The economic impact of early enteral feeding in gastrointestinal surgery: a prospective survey of 51 consecutive patients

Early postoperative oral feeding has been demonstrated to be safe and not increase postoperative morbidity. There are conflicting reports about its effect on postoperative length of stay. Some patients will fail attempts at early postoperative feeding and may be relegated to a longer postoperative course. Few studies to date have attempted to identify cost savings associated with early oral support, and those identified address nasoenteric support only. Fifty-one consecutive patients were randomized into either a traditional postoperative feeding group or an early postoperative feeding group after their gastrointestinal surgery. Length of hospital stay, hospital costs (excluding operating room costs), morbidity, and time to tolerance of a diet were compared. There was a tendency toward increased nasogastric tube use in the early feeding arm, but the morbidity rates were similar. Length of hospital stay and costs were similar in both arms. Early postoperative enteral support does not reduce hospital stay, nursing workload, or costs. It may come at a cost of higher nasogastric tube use, however, without an increase in postoperative morbidity.     

Early feeding after laparoscopic pyloromyotomy: the pros and cons

Background Early feeding after pyloromyotomy for hypertrophic pyloric stenosis (HPS) has been advocated because this would lead to earlier discharge. However, some authors remain reluctant to introduce early feeding because of concern about postoperative vomiting. This study aimed to clarify the effects of early versus later feeding after laparoscopic pyloromyotomy on postoperative vomiting, time required to reach full oral feeding, hospital stay, and follow-up evaluation.Methods During the period from October 1993 through March 2002, 185 infants underwent laparoscopic pyloromyotomy for HPS. Of these patients, 164 patients were included in the study. The initial feeding was within 4 h after surgery in group A and after 4 hours in group B. The outcome variables were postoperative vomiting subdivided into vomiting requiring adjustment of the feeding schedule or not, time required to reach full feeding, hospital stay, and vomiting as well as weight gain at follow-up assessment.Results In 23% of the 62 patients of group A and in 6% of the 102 patients of group B (p = 0.003), vomiting was so severe that it necessitated modification of the feeding schedule. Th time required to reach full feeding and the postoperative hospital stay were similar in the two groups. Analysis of the subgroups that required modification of the feeding schedule because of vomiting showed a significant delay in time required to reach full feedings as well as a significant delay in hospital discharge. There was an 11% incidence of ongoing vomiting after discharge irrespective of early or later feeding. Weight gain at follow-up assessment did not differ significantly between the two groups, and did not bear any relations to in-hospital vomiting.Conclusions Feeding within 4 h postoperatively leads to more severe vomiting than later feeding. Vomiting leads to discomfort for the child, anxiety for the parents, a prolonged time required to achieve full oral feeding, and a prolonged postoperative hospital stay. However, clinical outcome after discharge is not adversely affected by early feeding. According to this study, it appears that it would be better to withhold feeding for the first 4 h after surgery.     

A standardized feeding regimen for hypertrophic pyloric stenosis decreases length of hospitalization and hospital costs

BACKGROUND/PURPOSE: Before the institution of a standardized feeding regimen (SFR) for hypertrophic pyloric stenosis (HPS) at the authors' institution, the postoperative feeding regimen and, thus, the length of hospitalization for HPS patients was variable. The aim of this study was to evaluate whether a SFR would affect the length of hospitalization or hospital costs for HPS patients. METHODS: A 5-year retrospective analysis was performed on 242 patients who underwent pyloromyotomy via a standard right upper quadrant incision. The length of hospitalization and hospital costs were compared in these patients before and after the institution of a standardized postoperative feeding regimen. RESULTS: The SFR decreased total length of hospitalization by 19.4% (3.1 days v2.5 days, P = .002), postoperative length of stay by 21% (1.9 days v 1.5 days, P< .001), total costs by 11.9% (P= .05), direct costs by 7.7% (P= .22), and indirect costs by 18.6% (P= .003). This occurred despite a small increase in costs per day. The SFR did not change the complication rate (5.3% before SFR v6.1% after SFR, P = 1.0). CONCLUSION: A postoperative standardized feeding regimen for patients with HPS decreased length of hospitalization and hospital costs without adverse effects.     

