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1.
Ben Schwab Ezra N. Teitelbaum Jeffrey H. Barsuk Nathaniel J. Soper Eric S. Hungness 《Surgery》2018,163(3):503-508
Background
Laparoscopic common bile duct exploration is an underutilized treatment for choledocholithiasis. We sought to evaluate the impact of a simulation-based mastery-learning curriculum for surgical residents on laparoscopic common bile duct exploration utilization and to compare outcomes for patients treated with laparoscopic common bile duct exploration versus endoscopic retrograde cholangiopancreatography (ERCP).Methods
The number of laparoscopic common bile duct explorations performed before and after curriculum implementation was reviewed and outcomes were compared between patients with choledocholithiasis managed with laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography. Based on cost savings from increased utilization of laparoscopic common bile duct exploration, the annual return on investment associated with the curriculum was calculated.Results
Twenty-two residents completed the curriculum. In the pre-curriculum period, an average of 1.7 laparoscopic common bile duct explorations was performed yearly, which increased to 8.4 cases per year after curriculum implementation (P?<?.05). Identified were 155 patients with choledocholithiasis: 31 underwent laparoscopic common bile duct exploration plus laparoscopic cholecystectomy and 124 underwent endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. The laparoscopic common bile duct exploration and laparoscopic cholecystectomy group had a reduced duration of stay (2.5?±?1.8 days versus 4.3?±?2.2 days, P?<?.0001) and costs ($12,987?±?$3,286 versus $15,022?±?$4,613, P?=?.01) compared with endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. Rates of readmission and reoperation were equivalent between groups. Cost savings were more than $38,000, resulting in a 3.8 to 1 return on investment from curriculum implementation.Conclusion
A simulation-based mastery-learning curriculum increased institutional utilization of laparoscopic common bile duct exploration and adoption of the curriculum resulted in positive return on investment. 相似文献2.
Samuel Jang Meagan Mandabach Zviadi Aburjania Courtney J. Balentine Herbert Chen 《Surgery》2018,163(3):638-642
Background
Identifying hospital and provider variation in surgical cost is a potent method for controlling rising healthcare expenditure and delivering cost-effective care. The purpose of this study was to examine the variation of hospital cost by providers for parathyroidectomy in a single academic institution.Methods
We retrospectively evaluated 894 consecutive parathyroidectomies under 8 surgeons in our institution between September 2011 and July 2016. Total duration of stay and cost were evaluated using nonparametric tests. Categorical variables were evaluated with χ2.Results
The median total hospital cost for parathyroidectomy was $4,863.28 (interquartile range: 4,196–5,764), but the median costs per provider varied widely from $4,522.30 to $12,072.87. The median duration of stay was 0 days (IQR: 0–1) and demonstrated a wide variation among providers. Longer duration of practice was associated with lower cost. Despite the variation, only 2% was readmitted after discharge with no patient mortality.Conclusion
We found substantial variation in hospital cost among providers for parathyroidectomy despite practicing in the same academic institution, with some surgeons spending 4 time more for the same operation. Implementing institutional standards of practice could be a method to decrease variation and costs of surgical care. 相似文献3.
Background
Average costs associated with common procedures can vary by surgeon without a corresponding variation in outcome or case complexity.Methods
De-identified cost and equipment utilization data were collected from our hospital for elective laparoscopic cholecystectomy performed by 17 different surgeons over a 6-month period. A group of surgeons used this data to design a standardized equipment pick list that became optional (not mandated) for laparoscopic cholecystectomy. Cost and consumable surgical supply utilization data were collected for six months prior to and following the creation of the standardized pick-list.Results
280 elective laparoscopic cholecystectomies were performed during the study interval. In the 6 months after standardized pick list creation, the cost of disposable supplies utilized per case decreased by 32%.Conclusions
Surgical cost savings can be achieved with standardized procedure pick lists and attention to the cost of consumable surgical supplies. 相似文献4.
