Financial impact of thoracoabdominal aneurysm repair

National trends and regional variation of open and endovascular repair of thoracic and thoracoabdominal aneurysms in contemporary practice

OBJECTIVES

Successful surgical management of thoracic aortic aneurysms (TAA) and thoracoabdominal aortic aneurysms (TAAA) has historically relied upon open surgical repair (OSR). More recently, the advent and application of thoracic endovascular stent graft aneurysm repair (TEVAR) permutations have become increasingly performed in contemporary practice. To better determine the effect of TEVAR techniques on OSR, we examined national and regional trends in treatment use.

METHODS

All Medicare patients from 1998 through 2007 undergoing isolated TAA and TAAA repair were analyzed using a clinically validated algorithm using diagnostic International Classification of Disease 9th revision (ICD-9; 441.1, 441.2, 441.6, 441.7, 441.9) codes and procedural (ICD-9 OSR: 38.35, 38.45 and TEVAR: 39.73, 39.79) codes. Differential rates of OSR and TEVAR were compared across census tract regions during the study interval.

RESULTS

Total complex aortic repairs increased by 60%, from 10.8 to 17.8/100,000, between 1998 and 2007 (P < .001). A dramatic increase occurred in TEVAR (not performed in 1998, 5.8/100,000 in 2007) during the study period, but OSR rates remained stable during the same interval (10.7 to 12.0/100,000 in 2007, P = NS). There was substantial regional variation for both OSR and TEVAR. This regional variation was greater in OSR (range, 8.8-16.7/100,000) than in TEVAR (range, 4.5-6.9/100,000).

CONCLUSIONS

Degenerative TAA and TAAA aneurysms are being repaired in the United States at an increasing rate. This reflects the rapid acceptance of TEVAR, which apparently supplements rather than supplants OSR. There appears to be greater regional variation in OSR compared with TEVAR. These data may have significant implications for those interested in the effect of new technologies on health care and cost containment.

Thoracic aortic aneurysm repair. Direct hospital cost and Diagnosis Related Group reimbursement

OBJECTIVE

The main objective of this study was to analyze direct hospital cost and to compare cost with existing DRG reimbursement for open repair of thoracic and thoraco-abdominal aortic disease. STUDY SAMPLE AND METHODOLOGY: Between January 2003 and September 2003, the cost of treatment for 24 surgical procedures on ascending aorta and arch, descending or thoraco-abdominal aortic disease were examined prospectively. Seven patients had urgent or emergency surgeries. Ten had sternotomies for disease of the ascending aorta and aortic arch; two had left thoracotomies and three thoraco-laparotomy incisions with procedures performed on x-corporeal circulation. Nine other patients had more distal thoraco-abdominal aortic operations with a clamp-and-sew technique. Micro-cost analysis was performed on each hospital stay, in addition overhead hospital costs were allocated to each procedure.

RESULTS

The patients were grouped by discharge diagnosis (ICD-10) and surgical procedure performed (NCSP) into Norwegian DRG code. Patient with surgery on ascending aorta & aortic arch were allocated to DRG 108 (n=9) or 483 (tracheostomy, n=1) while patient with surgery on descending or thoraco-abdominal aorta were allocated to DRG 108 (n=3), 110 (n=4), 111 (n=4) or 483 (tracheostomy, n=3). The mean EuroSCORE for patients with proximal aortic disease was 11 (5-18), and the length of stay was 5 days (range 3-8 days), spending 2 days (range 1-7 days) in thoracic intensive care unit. For patients with distal aortic disease the mean Euroscore was 7 (2-14), and the mean length of stay 10 days (range 4-23 days) with a mean 4 days (range 1-13 days) in intensive care unit. Eight patients developed medical problems requiring new surgical procedures or prolonged ICU stay. The average direct hospital cost for proximal aortic surgery was USD 15,877 (USD 1=NOK 7.5) while the respective 100% DRG reimbursement including one patient needing a tracheostomy, was 19 803 USD. For patients with distal aortic disease, average direct hospital cost was 23 005 USD and DRG reimbursement including patients needing a tracheostomy was 31543 USD.

CONCLUSION

Our results underscore previous findings that these patients are resource intensive. This study shows that Norwegian 100% DRG reimbursement did over-compensate observed total hospital costs in this cohort. Detailed analysis showed that this was due to the higher DRG reimbursement for patients needing prolonged ventilatory support. Thus the actual DRG reimbursement seems to be relevant to the tertiary hospital actual costs when these complicated patients are considered as a group. It remains however unclear whether this reimbursement is sufficient to support the scientific infrastructure for new knowledge and skills needed for the further refinement of treatment.

