Comparison of health-care utilization and expenditures for minimally invasive vs. open colectomy for benign disease

Clinical and economic effects of the transformation from an open to a laparoscopic center for colorectal surgery

PURPOSE

The purpose of this study was to assess the feasibility of transitioning from open to laparoscopic surgery for colorectal carcinoma in a primary care hospital setting. Despite the recognized benefits of laparoscopic surgery in postoperative recovery and its demonstrated oncological equivalence, only a minority of patients (30-40%) in Germany undergo laparoscopic procedures, primarily due to concerns which, in addition to the perioperative quality data and economic aspects, focus on patient safety.

METHODS

Over a three-year period (2012-2014), the transformation process was observed in a colorectal cancer center. Data from 237 patients (115 laparoscopic; 122 open) were collected prospectively and analyzed retrospectively. Short-term outcomes, including demographic data, perioperative complications, and quality metrics, as well as long-term survival data, were included.

RESULTS

Laparoscopic surgery demonstrated several advantages. Postoperative intensive care needs decreased significantly (average length of stay: laparoscopic 1.2 days vs. open 2.5 days; p = 0.032). Hospital stays were also shorter following laparoscopic surgery (median laparoscopic 10 days vs. median open 14 days; p = 0.011). Quality of specimens, particularly lymph node retrieval, remained comparable (median laparoscopic = 18 vs. median open = 19). Survival data showed non- inferiority of the laparoscopic approach. Despite higher initial costs, laparoscopic surgery yielded cost savings of approximately 3150 € per case due to reduced intensive care and shorter hospital stays.

CONCLUSION

In conclusion, this study demonstrates the feasibility of transitioning from open to laparoscopic oncologic colorectal surgery in a primary care hospital setting. The findings suggest that such a transition can be accomplished without compromising the quality of specimens, while also realizing cost savings and maintaining patient safety.

Effect of telemedicine use on medical spending and health care utilization among patients with gastrointestinal cancer

BACKGROUND

We sought to assess the impact of telemedicine on healthcare utilization and medical expenditures among patients with a diagnosis of gastrointestinal (GI) cancer.

METHODS

Patients with newly diagnosed GI cancer from 2013 to 2020 were identified from the IBM MarketScan database (IBM Watson Health) . Healthcare utilization, total medical outpatient insurance payments within 1 year post-diagnosis, and out-of-pocket (OOP) expenses among telemedicine users and non-users were assessed after propensity score matching (PSM).

RESULTS

Among the 32,677 patients with GI cancer (esophageal, n = 1862, 5.7%; gastric, n = 2009, 6.1%; liver, n = 2929, 9.0%; bile duct, n = 597, 1.8%; pancreas, n = 3083, 9.4%; colorectal, n = 22,197, 67.9%), a total of 3063 (9.7%) utilized telemedicine. After PSM (telemedicine users, n = 3064; non-users, n = 3064), telemedicine users demonstrated a higher frequency of clinic visits (median: 5.0 days, IQR 4.0-7.0 vs non-users: 2.0 days, IQR 2.0-3.0, P < .001) and fewer potential days missed from daily activities (median: 7.5 days, IQR 4.5-12.5 vs non-users: 8.5 days, IQR 5.5-13.5, P < .001). Total medical spending per month and utilization of emergency room (ER) visits for telemedicine users were higher vs non-users (median: $10,658, IQR $5112-$18,528 vs non-users: $10,103, IQR $4628-$16,750; 46.8% vs 42.6%, both P < .01), whereas monthly OOP costs were comparable (median: $273, IQR $137-$449 for telemedicine users vs non-users: $268, IQR $142-$434, P = .625).

CONCLUSION

Telemedicine utilization was associated with increased outpatient clinic visits yet reduced potential days missed from daily activities among patients with GI cancer. Telemedicine users tended to have more ER visits and total medical spending per month, although monthly OOP costs were comparable with non-users.

Health-care expenditures are less for minimally invasive than open colectomy for colon cancer: A US commercial claims database analysis

BACKGROUND

Most studies comparing surgical platforms focus on short-term outcomes. In this study, we compare the expanding societal penetration of minimally invasive surgery (MIS) with open colectomy by assessing payer and patient expenditures up to one year for patients undergoing surgery for colon cancer.

METHODS

We analyzed the IBM MarketScan Database for patients who underwent left or right colectomy for colon cancer between 2013 and 2020. Outcomes included perioperative complications and total health-care expenditures up to 1 year following colectomy. We compared results for patients who had open colectomy (OS) to those with MIS operations. Subgroup analyses were performed for adjuvant chemotherapy (AC+) versus no adjuvant chemotherapy (AC-) groups and for laparoscopic (LS) versus robotic (RS) approaches.

RESULTS

Of 7,063 patients, 4,417 cases did not receive adjuvant chemotherapy (OS: 20.1%, LS: 67.1%, RS: 12.7%) and 2646 cases had adjuvant chemotherapy (OS: 28.4%, LS: 58.7%, RS: 12.9%) after discharge. MIS colectomy was associated with lower mean expenditure at index surgery and post-discharge periods for AC- patients (index surgery: $34,588 vs $36,975; 365-day post-discharge $20,051 vs $24,309) and for AC+ patients (index surgery: $37,884 vs $42,160; 365-day post-discharge $103,341vs $135,113; p < 0.001 for all comparisons). LS had similar index surgery expenditures but significantly higher expenditures at post-discharge 30 days (AC-: $2,834 vs $2276, p = 0.005; AC+: $9100 vs $7698, p = 0.020) than RS. The overall complication rate was significantly lower in the MIS group than the open group for AC- patients (20.5% vs 31.2%) and AC+ patients (22.6% vs 39.1%, both p < 0.001).