Christopher R. Shubert Michael L. Kendrick Elizabeth B. Habermann Amy E. Glasgow Bijan J. Borah James P. Moriarty Sean P. Cleary Rory L. Smoot Michael B. Farnell David M. Nagorney Mark J. Truty Florencia G. Que 《Surgery》2018,163(3):495-502
Background
Morbidity and costs after pancreatoduodenectomy remain increased, driven by postoperative pancreatic fistula (POPF). A risk-based pathway for pancreatoduodenectomy (RBP-PD) was implemented and the clinical and cost outcomes compared with that of our historic practice.Methods
Prospective clinical and cost outcomes for our RBP-PD cohort treated from September 2014 to September 2015 were compared with a previously published cohort of pancreatoduodenectomies from January 2007 to February 2014.Results
A total of 128 RBP-PD cases were compared with 808 historic controls. Apart from less blood loss, there were no significant clinical differences between the 2 groups. Overall POPF rate did not change. Average duration of stay decreased to 10 days from 12 (P?<?.001) despite similar readmission rates. Postsurgical interventional radiology procedures decreased to 18.0% from 26.4% (P?=?.048). Utilization of and duration of stay in monitored care decreased to 23.4% from 35.6% (P?<?.01) and to 1 day from 3 (P?<?.01). On multivariable analysis RBP-PD was independently associated with decreased odds of higher postoperative pancreatic fistula grade, monitored care, and prolonged duration of stay. Inpatient cost of care decreased $6,387 per patient (–11.1%, P?=?.016), and total 30-day costs decreased $8,565 per patient (–13.7%, P?=?.01), representing a total 30-day cost savings of $1.1 million.Conclusion
RBP-PD significantly improved patient outcomes, decreased costs of care, and likely has applicability for surgical care beyond pancreatoduodenectomy. 相似文献5.
E. Christopher Ellison Timothy M. Pawlik David P. Way Bhagwan Satiani Thomas E. Williams 《Surgery》2018,163(3):553-559
Background
Assessments of the future general surgery workforce continue to project substantial shortages of general surgeons. The general surgery workforce is targeted currently to maintain a surgeon/population ratio of 6.5–7.5/100,000.Methods
We examined population and age-associated incidence of cancer to estimate the number of general surgeons needed for initial surgical treatment of the patient with cancer in the year 2035 compared with 2010. We hypothesized that the number of general surgeons needed to provide future cancer care will exceed the projections of available general surgeons based on current training numbers, as well as on population-based ratios alone.Results
The total number of new patients with cancers treated by general surgeons is projected to increase 56% (511,450 in 2010 to 798,070 in 2035). To maintain the same patient census per surgeon, it is estimated that 34,698 general surgeons will be needed. This is an increase of 9,198 over that based on current training numbers and 5,300–7,400 greater than the need projected by population growth alone.Conclusion
The analysis supports the hypothesis that an increasing incidence of cancer in the future will exceed the potential capacity of the general surgeon workforce. Regionalization of cancer care may be one solution to projected access issues. 相似文献6.
Background
Intravenous (IV) fluid therapy should be individualized according to each patient's weight, disease, and comorbidities, as well as the type and duration of the operative procedure. Laparoscopic cholecystectomy represents one of the most common, short-duration operations; thus, the aim of this study was to assess the necessity of postoperative administration of IV fluids.Method
A randomized clinical trial with patients undergoing elective laparoscopic cholecystectomy was performed. Patients were randomly assigned to control group (IV fluids at the surgeon's discretion) and study group (no IV fluids after the operation). Body weight and composition, total intravenous fluids, urinary output, creatinine levels, and the presence of thirst and hunger were assessed. Costs related to the administration of postoperative IV fluids were measured.Results
The study and control groups were similar with regard to sex distribution, age, and general characteristics. There was a significant difference in the amount of infused IV fluids (1,600?mL vs 3,000?mL), directly related to the amount offered postoperatively to the control group. Weight, extracellular water, and urinary output (1,257?±?736?mL vs 888?±?392?mL; P?<?.05) were increased in the control group, and this was positively correlated with the volume of infused fluids (r?=?0.333). There were no differences in creatinine levels, thirst, hunger, and well-being features. An average of 10.7 minutes per patient of nursing time was required for IV administration. Cost related to IV fluids was increased in the control group.Conclusion
Postoperative intravenous fluids are not necessary in patients undergoing laparoscopic cholecystectomy, and their use is associated with increased nursing time and costs. 相似文献7.
