Hospital Cost-categories of Pancreaticoduodenectomy

Acta chir belg, 2007, 107, 373-377 Hospital Cost-categories of Pancreaticoduodenectomy B. Topal*, G. Peeters**, H. Vandeweyer**, R. Aerts*, F. Pennin...
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Acta chir belg, 2007, 107, 373-377

Hospital Cost-categories of Pancreaticoduodenectomy B. Topal*, G. Peeters**, H. Vandeweyer**, R. Aerts*, F. Penninckx* Departments of Abdominal Surgery* and Management Information & Reporting**, University Hospital Leuven, Leuven, Belgium.

Key words. Surgery ; cost ; healthcare ; pancreas. Abstract. Aims : In the era of cost-conscious healthcare, hospitals are focusing on costs. Analysis of hospital costs per cost-category may provide indications for potential cost saving measures in pancreaticoduodenectomy (PD). Methods : Between January 2004 and June 2005, 109 consecutive patients underwent curative PD for a pancreatic or peri-ampullary tumour. Costs were defined in different cost categories for each activity centre and were linked to the individual patient via the ‘bill of activities’. Results : Postoperative complication rate was 46.8%, postoperative pancreatic fistula (POPF) 12.8%, and mortality rate 1.8%. The overall median LOS was 17 (range 7-52) days. The length of hospital stay (LOS) was significantly (p < 0.0001) different between patients with POPF, those with other complications, and patients without complications i.e. 26 (10-36) vs. 21 (8-52) vs. 14 (7-33) days, respectively. Median hospital cost per patient was 10406 (5570-30999) euros. The total hospital costs were significantly related to the LOS (p < 0.0001). The increase of total hospital costs was influenced by the hospitalization (p < 0.0001) and medical staff (p < 0.0001) costs, but not by the cost for the operation room (p = 0.233). Conclusion : Postoperative complications, in particular POPF, are associated with increased LOS and higher hospital costs. Any measure to reduce the incidence and severity of complications after PD will save hospital costs.

Introduction

Patients and methods

In the era of cost-conscious healthcare, hospitals are focusing on costs to insure market share. Total hospital costs can be reduced by shortening length of hospital stay (LOS), even for complex operations such as pancreaticoduodenectomy (PD) that is considered a highrisk surgical procedure with high mortality and morbidity rates. During the last two decades the mortality rate of PD has decreased below 4% in high-volume centres, whereas no apparent changes are observed in either morbidity or LOS (1-3). Nevertheless, considerable variations with regard to this short-term clinical outcome exist between different centres (4-8). On the other hand, hospital-volume as well as the implementation of a clinical pathway may shorten LOS, reduce postoperative mortality rate, and save total hospital costs (9-11). Although costs of PD have been studied in the past, all studies, except one, focus on total hospital costs for a small number of patients, without further specification of the different cost-categories (9-15). The aim of the present cohort study was to analyse different cost-categories in a large number of patients undergoing PD. Analysis of hospital costs per cost-category may enable us to better understand the observed cost variations and provide indications for potential cost saving measures.

Patients Between January 2004 and June 2005, 109 consecutive patients (F/M : 47/62 ; median (range) age 61 (37-81) years) underwent curative PD for a pancreatic or periampullary tumour. According to the American Society of Anaesthesiology (ASA) physical status score, 73 patients had an ASA score II, 12 ASA score III, and 1 ASA IV. On histopathological examination of the resection specimen, the final diagnosis was adenocarcinoma of the pancreas in 42, ampulla in 27, distal bile duct in 9, duodenal cancer in 4, and miscellaneous tumours in 27 patients. Pylorus-preserving PD (PPPD) was performed in 65 patients as compared to classic PD (Whipple’s procedure) in 44. Endoscopic biliary drainage was performed pre-operatively in 54 patients. Surgical procedure Pancreaticoduodenectomy was performed with various extents of lymph node dissection according to the primary tumour type and cancer stage. Other organs were resected in 10 patients. Portal vein resection was performed in 12 pancreatic cancers. Absorbable monofila-