Surgical repair of ruptured thoracic and thoracoabdominal aortic aneurysms

BACKGROUND

Rupture is the single most common cause of death in patients with thoracic aortic and thoracoabdominal aneurysm (TAA/TAAA) and is almost uniformly fatal.

METHODS

This was a retrospective review of patients admitted to a single practice with rupture of a TAA/TAAA between 1993 and 2000.

RESULTS

Twenty-two consecutive patients with a leaking TAA/TAAA were identified. The aetiology of rupture was either secondary to a degenerative TAAA or a type B dissection. Seventeen patients underwent surgery; one had a Crawford extent I, seven an extent II, one an extent III and two an extent IV TAAA. Six patients had an acute type B dissection with rupture in the upper descending thoracic aorta. The 30-day survival rate was 88 per cent (15 of 17 patients). Actuarial survival at 1 year in patients who had surgery was 65 per cent. Survival at 1 year for all presenting patients who consented to surgery was 40 per cent. Median survival was greater than 36 months.

CONCLUSION

As a result of improving medical care, more patients with a contained rupture of a TAA/TAAA may present for treatment. Surgery is complex and requires specialist teams for optimal care.

Outcomes after lower-extremity reconstruction in DRGs 478 and 479

PURPOSE

To assess outcomes for 21,261 patients in DRGs 478 and 479 hospitalized in Veterans Affairs Medical Centers (VAMCs) during fiscal years 1991-1994. DRGs 478 and 479 contain patients undergoing a variety of vascular procedures including lower-extremity arterial reconstruction.

METHODS

VA Patient Treatment File (PTF) data were analyzed using Patient Management Category (PMC) software which defined illness severity, patient complexity as defined by PMC count, and calculated resource intensity scale (RIS), a measure of resource utilization, for each admission.

RESULTS

In-hospital mortality rate was 3.16% (671/21,261) for all patients. Mortality did not differ between the 14,155 patients who underwent extremity arterial reconstruction (3.22%) and the remaining patients (3.03%). The incidence of ICD-9-CM-coded complications was 20.4% after limb revascularization versus 12.8% for remaining patients (P < 0.001). Length of stay (LOS) was 18.6 +/- 17.6 days with versus 10.3 +/- 14. 5 days without limb revascularization (P < 0.001). As defined in this study, patients who underwent limb revascularization were older (64.1 +/- 9.6 vs 62.2 +/- 11.0, P < 0.001); had higher illness severity scores (3.63 +/- 1.60 vs 2.72 +/- 1.72, P < 0.001); were more complex (had higher PMC count: 2.59 +/- 1.35 vs 2.54 +/- 1.34, P = 0.016); and required utilization of more resources (had higher RIS: 2.16 +/- 0.81 vs 1.68 +/- 0.76, P < 0.001) than remaining patients. Logistic regression analysis limited to those undergoing extremity revascularization revealed that age, presence of complications, patient complexity, illness severity, and acute arterial thromboembolism were increasingly and independently associated with greater in-hospital mortality. The logistic regression model also showed that the type of arterial reconstruction was related to in-hospital mortality: arterial bypass (ICD-9-CM 39.29) was associated with lower mortality. Outcomes were defined for the subgroup (n = 7,728) undergoing arterial bypass (ICD-9-CM 39.29) who were assigned to Patient Management Category 4101, 4113, or 4141: Mortality rates were 2.26, 2.19, and 5.03% for those undergoing elective bypass (n = 3003), urgent bypass (n = 3,513), and bypass for gangrene (n = 1212), respectively. Octogenarians did not experience higher mortality rates after elective bypass ¿1.4% (1/73) vs 2.3% (67/2,930), n.s., but experienced higher mortality rates after urgent bypass ¿8.6% (8/93) vs 2.0% (69/3,420), P < 0.001 and after bypass for gangrene ¿11.6% (5/43) vs 4.8% (56/1,169), P < 0.045.

CONCLUSIONS

Outcomes for patients in DRGs 478 and 479 who underwent extremity revascularization differed from those who did not. Outcomes varied by the type of arterial reconstruction and its urgency and indication and within selected subpopulations (i.e., octogenarians). DRG-based reimbursement would not be sensitive to these clinically important factors which have a major impact on outcomes and resource utilization.