Stephanie J. Tapp Brook I. Martin Tor D. Tosteson Jon D. Lurie Milton C. Weinstein Richard A. Deyo Sohail K. Mirza Anna N.A. Tosteson 《The spine journal》2018,18(4):584-592
Background Context
Minimally invasive lumbar spinal stenosis procedures have uncertain long-term value.Purpose
This study sought to characterize factors affecting the long-term cost-effectiveness of such procedures using interspinous spacer devices (“spacers”) relative to decompression surgery as a case study.Study Design
Model-based cost-effectiveness analysis.Patient Sample
The Medicare Provider Analysis and Review database for the years 2005–2009 was used to model a group of 65-year-old patients with spinal stenosis who had no previous spine surgery and no contraindications to decompression surgery.Outcome Measures
Costs, quality-adjusted life years (QALYs), and cost per QALY gained were the outcome measures.Methods
A Markov model tracked health utility and costs over 10 years for a 65-year-old cohort under three care strategies: conservative care, spacer surgery, and decompression surgery. Incremental cost-effectiveness ratios (ICER) reported as cost per QALY gained included direct medical costsfor surgery. Medicare claims data were used to estimate complication rates, reoperation, and related costs within 3 years. Utilities and long-term reoperation rates for decompression were derived frompublished studies. Spacer failure requiring reoperation beyond 3 years and post-spacer health utilities are uncertain and were evaluated through sensitivity analyses. In the base-case, the spacer failure rate was held constant for years 4–10 (cumulative failure: 47%). In a “worst-case” analysis, the 10-year cumulative reoperation rate was increased steeply (to 90%). Threshold analyses were performed to determine the impact of failure and post-spacer health utility on the cost-effectiveness of spacer surgery.Results
The spacer strategy had an ICER of $89,500/QALY gained under base-case assumptions, and remained under $100,000 as long as the 10-year cumulative probability of reoperation did not exceed 54%. Under worst-case assumptions, the spacer ICER was $482,000/QALY and fell below $100,000 only if post-spacer utility was 0.01 greater than post-decompression utility or the cost of spacer surgery was $1,600 less than the cost of decompression surgery.Conclusions
Spacers may provide a reasonably cost-effective initial treatment option for patients with lumbar spinal stenosis. Their value is expected to improve if procedure costs are lower in outpatient settings where these procedures are increasingly being performed. Decision analysis is useful for characterizing the long-term cost-effectiveness potential for minimally invasive spinal stenosis treatments and highlights the importance of complication rates and prospective health utility assessment. 相似文献8.