374 ment sutures were used for the reconstruction that first involved a trans-mesocolic end-to-side pancreaticojejunostomy in two layers, followed by a one-layer endto-side bilio-enteric anastomosis. Neither the bilioenteric anastomosis nor the pancreatic reconstruction was ever stented. The gastric (in PD) or duodenal (in PPPD) reconstruction was achieved with the standard two-layer end-to-side anastomosis. A nasogastric tube was used in patients who underwent a classic PD, while a gastro-cutaneous catheter was placed in PPPD. Two closed suction drains were placed in the vicinity of the biliary and pancreatic anastomoses. Postoperative management All patients were monitored postoperatively in the postanaesthesia care unit during one night and subsequently transferred to the ward. Prophylactic intravenous antibiotics (cefazoline) were started intra-operatively and continued every 8 hours for one day. An H2-receptor blocker and a low-molecular-weight heparin were given during the postoperative hospital stay. Intravenous hyperalimentation was not routinely used. Prophylactic octreotide was started intra-operatively and continued for 5 days in 73 patients. The use of prophylactic octreotide was based on the judgment of the surgeon. It was used mainly in patients with soft pancreatic texture since these patients were considered at high risk for the development of POPF. Intra-peritoneal drains were removed, usually after postoperative day 5, depending on the drainage output and the fluid amylase level. Octreotide was administered with the intention to treat in 12 patients with POPF for 7 (5-16) days. Patients were evaluated on the outpatient clinic within 6 weeks after discharge. Assessment and statistics Patient and operative data were collected retrospectively. Postoperative complications were classified based on the therapy-oriented severity grading system (TOSGS ; grade 1 : no need for specific intervention ; grade 2 : need for drug therapy ; grade 3 : need for invasive therapy ; grade 4 : organ dysfunction with ICU stay ; grade 5 : death) (16), and allocated to surgical site (SSC) vs. non-surgical site complications (NSSC). Postoperative pancreatic fistula (POPF) was defined according to the International Study Group on Pancreatic Fistula (ISGPF) definition i.e. grade A : biochemical fistula without clinical sequelae ; grade B : fistula requiring any therapeutic intervention ; grade C : fistula with severe clinical sequelae (17). Analysis of the statistical significance of differences between groups of data was performed using Pearson Chi-square and Wilcoxon / Kruskal-Wallis test, as appropriate. A p-value of  0.05 was considered statis-

B. Topal et al. tically significant. All analyses were performed using the statistical software JMP (version 6.0.2). Cost analysis Cost analysis only considered the immediate peri-operative care, without accounting the pre-operative trajectory or re-admission. The analysis started at the time of admission on the day before PD and ended at the time of discharge. A cost accounting model was developed based on the concept of activity based costing, as described earlier (18). In brief, all hospital activities were allocated to the activity centres where the activities took place. Costs were defined in different cost categories for each activity centre and were linked to the individual patient via the “bill of activities”. All costs (both indirect and direct) were linked to the individual patient according to specific cost drivers per activity centre. The sum of these costs was defined to represent the overall cost of an individual patient during his/her hospital stay. Results Short-term clinical outcome The duration of surgery was 225 minutes (median ; range 135-420), with an intra-operative blood loss of 600 (100-3700) ml. Postoperative complications were observed in 51 patients, with subsequent re-operation in 6 patients. Two patients died postoperatively on day 8 and 10, respectively. Postoperative SSC and NSSC were observed in 40 and 13 patients, respectively. A pancreatic fistula occurred in 14 patients : grade A in 2 ; grade B in 9 ; grade C in 3 patients. According to the TOSGS the majority of complications needed therapeutic intervention : grade 1 in two patients ; grade 2 in 18 ; grade 3 in 27 ; and grade 4 in two patients. The overall median LOS was 17 (7-52) days. The LOS was significantly (p < 0.0001) different between patients with POPF, those with other complications, and patients without complications i.e. 26 (10-36) vs. 21 (852) vs. 14 (7-33) days, respectively. Longer LOS was observed with increasing TOSGS-scores (p < 0.0001) i.e. grade 1 : 15 (15-15) vs. grade 4 : 30 (29-31) days. Both the LOS and the occurrence of postoperative complications were similar in patients with or without preoperative biliary drainage and in patients with or without prophylactic octreotide (p > 0.198). Cost analysis Median hospital cost per patient was 10406 (557030999) euros. The overall cost distribution between different activity centres is shown in Table I. The total