Correlates of in-hospital cost among patients undergoing abdominal aortic aneurysm repair

BACKGROUND

Surgical repair of abdominal aortic aneurysms (AAA) is increasingly being performed, but little is known about the correlates of in-hospital cost associated with this procedure.

METHODS AND RESULTS

Baseline clinical characteristics, in-hospital outcomes, and total in-hospital costs were examined among a retrospective cohort of 71 patients who underwent AAA repair. Median age was 68 years, and 75% of the patients were men. High-risk characteristics for perioperative complications were common and included hypertension (73%), documented coronary artery disease (66%), smoking (60%), previous myocardial infarction (47%), history of congestive heart failure (12%), urgent or emergent AAA repair (16%), and diabetes mellitus (11%). Perioperative complications included congestive heart failure (13%), myocardial infarction (11 %), and death (1 %). Median length of stay in the surgical intensive care unit (SICU) was 2 days (range 0 to 28), and median in-hospital stay was 9 days (range 5 to 39). In-hospital cost for the 71 patients ranged from $13,766 to $82,435 (mean $25,931, median $21,633). Univariate and multiple linear regression analyses demonstrated that among the potential correlates investigated, number of SICU days (P= .007) and total length of stay (P< .0001) were the most closely associated with in-hospital cost.

CONCLUSIONS

Among patients undergoing AAA repair, the major correlates of in-hospital cost are the number of days spent in the SICU and the total number of days spent in the hospital. These results suggest that any intervention that reduces length of stay may significantly reduce the total in-hospital cost associated with AAA repair.

Resource use and costs of elective surgery for asymptomatic abdominal aortic aneurysm

OBJECTIVES

To determine the hospital costs of elective abdominal aortic aneurysm repair.

DESIGN

Observational study of resource use.

MATERIALS

Forty-six elective aneurysm surgery patients in a hospital; 116 vascular surgeons participating in the U.K. Small Aneurysm Trial.

METHODS

Data on resource use and associated costs were obtained in 1993 for 46 patients who had undergone elective surgery in a teaching hospital. Comparability of resource use with other hospitals in the U.K. was obtained from data on surgical patients in the U.K. Small Aneurysm Trial, and by questionnaire on use of resources sent to surgeons participating in the trial.

RESULTS

The total cost of an elective aneurysm repair calculated from patient data in the teaching hospital was Pounds 4592. One-third of costs were due to stay in a standard surgical ward, and 20% were attributable to the operation. Overall, the use of resources in U.K. hospitals was comparable to that for the teaching hospital. Based on the surgeons' estimates, however, considerable variation existed for typical elective aneurysm patients, with costs ranging from Pounds 2173 to Pounds 7024.

CONCLUSIONS

In the U.K. the average cost of an elective aneurysm repair in 1993 was around Pounds 4600, which was equivalent to around Pounds 5000 (US$8000) in 1996. This estimate is sufficiently reliable to be used in cost effectiveness analyses.

Economics of pancreatoduodenectomy in the elderly

BACKGROUND

Managed care and the increasing percentage of surgical procedures performed in the elderly have renewed the focus on hospital charges and expenditures. The objective of this study was to determine whether septuagenarians and octogenarians accrue more hospital charges or have a higher risk of morbidity and death.

METHODS

We retrospectively reviewed the charges and pertinent clinical outcomes data that were available on 70 of the last 100 pancreatoduodenectomies performed at our institution (1989 to 1994). Charges from four cost centers were analyzed and normalized to 1995 dollars by using the Consumer Price Index and Wilcoxon rank sum test. Patients were divided into two groups: group 1, 70 years of age or older (n = 21); group 2, younger than 70 years of age (n = 49).

RESULTS

Anesthetic charges were $2657 +/- $835 for group 1 versus $2815 +/- $826 for group 2, which was not a statistically significant difference. Laboratory charges were $4650 +/- $3284 for group 1 versus $5969 +/- $5169 for group 2, which was not a significant difference. Pharmaceutical charges were $5424 +/- $4435 for group 1 versus $9243 +/- $9695 for group 2, which was not a significant difference. Charges for operative units were $6198 +/- $1671 for group 1 versus $7469 +/- $2116 for group 2, p < 0.02. Total charges were $41,180 +/- $20,635 for group 1 versus $50,968 +/- $33,783 for group 2, which was not a significant difference. No difference was noted in morbidity, mortality, length of stay, or survival.