Chao-Hui Zheng Jun Lu Hua-Long Zheng Ping Li Jian-Wei Xie Jia-Bin Wang Jian-Xian Lin Qi-Yue Chen Long-Long Cao Mi Lin Ru-Hong Tu Chang-Ming Huang 《Surgery》2018,163(2):300-304
Objective
To determine the relative safety and efficacy of 3D laparoscopic gastrectomy and 2D laparoscopic surgery in patients with gastric cancer.Background
There is still a lack of randomized controlled trials regarding the safety and efficacy of 3D versus 2D laparoscopic surgery for gastric cancer.Methods
A large-scale, phase 3, prospective, randomized controlled trial was conducted. (ClinicalTrials.gov number NCT02327481).Results
A total of 438 patients were randomized (3D group: 219 cases; 2D group: 219 cases) between January 1, 2015, and April 1, 2016; 19 patients were excluded. Finally, data from 419 patients were analyzed (3D group: 211 cases; 2D group: 208 cases). There were no differences between the 2 groups regarding the operation time (3D versus 2D, 176?±?35?min vs. 174?±?33?min, P?=?.562). The intraoperative blood loss in the 3D group was somewhat less than in the 2D group (61?±?83?mL vs. 82?±?119?mL, P?=?.045). Further analysis suggested that the use of 3D laparoscopic surgery was a protective factor against excessive blood loss (≥200?mL).Conclusion
3D laparoscopic gastrectomy did not shorten the operation time compared with 2D laparoscopic gastrectomy, but provided the benefit of less intraoperative blood loss and a lesser occurrence of excessive bleeding than the conventional 2D laparoscopic gastrectomy; the clinical value of the difference is limited. 相似文献9.
Maysoon Gamaleldin Cigdem Benlice Conor P. Delaney Scott Steele Emre Gorgun 《Surgery》2018,163(3):522-527
Background
Colonoscopy is the gold standard for colorectal screening and surveillance. Advanced endoscopic polypectomy techniques such as endoscopic submucosal dissection (ESD) have been introduced to remove large colorectal polyps. Our aim was to compare the outcomes of patients who underwent ESD with those of who underwent laparoscopic colectomy for benign colorectal polyps.Methods
Patients with a preoperative diagnosis of benign colorectal polyp who underwent ESD or colectomy between 2011 and 2016 were case matched for age, sex, body mass index, American Society of Anesthesiologists status, polyp size, and location. Outcomes and cost data were analyzed. Polyps proximal to the splenic flexure were grouped as right-sided polyps, and polyps distal to the splenic flexure were grouped as left-sided polyps.Results
We identified 144 patients in the laparoscopic resection group and 111 patients in the ESD group; 48 patients met the matching criteria. Of the 48 patients in the ESD group, 5 required operative resection. Mean duration of stay in laparoscopic resection group and the ESD group was 5.2?±?2.4 days vs 1.5?±?1.4 (P?<?.001). Mean operative time was no different (136?±?45 vs 133?±?72.7 minutes, respectively). Six patients had follow-up colonoscopy within a year in the laparoscopic resection group versus 22 patients in the ESD group. The laparoscopic group had 21% complication rate versus 15% for the ESD group (P?>?.05). ESD had a 43% cost-reduction advantage over laparoscopic colectomy, with a 44% and 39% cost advantage for right- and left-sided lesions, respectively.Conclusion
ESD is more cost effective than conventional segmental resection. With an experienced endoscopist, ESD can be offered as a colon-preserving procedure. 相似文献10.
Background
We evaluated whether diagnostic thyroidectomy for indeterminate thyroid nodules would be more cost-effective than genetic testing after including the costs of long-term surveillance.Methods
We used a Markov decision model to estimate the cost-effectiveness of thyroid lobectomy versus genetic testing (Afirma®) for evaluation of indeterminate (Bethesda 3–4) thyroid nodules. The base case was a 40-year-old woman with a 1-cm indeterminate nodule. Probabilities and estimates of utilities were obtained from the literature. Cost estimates were based on Medicare reimbursements with a 3% discount rate for costs and quality-adjusted life-years.Results
During a 5-year period after the diagnosis of indeterminate thyroid nodules, lobectomy was less costly and more effective than Afirma® (lobectomy: $6,100; 4.50 quality-adjusted life- years vs Afirma®: $9,400; 4.47 quality-adjusted life-years). Only in 253 of 10,000 simulations (2.5%) did Afirma® show a net benefit at a cost-effectiveness threshold of $100,000 per quality- adjusted life-years. There was only a 0.3% probability of Afirma® being cost saving and a 14.9% probability of improving quality-adjusted life-years.Conclusions
Our base case estimate suggests that diagnostic lobectomy dominates genetic testing as a strategy for ruling out malignancy of indeterminate thyroid nodules. These results, however, were highly sensitive to estimates of utilities after lobectomy and living under surveillance after Afirma®. 相似文献11.