Effect of the Deyo score on outcomes and costs in shoulder arthroplasty patients

PURPOSE. To evaluate the effect of preoperative comorbidity status (defined by the Deyo index) on hospital mortality, postoperative complications, length of hospital stay, and hospital costs for shoulder arthroplasty patients. METHODS. The overall mean hospital mortality and postoperative complication rates, and length of hospital stay and hospital costs stratified by the Deyo score were compared using the Pearson Chi squared test and the F-test, respectively. The effects of the Deyo score on hospital mortality and postoperative complications were estimated using multiple logistic regression. The length of hospital stay and hospital costs were estimated using multiple linear regression. The magnitude of the estimated effects of the Deyo score on the 4 outcomes were expressed as crude odds ratios (ORs) and adjusted ORs for age, race, gender, surgeon volume, and hospital volume. RESULTS. Higher Deyo scores tended to be associated with higher hospital mortality, length of hospital stay, postoperative complications, and hospital costs. Compared with the referent group (Deyo score=0), patients with the highest Deyo scores (5-36) exhibited adjusted ORs of 11.8 for hospital mortality (p=0.011) and 1.1 for developing postoperative complications (p=0.098), and had the highest length of hospital stay (mean, 4.1 days) and hospital costs (mean, US$18 549). CONCLUSION. The Deyo score was a predictor of outcomes and costs in the shoulder arthroplasty population. By identifying relevant factors, health care providers can better determine who should be referred for shoulder arthroplasty and what should be considered when assessing risks and benefits.     

The economic impact of opioids on postoperative pain management

STUDY OBJECTIVE: To evaluate the consequences of opioid use for postoperative pain management and the degree to which these consequences may be reduced or minimized with opioid-sparing or opioid-replacement techniques. DESIGN: Literature review relating to the economics of postoperative pain management. Comparisons between opioids and opioid-sparing techniques were identified and selected for study. MEASUREMENTS AND MAIN RESULTS: Studies evaluating overall economic impacts or surrogate outcomes (e.g., resource use or recovery milestones) showed benefits with opioid-sparing therapies. CONCLUSIONS: Opioids will likely remain an integral part of postoperative pain management, but side effects increase the costs of care. The challenge is to identify situations where opioid-sparing techniques improve surrogate economic measurements and decrease overall hospital costs.     

Ad libitum feeding: safely improving the cost-effectiveness of pyloromyotomy

Background/Purpose: Patients undergoing pyloromyotomy traditionally have been placed on complex postoperative feeding regimens. The authors evaluated the substitution of an ad libitum feeding regimen to determine if it could decrease length of hospital stay and cost without increasing the moribidity rate. Methods: Fifty-six consecutive patients undergoing open pyloromyotomy were evaluated. The initial 31 patients were treated with a traditional protocol, whereas the next 25 patients received ad libitum feeding. Time to first full-strength feeding, amount and time of any emesis, and time to discharge were recorded. Hospital costs and number of readmissions were assessed. Results: Patients in the ad libitum group had a statistically significant shorter time to discharge (25.1 hours versus 38.8 hours), which translated into a savings of $1,290 per patient. Whereas more patients in the ad libitum group experienced postoperative emesis (32% v 26%), this was not statistically significant. There was no other morbidity and there were no readmissions in either group. Conclusions: Postoperative ad libitum feedings resulted in significant decreases in hospital stay and associated costs without increasing morbidity. Ad libitum feeding is safe, simple, and cost effective, and may offer an avenue for short-stay pyloromyotomy in selected patients.     

Epidural analgesia in gastrointestinal surgery

BACKGROUND: The ideal perioperative analgesia should provide effective pain relief, avoid the detrimental effects of the stress response, be simple to administer without the need for intensive monitoring, and have a low risk of complications. METHODS: This review defines the physiological effects of epidural analgesia and assesses whether the available evidence supports its preferential use in gastrointestinal surgery. All papers studied were identified from a Medline search or selected by cross-referencing. RESULTS: Epidural analgesia is associated with a shorter duration of postoperative ileus, attenuation of the stress response, fewer pulmonary complications, and improved postoperative pain control and recovery. It does not reduce anastomotic leakage, intraoperative blood loss, transfusion requirement, risk of thromboembolism or cardiac morbidity, or hospital stay compared with that after conventional analgesia in unselected patients undergoing gastrointestinal surgery. Thoracic epidural analgesia reduces hospital costs and stay in patients at high risk of cardiac or pulmonary complications. CONCLUSIONS: Epidural analgesia enhances recovery after gastrointestinal surgery. The results support the development of structured regimens of early postoperative feeding and mobilization to exploit the potential for thoracic epidural analgesia to reduce hospital stay after gastrointestinal surgery.     