CONCLUSION

MIS colectomy is associated with better value at lower expenditure than open colectomy for colon cancer at the index operation and up to one year after surgery. RS expenditure is less than LS in the first 30 postoperative days regardless of chemotherapy status and may extend to 1 year for AC- patients.

Implementation of a standardized multimodal pain regimen significantly reduces postoperative inpatient opioid utilization in patients undergoing bariatric surgery

BACKGROUND

Routine opioid use in surgical patients has received attention given the opioid epidemic and a renewed focus on the dangers and drawbacks of opioids in the postoperative setting. Little is known about opioid use in bariatric surgery, especially in the inpatient setting. We hypothesize that a standardized opioid-sparing protocol reduces postoperative inpatient opioid use in bariatric surgery patients.

METHODS

A retrospective cohort study was conducted of bariatric surgery patients at a single institution. From March to September 2019, a standardized intraoperative and postoperative opioid-sparing protocol was designed and implemented along with an educational program for patients regarding safe pain management. Inpatient opioid utilization in patients undergoing surgery in the preintervention phase between April and March 2019 was compared to patients from a postintervention phase of October 2019 to December 2020. Opioid utilization was measured in morphine milliequivalents (MME).

RESULTS

A total of 359 patients were included; 192 preintervention and 167 postintervention. Patients were similar demographically. For all patients, mean age was 44.1 years, mean BMI 49.2 kg/m2, and 80% were female. Laparoscopic sleeve gastrectomy was performed in 48%, laparoscopic gastric bypass in 34%, robotic sleeve gastrectomy in 17%, and robotic gastric bypass in 1%. In the postintervention phase inpatient opioid utilization was significantly lower [median 134.8 [79.0-240.8] MME preintervention vs. 61.5 [35.5-150.0] MME postintervention (p < 0.001)]. MME prescribed at discharge decreased from a median of 300 MME preintervention to 75 MME postintervention (p < 0.001). In the postintervention phase, 16% of patients did not receive an opioid prescription at discharge compared to 0% preintervention (p < 0.001). When examining by procedure, statistically significant reductions in opioid utilization were seen for each operation.

CONCLUSION

Implementation of a standardized intraoperative and postoperative multimodal pain regimen and educational program significantly reduces inpatient opioid utilization in patients undergoing bariatric surgery.

Robotic versus laparoscopic left colectomy: a systematic review and meta-analysis

BACKGROUND

This study aimed to review the new evidence to understand whether the robotic approach could find some clear indication also in left colectomy.

METHODS

A systematic review of studies published from 2004 to 2022 in the Web of Science, PubMed, and Scopus databases and comparing laparoscopic (LLC) and robotic left colectomy (RLC) was performed. All comparative studies evaluating robotic left colectomy (RLC) versus laparoscopic (LLC) left colectomy with at least 20 patients in the robotic arm were included. Abstract, editorials, and reviews were excluded. The Newcastle-Ottawa Scale for cohort studies was used to assess the methodological quality. The random-effect model was used to calculate pooled effect estimates.

RESULTS

Among the 139 articles identified, 11 were eligible, with a total of 52,589 patients (RLC, n = 13,506 versus LLC, n = 39,083). The rate of conversion to open surgery was lower for robotic procedures (RR 0.5, 0.5-0.6; p < 0.001). Operative time was longer for the robotic procedures in the pooled analysis (WMD 39.1, 17.3-60.9, p = 0.002). Overall complications (RR 0.9, 0.8-0.9, p < 0.001), anastomotic leaks (RR 0.7, 0.7-0.8; p < 0.001), and superficial wound infection (RR 3.1, 2.8-3.4; p < 0.001) were less common after RLC. There were no significant differences in mortality (RR 1.1; 0.8-1.6, p = 0.124). There were no differences between RLC and LLC with regards to postoperative variables in the subgroup analysis on malignancies.

CONCLUSIONS

Robotic left colectomy requires less conversion to open surgery than the standard laparoscopic approach. Postoperative morbidity rates seemed to be lower during RLC, but this was not confirmed in the procedures performed for malignancies.

Is robotic lobectomy cheaper? A micro-cost analysis

Higher capital costs and operating room costs associated with Lobectomy via Robot Assisted Thoracic Surgery (RATS) have previously been suggested as the principal contributors to the elevated overall cost. This study uses a micro-costing approach to a previous analysis of clinical outcomes of RATS, Video-Assisted Thoracic Surgery (VATS) and Open Lobectomy to evaluate the most significant cost drivers for the higher cost of robot-assisted lobectomy. A micro-costing model was developed to reflect the pathway of patients from day of surgery through the first 30 days following lobectomy. Costs were provided for RATS, VATS and Open approaches. Sensitivity analysis was performed specifically in the area of staff costs. A threshold sensitivity analysis of the overall cost components was also performed. Total cost per case for the RATS approach was €13,321 for the VATS approach €11,567, and for the Open approach €12,582. The overall cost differences were driven primarily by the elevated consumable costs associated with RATS Lobectomy. Capital costs account for a relatively small proportion of the per-case cost difference. This study presents a detailed analysis of the cost drivers for lobectomy, modelled for the three primary surgical approaches. We believe this is a useful tool for surgeons, hospital management, and service commissioning agencies to accurately and comprehensively determine where cost savings can be applied in their programme to improve the cost-effectiveness of RATS lobectomy.