Herbert P. Stride Brian C. George Reed G. Williams Jordan D. Bohnen Megan J. Eaton Mary C. Schuller Lihui Zhao Amy Yang Shari L. Meyerson Rebecca Scully Gary L. Dunnington Laura Torbeck John T. Mullen Samuel P. Mandell Michael Choti Eugene Foley Chandrakanth Are Edward Auyang Jonathan P. Fryer 《Surgery》2018,163(3):488-494
Background
Concerns exist regarding the competency of general surgery graduates with performing core general surgery procedures. Current competence assessment incorporates minimal procedural numbers requirements.Methods
Based on the Zwisch scale we evaluated the level of autonomy achieved by categorical PGY1-5 general surgery residents at 14?U.S. general surgery resident training programs between September 1, 2015 and December 31, 2016. With 5 of the most commonly performed core general surgery procedures, we correlated the level of autonomy achieved by each resident with the number of procedures they had performed before the evaluation period, with the intent of identifying specific target numbers that would correlate with the achievement of meaningful autonomy for each procedure with most residents.Results
Whereas a definitive target number was identified for laparoscopic appendectomy (i.e. 25), for the other 4 procedures studied (i.e. laparoscopic cholecystectomy, 52; open inguinal hernia repair, 42; ventral hernia repair, 35; and partial colectomy, 60), target numbers identified were less definitive and/or were higher than many residents will experience during their surgical residency training.Conclusions
We conclude that procedural target numbers are generally not effective in predicting procedural competence and should not be used as the basis for determining residents' readiness for independent practice. 相似文献12.
Jonathan C. DeLong Erin P. Ward Thinzar M. Lwin Kevin T. Brumund Kaitlyn J. Kelly Santiago Horgan Michael Bouvet 《Surgery》2018,163(2):388-392
Background
Our aim was to evaluate the ease and utility of using indocyanine green fluorescence angiography for intraoperative localization of the parathyroid glands.Methods
Indocyanine green fluorescence angiography was performed during 60 parathyroidectomies for primary hyperparathyroidism during a 22-month period. Indocyanine green was administered intravenously to guide operative navigation using a commercially available fluorescence imaging system. Video files were graded by 3 independent surgeons for strength of enhancement using an adapted numeric scoring system.Results
There were 46 (77%) female patients and 14 (23%) male patients whose ages ranged from 17 to 87 (average 60) years old. Of the 60 patients, 43 (71.6%) showed strong enhancement, 13 (21.7%) demonstrated mild to moderate vascular enhancement, and 4 (6.7%) exhibited little or no vascular enhancement. Of the 54 patients who had a preoperative sestamibi scan, a parathyroid adenoma was identified in 36, while 18 failed to localize. Of the 18 patients who failed to localize, all 18 patients (100%) had an adenoma that fluoresced on indocyanine green imaging. The operations were performed safely with minimal blood loss and short operative times.Conclusion
Indocyanine green angiography has the potential to assist surgeons in identifying parathyroid glands rapidly with minimal risk. 相似文献13.
Vikrom K. Dhar Young Kim Justin T. Graff Andrew D. Jung Jennifer Garrett Lauren E. Dick Jenifer Harris Shimul A. Shah 《Surgery》2018,163(3):565-570
Background
Despite the potential benefits of social media, health care providers are often hesitant to engage patients through these sites. Our aim was to explore how implementation of social media may affect patient engagement and satisfaction.Methods
In September 2016 a Facebook support group was created for liver transplant patients to use as a virtual community forum. Data including user demographics and group activity were reviewed. A survey was conducted evaluating users' perceptions regarding participation in the group.Results
Over 9 months, 350 unique users (50% liver transplant patients, 36% caregivers/friends, 14% health care providers) contributed 339 posts, 2,338 comments, and 6,274 reactions to the group; 98% of posts were reacted to or commented on by other group members. Patients were the most active users compared with health care providers and caregivers. A total of 95% of survey respondents reported that joining the group had a positive impact on their care; and 97% reported that their main motivation for joining was to provide or receive support from other patients.Conclusion
This pilot study indicates that the integration of social media into clinical practice can empower surgeons to synthesize effectively a patient support community that augments patient engagement and satisfaction. 相似文献14.
