Given that the total burden of surgically treatable conditions in DALYs is more than that of malaria, tuberculosis, and HIV combined, our findings strengthen the argument for greater investment in primary surgical capacity in low- and middle-income countries.
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Análisis Costo-Beneficio , Países en Desarrollo/economía , Laparotomía/economía , Centros de Atención Terciaria/economía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Países en Desarrollo/estadística & datos numéricos , Equipos y Suministros de Hospitales/economía , Femenino , Fuerza Laboral en Salud/economía , Fuerza Laboral en Salud/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Laparotomía/estadística & datos numéricos , Esperanza de Vida , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Años de Vida Ajustados por Calidad de Vida , Regionalización/economía , Centros de Atención Terciaria/estadística & datos numéricos , Uganda , Adulto JovenRESUMEN
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.
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Colectomía/métodos , Ahorro de Costo , Laparoscopía/economía , Laparotomía/economía , Tiempo de Internación/economía , Piperidinas/uso terapéutico , Anciano , Estudios de Cohortes , Colectomía/economía , Bases de Datos Factuales , Procedimientos Quirúrgicos Electivos/economía , Procedimientos Quirúrgicos Electivos/métodos , Femenino , Fármacos Gastrointestinales/uso terapéutico , Costos de la Atención en Salud , Humanos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Laparotomía/efectos adversos , Laparotomía/métodos , Modelos Lineales , Masculino , Persona de Mediana Edad , Análisis Multivariante , Complicaciones Posoperatorias/tratamiento farmacológico , Complicaciones Posoperatorias/prevención & control , Estudios Retrospectivos , Estados UnidosRESUMEN
OBJECTIVE: To investigate morbidity for patients after the primary surgical management of cervical cancer in low and middle-income countries (LMIC). METHODS: The Pubmed, Cochrane, the Cochrane Central Register of Controlled Trials, Embase, LILACS and CINAHL were searched for published studies from 1st Jan 2000 to 30th June 2017 reporting outcomes of surgical management of cervical cancer in LMIC. Random-effects meta-analytical models were used to calculate pooled estimates of surgical complications including blood transfusions, ureteric, bladder, bowel, vascular and nerve injury, fistulae and thromboembolic events. Secondary outcomes included five-year progression free (PFS) and overall survival (OS). FINDINGS: Data were available for 46 studies, including 10,847 patients from 11 middle income countries. Pooled estimates were: blood transfusion 29% (95%CI 0.19-0.41, P = 0.00, I2 = 97.81), nerve injury 1% (95%CI 0.00-0.03, I2 77.80, P = 0.00), bowel injury, 0.5% (95%CI 0.01-0.01, I2 = 0.00, P = 0.77), bladder injury 1% (95%CI 0.01-0.02, P = 0.10, I2 = 32.2), ureteric injury 1% (95%CI 0.01-0.01, I2 0.00, P = 0.64), vascular injury 2% (95% CI 0.01-0.03, I2 60.22, P = 0.00), fistula 2% (95%CI 0.01-0.03, I2 = 77.32, P = 0.00,), pulmonary embolism 0.4% (95%CI 0.00-0.01, I2 26.69, P = 0.25), and infection 8% (95%CI 0.04-0.12, I2 95.72, P = 0.00). 5-year PFS was 83% for laparotomy, 84% for laparoscopy and OS was 85% for laparotomy cases and 80% for laparoscopy. CONCLUSION: This is the first systematic review and meta-analysis of surgical morbidity in cervical cancer in LMIC, which highlights the limitations of the current data and provides a benchmark for future health services research and policy implementation.