Cost of Pancreaticoduodenectomy

375

Table I Different hospital cost-categories of pancreaticoduodenectomy

Care Logistics Emergency Functional Measurement Hospitalization ICU Imaging Laboratory Medical Staff Operation room Paramedical Personnel Pharmacy Total

Median (range) cost €

% of total costs

53 (53 - 212) 0 (0 - 673) 0 (0 - 821) 3120 (520 - 13493) 0 (0 - 7215) 78 (0 - 686) 762 (277 - 9712) 1856 (1158 - 5750) 2138 (970 - 6475) 0 (0 - 1805) 1348 (460 - 7298)

1

33 1 8 20 23 14

10406 (5570 - 30999)

ICU intensive care unit.

A significant relation was found between length of hospital stay (LOS) and total hospital costs (p < 0.0001). Fig. 1 Relation between length of hospital stay and total hospital costs of pancreaticoduodenectomy.

hospital costs were significantly related to the LOS (Spearman 0.764 ; p < 0.0001) (Fig. 1). The increase of total hospital costs was influenced by the hospitalization (Spearman 0.376 ; p < 0.0001) and medical staff (Spearman 0.376 ; p < 0.0001) costs, but not by the cost for the operation room (Spearman 0.115 ; p 0.233). The relation between postoperative clinical outcome and hospital costs per cost-category is presented in Table II. Total hospital costs for patients with POPF were 15225 (10170-30685) euros as compared to 11393 (671630999) euros for patients with other complications, and 8565 (5569-16921) euros for those without complications (p < 0.0001). Total hospital costs increased with severity of complications according to the TOSGS i.e. grade 1 : 7696 (7013-8378) vs. grade 5 : 19355 (802630685) euros ; p < 0.0001. Patients who received prophylactic octreotide had similar hospital costs as those without octreotide (10213 (5569-30998) vs. 10549 (6175-23139) ; p = 0.857). Discussion The structure of the Belgian healthcare system contains a compulsory health insurance that is organized through private non-profit sickness funds (19). Economic pressures have forced the medical community to evaluate admission policies since significant savings can be obtained by decreasing hospital stay. This measure seems to be efficient for high-frequency and low-risk surgical procedures such as in ambulatory surgery (18). The development and publication of clinical and financial information solutions may improve patient-centeredness, efficiency, and effectiveness of the healthcare

system, in particular for high-risk surgical procedures. The present cost analysis was performed on a consecutive series of patients who underwent PD in a highvolume university hospital. The largest cost-categories were (in descending order) hospitalization, operation room (OR), medical staff, and pharmacy. It is not surprising that postoperative complications cost money. Indeed, patients who developed a postoperative complication were significantly more expensive than patients with an uneventful postoperative course. Postoperative pancreatic fistula was responsible for the highest costs. Whether a postoperative complication occurred or not, hospitalization carried the major costs after PD. Costs of the OR were the second largest cost-category for patients without a complication and for patients with complications other than POPF. No significant differences in OR-costs were observed between patients without or with any type of postoperative complication. In patients with POPF, pharmacy costs were the second largest cost-category, followed by OR and medical staff costs. The LOS can be considered as a parameter for the short-term outcome and reflects well the complication rate after PD (3). Several studies have demonstrated the importance of hospital volume in reducing the morbidity and mortality associated with PD (7, 8, 20). Since POPF is a major adverse event in PD, and it is responsible for longer LOS and hospital costs, more efforts should be undertaken to reduce both the incidence and severity of this complication. Beside higher re-operation rate and longer hospital stay associated with POPF, the “therapeutic” administration of octreotide may be one of the reasons of higher costs in these patients (3).