Jamie R. Robinson Nicholas H. Carter Corinne Gibson Adam S. Brinkman Kyle Van Arendonk Karen E. Speck Melissa E. Danko Gretchen P. Jackson Harold N. Lovvorn Martin L. Blakely 《Journal of pediatric surgery》2018,53(6):1181-1186
Purpose
Standardized care via a unified surgeon preference card for pediatric appendectomy can result in significant cost reduction. The purpose of this study was to evaluate the impact of cost and outcome feedback to surgeons on value of care in an environment reluctant to adopt a standardized surgeon preference card.Methods
Prospective observational study comparing operating room (OR) supply costs and patient outcomes for appendectomy in children with 6-month observation periods both before and after intervention. The intervention was real-time feedback of OR supply cost data to individual surgeons via automated dashboards and monthly reports.Results
Two hundred sixteen children underwent laparoscopic appendectomy for non-perforated appendicitis (110 pre-intervention and 106 post-intervention). Median supply cost significantly decreased after intervention: $884 (IQR $705–$1025) to $388 (IQR $182–$776), p < 0.001. No significant change was detected in median OR duration (47 min [IQR 36–63] to 50 min [IQR 38–64], p = 0.520) or adverse events (1 [0.9%] to 6 [4.7%], p = 0.062). OR supply costs for individual surgeons significantly decreased during the intervention period for 6 of 8 surgeons (87.5%).Conclusion
Approaching value measurement with a surgeon-specific (rather than group-wide) approach can reduce OR supply costs while maintaining excellent clinical outcomes.Level of Evidence
Level II. 相似文献15.
Vikrom K. Dhar Dennis J. Hanseman Brad M. Watkins Ian M. Paquette Shimul A. Shah Jonathan R. Thompson 《Surgery》2018,163(3):571-577
Background
The impact of operative technique on outcomes in laparoscopic sleeve gastrectomy has been explored previously; however, the relative importance of patient characteristics remains unknown. Our aim was to characterize national variability in operative technique for laparoscopic sleeve gastrectomy and determine whether patient-specific factors are more critical to predicting outcomes.Methods
We queried the database of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program for laparoscopic sleeve gastrostomies performed in 2015 (n?=?88,845). Logistic regression models were used to determine predictors of postoperative outcomes.Results
In 2015, >460 variations of laparoscopic sleeve gastrectomy were performed based on combinations of bougie size, distance from the pylorus, use of staple line reinforcement, and oversewing of the staple line. Despite such substantial variability, technique variants were not predictive of outcomes, including perioperative morbidity, leak, or bleeding (all P ≥ .05). Instead, preoperative patient characteristics were found to be more predictive of these outcomes after laparoscopic sleeve gastrectomy. Only history of gastroesophageal disease (odds ratio 1.44, 95% confidence interval 1.08–1.91, P < .01) was associated with leak.Conclusion
Considerable variability exists in technique among surgeons nationally, but patient characteristics are more predictive of adverse outcomes after laparoscopic sleeve gastrectomy. Bundled payments and reimbursement policies should account for patient-specific factors in addition to current accreditation and volume thresholds when deciding risk-adjustment strategies. 相似文献16.