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Laparoscopía/efectos adversos , Laparotomía/efectos adversos , Complicaciones Posoperatorias/mortalidad , Neoplasias del Cuello Uterino/mortalidad , Neoplasias del Cuello Uterino/cirugía , Países en Desarrollo/economía , Supervivencia sin Enfermedad , Femenino , Humanos , Laparoscopía/economía , Laparotomía/economía , Complicaciones Posoperatorias/economía , Tasa de Supervivencia , Neoplasias del Cuello Uterino/economíaRESUMEN
BACKGROUND: In women with abnormal uterine bleeding, fibroids are a frequent finding. In case of heavy menstrual bleeding and presence of submucosal type 0-1 fibroids, hysteroscopic resection is the treatment of first choice, as removal of these fibroids is highly effective. Hysteroscopic myomectomy is currently usually performed in the operating theatre. A considerable reduction in costs and a higher patient satisfaction are expected when procedural sedation and analgesia with propofol (PSA) in an outpatient setting is applied. However, both safety and effectiveness - including the necessity for re-intervention due to incomplete resection - have not yet been evaluated. METHODS: This study is a multicentre randomised controlled trial with a non-inferiority design and will be performed in the Netherlands. Women > 18 years with a maximum of 3 symptomatic type 0 or 1 submucosal fibroids with a maximum diameter of 3.5 cm are eligible to participate in the trial. After informed consent, 205 women will be randomised to either hysteroscopic myomectomy using procedural sedation and analgesia with propofol in an outpatient setting or hysteroscopic myomectomy using general anaesthesia in a clinical setting in the operating theatre. Primary outcome will be the percentage of complete resections, based on transvaginal ultrasonography 6 weeks postoperatively. Secondary outcomes are cost effectiveness, menstrual blood loss (Pictorial blood assessment chart), quality of life, pain, return to daily activities/work, hospitalization, (post) operative complications and re-interventions. Women will be followed up to one year after hysteroscopic myomectomy. DISCUSSION: This study may demonstrate comparable effectiveness of hysteroscopic myomectomy under procedural sedation and analgesia versus general anaesthesia in a safe and patient friendly environment, whilst achieving a significant cost reduction. TRIAL REGISTRATION: Dutch trial register, number NTR5357 . Registered 11th of August 2015.
Asunto(s)
Analgesia/economía , Anestesia General/economía , Miomectomía Uterina/economía , Neoplasias Uterinas/economía , Neoplasias Uterinas/cirugía , Adulto , Analgesia/métodos , Anestesia General/métodos , Análisis Costo-Beneficio , Femenino , Humanos , Histeroscopía/economía , Laparotomía/economía , Persona de Mediana Edad , Países Bajos , Manejo del Dolor , Satisfacción del Paciente , Miomectomía Uterina/métodosRESUMEN
BACKGROUND: Considering the increasing evidence on the feasibility of laparoscopic major hepatectomies (LMH), their clinical outcomes and associated costs were herein evaluated compared to open (OMH). METHODS: Major contributors of perioperative expenses were considered. With respect to the occurrence of conversion, a primary intention-to-treat analysis including conversions in the LMH group (ITT-A) was performed. An additional per-protocol analysis excluding conversions (PP-A) was undertaken, with calculation of additional costs of conversion analysis. RESULTS: One hundred forty-five LMH and 61 OMH were included (14.5% conversion rate). At the ITT-A, LMH showed lower blood loss (p < 0.001) and morbidity (global p 0.037, moderate p 0.037), shorter hospital stay (p 0.035), and a lower need for intra- and postoperative red blood cells transfusions (p < 0.001), investigations (p 0.004), and antibiotics (p 0.002). The higher intraoperative expenses (+ 32.1%, p < 0.001) were offset by postoperative savings (- 27.2%, p 0.030), resulting in a global cost-neutrality of LMH (- 7.2%, p 0.807). At the PP-A, completed LMH showed also lower severe complications (p 0.042), interventional procedures (p 0.027), and readmission rates (p 0.031), and postoperative savings increased to - 71.3% (p 0.003) resulting in a 29.9% cost advantage of completed LMH (p 0.020). However, the mean additional cost of conversion was significant. CONCLUSIONS: Completed LMH exhibit a high potential treatment effect compared to OMH and are associated to significant cost savings. Despite some of these benefits may be jeopardized by conversion, a program of LMH can still provide considerable clinical benefits without cost disadvantage and appears worth to be implemented in high-volume centers.