CONCLUSIONS

Pancreatoduodenectomy in the elderly can be performed safely without accruing higher cost, increased morbidity, or increased mortality.

Predicting length of hospital stay and cost by aneurysm grade on admission

To determine the relationship between clinical grade on admission and treatment cost after aneurysm rupture, the authors retrospectively examined the length of hospital stay (LOS) and total hospitalization costs (excluding professional fees) for 543 patients admitted for aneurysm surgery between 1983 and 1993. The overall median LOS was 18 days, with a range of 1 to 165 days. Increased median LOS correlated with Hunt and Hess Grades 0 to IV on admission (p < 0.001). Median LOS for Grade V patients was reduced, in part, because of early mortality. Increased treatment cost also correlated with worse admission clinical grade (p < 0.001). A significant proportion of total expenditures occurred early in the hospitalization for patients in all clinical grades. Identification of additional factors affecting the cost of aneurysm treatment is indicated to complement treatment outcome studies.

Sociologic factors are major determinants of prolonged hospital stay after abdominal aneurysm repair

BACKGROUND

With increasing pressure to optimize the utilization of hospital resources, it is important to identify patients who may have prolonged hospital length of stay (LOS). The purpose of this report was to identify the preoperative variables that are predictive of prolonged postoperative hospital LOS for patients undergoing elective infrarenal abdominal aneurysm repair and to discuss strategies that might assist in minimizing LOS for these patients.

METHODS

Three hundred sixty-five consecutive patients underwent elective infrarenal abdominal aneurysm repair between 1989 and 1994. The relationship between 13 preoperative variables and LOS was analyzed by using both univariate (Kaplan-Meier) and multivariate (Cox regression) statistical techniques.

RESULTS

By using Cox regression a model was developed to estimate LOS (p < 0.001 for model). The independent predictors for prolonged LOS were (1) age older than 70 years and (2) absence of a spouse.

CONCLUSIONS

Knowledge of the predictive factors that are associated with prolonged LOS should identify those patients who may require prompt and efficient discharge planning, early consultation with a home care nurse, or transfer to a convalescent facility. This approach may significantly improve the utilization of hospital resources.

Visceral ischemia and organ dysfunction after thoracoabdominal aortic aneurysm repair. A clinical and cost analysis

OBJECTIVE

Repair of thoracoabdominal aortic aneurysms (TAAAs) is associated with significant postoperative morbidity and mortality. Reperfusion of acutely ischemic abdominal viscera in animals leads to release of multiple factors that cause local and distant organ damage, and similar phenomena occurring in humans after TAAA repair could contribute to the high morbidity/mortality and cost associated with this procedure.

METHODS

Twenty-nine patients undergoing elective TAAA repair were studied prospectively. Preoperative organ dysfunction and intraoperative risk factors (cross-clamp time, blood loss, operative time) were assessed and compared with postoperative organ dysfunction (defined as: pulmonary, positive pressure ventilation for > 7 days; renal, increase in serum creatinine > 2.0 mg/dL over baseline; hepatic, lactate dehydrogenase > 500 international units and total bilirubin > 3.0 mg/dL or serum transaminase level > 200 international units; hematopoietic, platelet count > 50 K or leukocyte count > 4.5 K, mortality, and costs.

RESULTS

No relationship between preoperative organ dysfunction, blood loss, or operative time and postoperative organ dysfunction or mortality was seen; however, cross-clamp times > 40 minutes were associated with a significantly greater incidence of pulmonary (59%), renal (47%), hepatic (35%), and hematopoietic (47%) dysfunction. In addition, multiple-organ dysfunction (> 2 organ systems) was more common after > 40 minutes of visceral ischemia and led to significantly greater overall hospital ($88,465 + $76,155 vs. $41,782 + $31,244) and intensive care unit ($26,726 + $28,256 vs. $11,234 + $12,146) costs (p < 0.01, Mann-Whitney U test). Mortality associated with leukopenia was 67% compared with 4% without leukopenia (p < 0.01).

CONCLUSION

Increasing durations of acute visceral ischemia led to significant multiple organ dysfunction after TAAA repair. Methods of limiting visceral ischemia or the systemic effects of visceral ischemia may decrease both the morbidity and mortality and the overall hospital cost associated with this procedure.