Jeffrey L. Gum Richard Hostin Chessie Robinson Michael P. Kelly Leah Yacat Carreon David W. Polly R. Shay Bess Douglas C. Burton Christopher I. Shaffrey Justin S. Smith Virginie LaFage Frank J. Schwab Christopher P. Ames Steven D. Glassman 《The spine journal》2017,17(1):96-101
Background Context
Over the past decade, the number of adult spinal deformity (ASD) surgeries has more than doubled in the United States. The complex surgeries needed to manage ASD are associated with significant resource utilization and high cost, making them a primary target for increased scrutiny. Accordingly, it is important to not only demonstrate value in ASD surgery as clinical effectiveness but also to translate outcome assessment to cost-effectiveness.Purpose
To compare the difference between Medicare allowable rates and the actual, direct hospital costs for ASD surgeries.Study Design
Longitudinal cohort.Patient Sample
Consecutive patients enrolled in an ASD database from a single institution.Outcome Measures
Short Form (SF)-6D.Methods
Consecutive patients enrolled in an ASD database from a single institution from 2008 to 2013 were identified. Direct hospital costs were collected from hospital administrative records for the entire inpatient episode of surgical care. Medicare allowable rates were calculated for the same inpatient stays using the year-appropriate Center for Medicare-Medicaid Services Inpatient Pricer Payment System Tool. The SF-6D, a utility index derived from the SF-36v1, was used to determine quality-adjusted life years (QALY). Costs and QALYs were discounted at 3.5% annually.Results
Of 580 surgical ASD patients eligible for 2-year follow up, 346 (60%) had complete baseline and 2-year data, and 60 were Medicare beneficiaries comprising the cohort for the present study. Mean SF-6D gained is 0.10 during year 1 after surgery and 0.02 at year 2, resulting in a cumulative SF-6D gain of 0.12 over 2 years. Mean Medicare allowable rate over the 2 years is $82,050 (range $42,383 to $220,749) and mean direct cost is $99,114 (range $28,447 to $217,717). Mean cost per QALY over 2 years is $683,750 using Medicare allowable rates and $825,950 using direct costs. This difference of $17,181 between the 2 cost calculation represents a 17% difference, which was statistically significant (p<.001).Conclusions
There is a significant difference in direct hospital costs versus Medicare allowable rates in ASD surgery and in turn, there is a similar difference in the cost per QALY calculation. Utilizing Medicare allowable rates not only underestimates (17%) the cost of ASD surgery, but it also creates inaccurate and unrealistic expectations for researchers and policymakers. 相似文献17.
Paul T. Ogink Teun Teunis Olivier van Wulfften Palthe Karen Sepucha Christopher M. Bono Joseph H. Schwab Thomas D. Cha 《The spine journal》2018,18(9):1584-1591
Background Context
Lumbar spinal stenosis is a common condition in the elderly for which costs vary substantially by region. Comparing differences between surgeons from a single institution, thereby omitting regional variation, could aid in identifying factors associated with higher costs and individual drivers of costs. The use of decision aids (DAs) has been suggested as one of the possible tools for diminishing costs and cost variation.Purpose
(1) To determine factors associated with higher costs for treatment of spinal stenosis in the first year after diagnosis in a single institution; (2) to find individual drivers of costs for providers with higher costs; and (3) to determine if the use of DAs can decrease costs and cost variability.Study Design
Retrospective cohort study.Patient Sample
A total of 10,858 patients in 18 different practices diagnosed with lumbar spinal stenosis between January 2003 and July 2015 in three associated hospitals of a single institution.Outcome Measures
Mean cost for a patient per provider in US dollars within 1 year after diagnosis of lumbar spinal stenosis.Methods
We collected all diagnostic testing, office visits, injections, surgery, and occupational or physical therapy related to lumbar spinal stenosis within 1 year after initial diagnosis. We used multivariable linear regression to determine independent predictors for costs. Providers were grouped in tiers based on mean total costs per patient to find drivers of costs. To assess the DAs effect on costs and cost variability, we matched DA patients one-to-one with non-DA patients.Results
Male gender (β 0.10, 95% confidence interval [CI] 0.05–0.15, p<.001), seeing an additional provider (β 0.77, 95% CI 0.69–0.86, p<.001), and having an additional spine diagnosis (β 0.79, 95% CI 0.74–0.84, p<.001) were associated with higher costs. Providers in the high cost tier had more office visits (p<.001), more imaging procedures (p<.001), less occupational or physical therapy (p=.002), and less surgery (p=.001) compared with the middle tier. Eighty-two patients (0.76%) received a DA as part of their care; there was no statistically significant difference between the DA group and the matched group in costs (p=.975).Conclusions
Male gender, seeing an additional provider, and having an additional spine diagnosis were independently associated with higher costs. The main targets for cost reduction we found are imaging procedures and number of office visits. Decision aids were not found to affect cost. 相似文献18.