Asunto(s)
Hepatectomía/métodos , Costos de Hospital , Hospitales de Alto Volumen/estadística & datos numéricos , Laparoscopía/métodos , Laparotomía/métodos , Anciano , Análisis Costo-Beneficio , Femenino , Hepatectomía/economía , Humanos , Laparoscopía/economía , Laparotomía/economía , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Estudios Prospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: Surgical technique process innovations are expected to generally incur no additional cost but gain better quality. Whether a mini-laparotomy surgery (MLS) in the treatment of colorectal cancer (CRC) is more cost effective than conventional open surgery had not been well examined. The objective of this study was to apply cost-effectiveness approaches to investigate the cost effectiveness of adopting MLS compared with open surgery 1 year following resection in CRC patients. RESEARCH DESIGN: A prospective non-randomized cohort study design. SETTING: An academic medical center. PARTICIPANTS: A total of 224 patients who received elective MLS and 339 who received conventional surgery; after propensity score matching, 212 pairs were included for analysis. INTERVENTION: None. MAIN OUTCOME MEASURES: Cost measures were hospital-index cost and outpatient and inpatient costs within 1 year after discharge. Effectiveness measures were life-years (LYs) gained and quality-adjusted life-year (QALYs) gained. STATISTICAL METHODS: We calculated incremental costs and effectiveness by differences in these values between MLS and conventional surgery using adjusted predicted estimates. RESULTS: MLS patients had lower rates of blood transfusions, less complication, and shorter post-surgical lengths of stay and more medical cost savings. One-year overall medical costs for MLS patients were TWD 748,269 (USD 24,942) per QALY gained, significant lower than for the comparison group (p-value = 0.045). CONCLUSION: Our findings supported that the less invasive surgical process through MLS not only saved medical costs, but also increased QALYs for surgical treatment in CRC patients.
Asunto(s)
Neoplasias Colorrectales/cirugía , Laparotomía/economía , Anciano , Estudios de Cohortes , Análisis Costo-Beneficio/métodos , Femenino , Humanos , Masculino , Puntaje de Propensión , Estudios Prospectivos , Años de Vida Ajustados por Calidad de VidaRESUMEN
BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold standard for the management of symptomatic cholelithiasis and complications of gallstone disease. Mini laparotomy cholecystectomy (MOC) may be a more appropriate option in the resource constrained rural setting due to its widespread applicability and comparable outcome with LC. The study aimed to provide an epidemiological analysis of gallstone disease in the rural population and to evaluate the outcome of MOC in a rural hospital. METHOD: A retrospective chart analysis of 248 patients undergoing cholecystectomy in a rural regional referral hospital in KwaZulu-Natal from January 2009 to December 2013 was undertaken. RESULTS: Of the 248 patients, the majority were females (n = 211, [85%]). The most frequent indications for cholecystectomy included: biliary colic (n = 115, [46.3%]); acute cholecystitis (n = 80, [32.3%]); gallstone pancreatitis (n = 27, [10.8%]). Forty cases (16.1%) were converted to open cholecystectomy (OC). The median operative time was 40 minutes (range18-57). Twenty-three morbidities (9.3%) occurred including: bile leaks (n = 6, [2.4%]); bleeding from drain site (n = 1, [0.4%]), incisional hernia (n = 8 [3.2%]) and wound sepsis (n = 8 [3.2%]). The median length of hospital stay in patients who underwent MOC was 48 hours (range: 24-72 hours) and the median time to return to work was 10 days (range: 4-14 days). There was one mortality in the entire cohort. CONCLUSION: MOC is a safe and feasible operation for symptomatic cholelithiasis when cholecystectomy is indicated. The low operative morbidity and mortality in the context of a high risk patient profile and complicated gallstone disease makes this procedure an alternative to LC where LC is inaccessible.
Asunto(s)
Colecistectomía/métodos , Colelitiasis/cirugía , Ahorro de Costo , Laparotomía/economía , Seguridad del Paciente/estadística & datos numéricos , Adulto , Anciano , Colecistectomía/economía , Colecistectomía Laparoscópica , Colelitiasis/diagnóstico por imagen , Estudios de Cohortes , Países en Desarrollo , Femenino , Hospitales Rurales/economía , Humanos , Laparotomía/efectos adversos , Laparotomía/métodos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/efectos adversos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Tempo Operativo , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/fisiopatología , Áreas de Pobreza , Estudios Retrospectivos , Sudáfrica , Resultado del TratamientoRESUMEN
Robotic technology currently offers some technical advantages in pelvic dissection compared with competing minimally invasive techniques, and adoption for the surgical treatment of rectal cancer is rapidly increasing worldwide. While there are some early data demonstrating modest improvement in patient outcomes, benefits in terms of long-term oncological outcomes, as well as potential improvements in surgeon-centered outcomes such as fatigue and repetitive stress injury are actively being investigated. Rapid innovation, with the impending release of several new robotic platforms, is likely to further expand the application of these technologies, improve on current limitations, and reduce capital and consumable costs. It is imperative that, as the technology develops and adoption increases further, clinician and research led programs drive safe implementation with a patient-first approach.