Quality assurance: the cost of utilization review and the educational value of medical audit in a university hospital.

The components of mandated quality assurance, that is, utilization review (UR) and medical audit, have been analyzed to determine their cost-effectiveness and educational value in a university hospital. At Ths in 1975 were $205,272--$6.71 per admission or $0.69 per patient day. The average costs per admission and per patient day in teaching hospitals in the New York area in 1975 were $10.42 and $0.93, respectively. It is anticipated that these costs will increase markedly in 1976 because of admission review. Since 1972 approximately 9,500 hospital charts have been reviewed annually to identify an average of six patients per year who required the intervention of the UR committee because of unnecessarily prolonged length of stay. The cost of identifying each patient was $33, 212. In the university hospital, the active participation of the graduate (house) staff in patient care renders the requirements for certification/recertification of the need for hospital services or admission review superfluous. From September, 1973, through December, 1975, 15 studies of evaluation of medical care (medical audit) have been completed at an average cost of $4,788 per audit. In ten audits the principal criticism was inadequate documentation of data in the hospital record. Nine audits were critical of excessive use of laboratory services and deviations of practice were identified in seven audits. Medical audit has failed to achieve its objective to identify the educational needs of the hospital staff. It is suggested that a more satisfactory and less costly form of medical audit should be devised. Clinical studies, published in scientific journals, should be considered in the context of medical audit.     

Anastomotic leakage after resection of colorectal cancer generates prodigious use of hospital resources

Objective  The aim of this study was to determine the demand for hospital resources generated by anastomotic leakage, including surgical, medical, imaging, pathology, and other allied health consultations or services and length of postoperative hospital stay.
Method  Data were obtained from a comprehensive, prospective hospital registry of all resections for colorectal cancer from January 1995 to December 2004 and from retrospective review of patients' notes.
Results  Forty-one patients with a leak spent 92 days in intensive care, required 129 days of total parenteral nutrition, 69 days of enteric feeding and 41 days on ventilation and had a median postoperative hospital stay of 28 days (range 11–104). These patients required 24 re-operations and 2273 separate medical consultations or allied services.
Conclusion  Anastomotic leakage generates a very considerable demand for hospital resources and diverts these resources from the hospital population at large.     

Randomized clinical trial of open versus laparoscopic cholecystectomy in the treatment of acute cholecystitis

BACKGROUND: The aim of this prospective trial was to determine whether surgical approach (open versus laparoscopic) had an impact on morbidity and postoperative recovery after cholecystectomy for acute cholecystitis. METHODS: Seventy patients who met the criteria for acute cholecystitis were randomized to open or laparoscopic cholecystectomy. The type of operation was unknown to the patient and all hospital staff involved in the postoperative care. RESULTS: The two groups were similar with respect to demographic and clinical characteristics. There were no significant differences in rate of postoperative complications, pain score at discharge and sick leave. In eight patients a laparoscopic procedure was converted to open cholecystectomy. Median operating time was 90 (range 30-155) and 80 (range 50-170) min in the laparoscopic and open groups respectively (P = 0.040). The direct medical costs were equivalent in the two groups. Although median postoperative hospital stay was 2 days in each group, it was significantly shorter in the laparoscopic group (P = 0.011). CONCLUSION: Cholecystectomy for acute cholecystitis can be performed by either laparoscopic or open techniques without any major clinically relevant differences in postoperative outcome. Both techniques offer low morbidity and rapid postoperative recovery.     

Feeding jejunostomy during Whipple is associated with increased morbidity

Background

Placement of a feeding jejunostomy tube (FJ) is often performed during pancreaticoduodenectomy (PD). Few studies, however, have sought to determine whether such placement affects postoperative outcomes after PD.

Materials and methods

This is a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database to determine the 30-d-postoperative mortality rate, major complication rate, and overall complication rate of jejunostomy tube placement at the time of PD. Univariate and multivariate comparison of postoperative outcomes between patients with and without FJ placement during PD was performed on a total of 4930 patients.