Nicholas E. Anton John M. Sawyer James R. Korndorffer Christopher G. DuCoin Graham McRary Lava R. Timsina Dimitrios Stefanidis 《Surgery》2018,163(3):560-564
Background
Assessment tools specific to intracorporeal suturing are lacking. The purpose of this study was to validate a novel Intracorporeal Suturing Assessment Tool (ISAT) by comparing it with existing measures that have been reported to have validity evidence.Methods
Videos of laparoscopic suturing were assessed by 3 blinded laparoscopic experts using the validated Global Operative Assessment of Laparoscopic Skills (GOALS) scale and the ISAT. Correlations between these instruments were calculated, and sensitivity analyses compared both tools with objective suturing scores. A factor analysis was also performed.Results
The ISAT and GOALS ratings were significantly correlated with the objective suturing score (r?=?0.58 and 0.61, respectively; P?<?.0001), and with each other (r?=?0.92, P?<?.0001). A weighted κ test indicated significantly higher agreement than expected between these instruments (P?<?.0001). All ISAT items had a factor loading approaching or greater than 0.50.Conclusion
The ISAT accurately assessed laparoscopic suturing skill related to other instruments. ISAT was highly correlated with GOALS, which is often used for laparoscopic performance assessment. Unlike the generic GOALS, ISAT includes specific information that can provide feedback on trainee suturing ability and targeted performance improvements. ISAT may provide a better alternative for intracorporeal suturing assessment. 相似文献19.
Punam P. Parikh Jun Tashiro Amy E. Wagenaar Miosotys Curbelo Eduardo A. Perez Holly L. Neville Anthony R. Hogan Juan E. Sola 《Journal of pediatric surgery》2018,53(4):616-619
Background
Appendiceal ligation during pediatric laparoscopic appendectomy (LA) may be performed using looped suture versus stapler. Controversy regarding the utility of either method exists. Clinical outcomes and cost analysis of LA with both methods were compared.Methods
All pediatric LA were performed from fiscal years 2013 and 2014 by two pediatric surgeons. While one surgeon used looped suture, the other used stapler exclusively. chi-Square tests were performed to analyze associations.Results
Two hundred thirty-eight cases were analyzed where looped suture versus stapler LA was performed in 46% and 54% of patients, respectively. Operating room costs were $317.10 and $707.12/person for looped suture and stapler LA, respectively (P < 0.0001). Difference in cost of $390.02/person was attributed solely to ligation type. On bivariate analysis, rate of in-hospital complications, length of stay, return-to-ER and readmission within 30 days did not significantly differ between groups.Conclusion
A comparative analysis of looped suture versus stapler device during LA for pediatric appendicitis revealed that postoperative complications, length of stay, ER visits and readmissions were not significantly different. Looped suture LA was significantly more cost efficient than stapler LA. In pediatric appendicitis, appendiceal ligation during LA may be performed safely and cost effectively with looped suture versus stapler.Type of study
Cost effectivenessLevel of evidence
III. 相似文献20.
Kibileri Williams Lauren Baumann Fizan Abdullah Shawn D. St. Peter Tolulope A. Oyetunji 《Journal of pediatric surgery》2018,53(1):48-51