Asunto(s)
Neoplasias del Recto/cirugía , Procedimientos Quirúrgicos Robotizados/métodos , Costos y Análisis de Costo , Fatiga/prevención & control , Predicción , Humanos , Complicaciones Intraoperatorias/etiología , Complicaciones Intraoperatorias/prevención & control , Laparoscopía/economía , Laparoscopía/métodos , Laparotomía/economía , Laparotomía/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos , Traumatismos Ocupacionales/prevención & control , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Ensayos Clínicos Controlados Aleatorios como Asunto , Procedimientos Quirúrgicos Robotizados/economía , Percepción del Tacto , Resultado del TratamientoRESUMEN
BACKGROUND: As reimbursement models evolve, there is increasing emphasis on maximizing value-based care for inpatient conditions. We hypothesized that longer intervals between admission and surgery would be associated with worse outcomes and increased costs for acute care surgery patients, and that these associations would be strongest among patients with high-risk conditions. METHODS: We performed a 5-year retrospective analysis of three risk cohorts: appendectomy (low-risk for morbidity and mortality, n = 618), urgent hernia repair (intermediate-risk, n = 80), and laparotomy for intra-abdominal sepsis with temporary abdominal closure (sTAC; high-risk, n = 102). Associations between the interval from admission to surgery and outcomes including infectious complications, mortality, length of stay, and hospital charges were assessed by regression modeling. RESULTS: Median intervals between admission and surgery for appendectomy, hernia repair, and sTAC were 9.3, 13.5, and 8.1 h, respectively, and did not significantly impact infectious complications or mortality. For appendectomy, each 1 h increase from admission to surgery was associated with increased hospital LOS by 1.1 h (p = 0.002) and increased intensive care unit (ICU) LOS by 0.3 h (p = 0.011). For hernia repair, each 1 h increase from admission to surgery was associated with increased antibiotic duration by 1.6 h (p = 0.007), increased hospital LOS by 3.3 h (p = 0.002), increased ICU LOS by 1.5 h (p = 0.001), and increased hospital charges by $1918 (p < 0.001). For sTAC, each 1 h increase from admission to surgery was associated with increased antibiotic duration by 5.0 h (p = 0.006), increased hospital LOS by 3.9 h (p = 0.046), increased ICU LOS by 3.5 h (p = 0.040), and increased hospital charges by $3919 (p = 0.002). CONCLUSIONS: Longer intervals from admission to surgery were associated with prolonged antibiotic administration, longer hospital and ICU length of stay, and increased hospital charges, with strongest effects among high-risk patients. To improve value of care for acute care surgery patients, operations should proceed as soon as resuscitation is complete.
Asunto(s)
Apendicectomía/economía , Herniorrafia/economía , Precios de Hospital , Unidades de Cuidados Intensivos , Tiempo de Internación/estadística & datos numéricos , Sepsis/cirugía , Tiempo de Tratamiento/economía , Adulto , Anciano , Antibacterianos/uso terapéutico , Femenino , Humanos , Laparotomía/economía , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Análisis de Regresión , Estudios Retrospectivos , RiesgoRESUMEN
BACKGROUND AND OBJECTIVES: Accurate preoperative staging helps avert morbidity, mortality, and cost associated with non-therapeutic laparotomy in gastric cancer (GC) patients. Diagnostic staging laparoscopy (DSL) can detect metastases with high sensitivity, but its cost-effectiveness has not been previously studied. We developed a decision analysis model to assess the cost-effectiveness of preoperative DSL in GC workup. METHODS: Analysis was based on a hypothetical cohort of GC patients in the U.S. for whom initial imaging shows no metastases. The cost-effectiveness of DSL was measured as cost per quality-adjusted life-year (QALY) gained. Drivers of cost-effectiveness were assessed in sensitivity analysis. RESULTS: Preoperative DSL required an investment of $107 012 per QALY. In sensitivity analysis, DSL became cost-effective at a threshold of $100 000/QALY when the probability of occult metastases exceeded 31.5% or when test sensitivity for metastases exceeded 86.3%. The likelihood of cost-effectiveness increased from 46% to 93% when both parameters were set at maximum reported values. CONCLUSIONS: The cost-effectiveness of DSL for GC patients is highly dependent on patient and test characteristics, and is more likely when DSL is used selectively where procedure yield is high, such as for locally advanced disease or in detecting peritoneal and superficial versus deep liver lesions.