Results

Thirty-day-postoperative mortality did not differ between the two groups (4.0% for patients with FJ versus 2.7% without, P = 0.13), whereas overall morbidity (43.3% with FJ versus 34.6% without, P < 0.0001) and serious morbidity (29.5% with FJ versus 22.8% without, P < 0.0001) were significantly higher in patients undergoing FJ placement during PD. The specific complications that occurred more frequently in FJ patients than patients without FJ included deep space surgical site infection, pneumonia, unplanned reintubation, acute renal failure, and sepsis.

Conclusion

Although FJ placement during PD is considered to be routine at many institutions, our analysis of data from NSQIP suggest that FJ placement may be associated with increased postoperative morbidity.     

Enteral nutrition and surgical patient

Enteral nutrition can be applicated alone or in combination with parenteral nutrition. Enteral feeding should be applicated as early as possible in preoperative preparation or in postoperative period in respect of contraindications and everyday evaluation of patients. Immunomodulatory substances like arginine, 3-omega-fat acids, ribonucleic acid and glutamine are incorporated in "ready to use" solution for enteral feeding. Enteral feedings oral or via tubes are safe if some precautions are taken: like sitting position and control of feeding tubes position. Use of jejunostomy and promotility agents improved enteral feeding after major abdominal surgery and acute pancreatitis. Enteral feeding and immunonutrition improved postoperative course in reduction of hospital stay, incidence of postoperative complications especially infections. The aim of this review article is to validate pro and con for enteral nutrition in preoperative and postoperative course.     

Predictors of Health Care Use of Women with Breast Cancer: A Systematic Review

The aim of this study was to identify predictors of health care use among women with breast cancer by conducting a systematic review. Potentially relevant studies were identified by searching the PubMed, EMBASE, PsycINFO, CINAHL, and Cochrane Library databases. Also, backward and forward citation searches were performed. Studies were selected if they addressed associations between (a) sociodemographic, enabling (e.g., income), clinical and health related, or psychosocial predictors, and (b) medical, psychosocial, or paramedical health care use of adult women with breast cancer. The health care types of interest were hospital utilization and provider visits. An evaluation of aggregated findings was performed to determine consistency of findings between studies. Sixteen studies were included in the review. Higher age, a more advanced cancer stage, more comorbid disorders, having a mastectomy, a lymph node dissection, and breast reconstruction were consistently associated with higher hospital utilization. None of the patient characteristics were consistently associated with medical, psychosocial, or paramedical health care use—but psychosocial or paramedical associations were also less examined. In conclusion, sociodemographic, medical, and treatment‐related factors were consistently associated with (higher) health care use of breast cancer patients. Practitioners may use this information to anticipate future use of subgroups of patients. Results may also be used in the development of interventions that target relevant predictors, to reduce patients’ health care use and accompanying health care costs. Furthermore, more research is needed to identify predictors of psychosocial and paramedical health care use.     

Use of Tisseel fibrin sealant in neurosurgical procedures: incidence of cerebrospinal fluid leaks and cost-benefit analysis in a retrospective study

OBJECTIVE: To determine the clinical efficacy and cost effectiveness of using the fibrin sealant (FS) Tisseel (Baxter Healthcare Corp., Deerfield, IL) for patients undergoing anterior cranial base, infratemporal, and retromastoid surgical procedures. METHODS: A retrospective review was performed, comparing two matched populations of patients who underwent surgical procedures using anterior cranial, infratemporal, or retromastoid approaches to intracranial pathological lesions. The incidences of cerebrospinal fluid (CSF) leaks in matched groups treated with the FS Tisseel or treated without FS were compared. The costs of Tisseel use were examined in comparison with the costs of postoperative management of CSF leaks and/or tension pneumocranium with spinal drainage and occasionally surgical reexploration, when lumbar drainage failed. RESULTS: Patients who received the FS Tisseel exhibited no detectable postoperative CSF leaks or tension pneumocranium. Patients who did not receive Tisseel demonstrated 4 to 16% incidences of postoperative leaks, depending on the surgical approach used. The costs of treating those leaks far exceeded the costs of using Tisseel, even if it were used indiscriminately for all patients. CONCLUSION: This retrospective review indicates that the FS Tisseel reduces the incidence of postoperative CSF leaks and tension pneumocranium while reducing overall management costs. Further prospective study is needed to determine which patients can benefit most from FS use.     

Systematic Review and Meta-Analysis of Chewing-Gum Therapy in the Reduction of Postoperative Paralytic Ileus Following Gastrointestinal Surgery

Background  

Postoperative ileus has long been considered an inevitable consequence of gastrointestinal surgery. It prolongs hospital stay, increases morbidity, and adds to treatment costs. Chewing is a form of sham feeding reported to stimulate bowel motility. This analysis examines the value of chewing-gum therapy in treatment of postoperative ileus.     

Benefits of early feeding and early hospital discharge in elderly patients undergoing open colon resection

BACKGROUND: Recent studies have demonstrated a reduction in hospital stay and postoperative complications in elderly patients undergoing laparoscopy-assisted colectomy, and have attributed the shorter stays and reduced morbidity to the laparoscopic approach. We questioned whether the improved outcomes in these studies were a result of the laparoscopic procedure alone or a result of early postoperative feeding and early hospital discharge. We hypothesized that early feeding in elderly patients undergoing open colorectal resection results in a short hospital stay and favorably affects postoperative morbidity. STUDY DESIGN: Patients aged 70 years and older who were undergoing elective open colon resection were placed on an early postoperative feeding protocol. The early feeding protocol consisted of clear liquids on postoperative day 2, regular diet on postoperative day 3, and discharge to home as tolerated. The main outcomes measurements included early feeding tolerance, hospital stay, postoperative morbidity, and requirement for postoperative assisted care. RESULTS: There were 87 study patients (42 men and 45 women, mean age 77 years). The most common operation was right hemicolectomy (53%). Overall 78 of 87 patients (89.6%) tolerated early feeding. Five patients (5.7%) initially tolerated a diet but required readmission for ileus. Nine patients (10.4%) did not tolerate early feeding initially. The mean hospital stay for all patients was 3.9 days. There were 15 postoperative complications in 13 patients (14.9%), the most common of which was urinary retention. There were no deaths, anastomotic leaks, abscesses, or pneumonia. Only 3 of 86 patients (3.5%) who were previously independent required assisted care after colectomy. CONCLUSIONS: In elderly patients undergoing elective open colon resection, early feeding results in a short hospital stay and low postoperative morbidity. These results are comparable to those reported for laparoscopy-assisted colectomy.     

The cost of intraoperative adverse events in abdominal and pelvic surgery: A systematic review

Background

The assessment of intra-operative adverse events (iAEs) is a vastly under researched area with the potential to provide new methods on how to improve patient outcomes and hospital costs. Our objective was to determine the relationship between iAEs and total hospital costs in abdominal and pelvic surgery.

Pharmacological management of postoperative ileus

The duration of postoperative ileus following abdominal surgery is quite variable, and prolonged postoperative ileus is an iatrogenic phenomenon with important influence on patient morbidity, hospital costs and length of stay in hospital. Adequate treatment for prolonged postoperative ileus is important to improve patient morbidity and clinical efficiency. Both clinical and pharmacological management strategies have improved rapidly over the last decade, and appropriate and timely management using multimodal techniques should be used for optimal care. In this review, we define postoperative ileus, describe the pathogenesis and briefly discuss clinical management before detailing potential pharmacologic management options.     

Radiographic cost reduction strategy in total joint arthroplasty: A prospective analysis

A consecutive series of 222 patients who underwent cemented total knee arthroplasty (124) and uncemented total hip arthroplasty (98) were evaluated prospectively. The purpose of this study was to determine if routine radiologic interpretation of postoperative total hip and total knee radiographs is cost effective. Also, the study was designed to determine if routine predischarge radiographs, in conjunction with recovery room radiographs, are worthwhile. There were no changes in postoperative patient management based on orthopaedic or radiologic review of either radiograph. No additional information was gained from review of the radiologic evaluations. Therefore, obtaining one series of routine inpatient postoperative total joint radiographs and eliminating postoperative radiologic consultation will significantly reduce costs without compromising patient care.     

Pyloric stenosis--a timed perspective

In a review of 90 infants with pyloric stenosis who underwent pyloromyotomy, preoperative nasogastric drainage for more than six hours during the period of fluid resuscitation accompanied by a period of postoperative drainage for more than 12 hours resulted in better acceptance of a graduated feeding protocol with fewer emesis, earlier completion of full feeding, and shortened hospital stay.