376

B. Topal et al. Table II Relation between postoperative outcome and hospital costs of pancreaticoduodenectomy No postoperative complication (n 58)

Postoperative complication other than POPF (n 37)

POPF (n 14)

p

Care Logistics Emergency Functional Measurement Hospitalization ICU Imaging Laboratory Medical Staff Operation room Paramedical Personnel Pharmacy

53 (53-124) 0 (0-673) 0 (0-120) 2686 (1213-7358) 0 (0-1467) 53 (0-289) 640 (277-2206) 1735 (1158-3060) 2131 (970-6425) 0 (0-776) 978 (460-4340)

53 (53-159) 0 (0-499) 33 (0-821) 3639 (1213-13493) 0 (0-7215) 109 (0-685) 877 (412-5147) 1950 (1301-5750) 2199 (1002-5079) 194 (0-1805) 1526 (500-5871)

53 (53-212) 0(0-87) 0 (0-227) 4847 (520-7956) 0 (0-3667) 142 (0-512) 1164 (707-9712) 2057 (1296-5132) 2264 (1007-6475) 259 (0-1035) 3140 (2008-7298)

0.022 0.107 0.176 < 0.0001 0.540 0.001 < 0.0001 0.0005 0.306 0.036 < 0.0001

Total

8565 (5569-16921)

11393 (6716- 30999)

15225 (10171-30685)

< 0.0001

ICU intensive care unit ; POPF postoperative pancreatic fistula.

Pylorus-preserving PD can be considered the standard surgical procedure to treat resectable pancreatic head and peri-ampullary tumours. There is disagreement on whether to perform a pancreatico-jejunostomy (PJS) or pancreatico-gastrostomy (PGS) after PPPD. Although PGS may have theoretical advantages and it has been shown in several retrospective studies to be superior with respect to POPF as compared to PJS, these benefits could not be confirmed in two randomized controlled trials. Also stenting of the pancreatic anastomosis might help reduce the incidence and/or severity of POPF (21). Cost data, as determined in the present study, seem to be much lower as compared to other reports (10). Of course, one should bear in mind that hospital costs between nations cannot be compared due to large diversities with respect to socio-economical aspects, healthcare systems, and insurance policies. Conclusion Largest cost-categories of PD are hospitalization, OR, medical staff, and pharmacy. Postoperative complications, in particular POPF, are associated with increased LOS and higher hospital costs. Any measure to reduce the incidence and severity of complications after PD will save hospital costs. References 1. BALCOM J. H., RATTNER D. W., WARSHAW A. L., CHANG Y., FERNANDEZ-DEL CASTILLO C. Ten-year experience with 733 pancreatic resections : changing indications, older patients, and decreasing length of hospitalization. Arch Surg, 2001, 136 : 391-8. 2. YEO C. J., CAMERON J. L., SOHN T. A. et al. Six hundred fifty consecutive pancreaticoduodenectomies in the, 1990s : pathology, complications, and outcomes. Ann Surg, 1997, 226 : 248-57, discussion 257-60.

3. TOPAL B., AERTS R., HENDRICKX T., FIEUWS S., PENNINCKX F. Determinants of complications in pancreaticoduodencetomy. Eur J Surg Oncol, 2007, 33 : 488-92. 4. VAN HEEK N. T., KUHLMANN K. F. D., SCHOLTEN R. J. et al. Hospital volume and mortality after pancreatic resection. A systematic review and an evaluation of intervention in the Netherlands. Ann Surg, 2005, 242 : 781-790. 5. LIEBERMAN M. D., KILBURN H., LINDSEY M., BRENNAN M. F. Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy. Ann Surg, 1995, 222 : 638-645. 6. BRAMHALL S. R., ALLUM W. H., JONES A. G., ALLWOOD A., CUMMINS C., NEOPTOLEMOS J. P. Treatment and survival in 13,560 patients with pancreataic cancer, and incidence of the disease, in the West Midlands : an epidemiological study. Br J Surg, 1995, 82 : 111-115. 7. BIRKMEYER L. D., STUKEL T. A., SIEWERS A. E., GOODNEY P. P., WENNBERG D. E., LUCAS F. L. Surgeon volume and operative mortality in the United States. NEJM, 2003, 349 : 2117-27. 8. GOUMA D. J., VAN GEENEN R. C., VAN GULIK T. M. et al. Rates of complications and death after pancreaticoduodenectomy : risk factors and the impact of hospital volume. Ann Surg, 2000, 232 : 786-95. 9. ROSEMURGY A. S., BLOOMSTON M., SERAFINI F. M., COON B., MURR M. M., CAREY L. C. Frequency with which surgeons undertake pancreaticoduodenectomy determines length of stay, hospital charges, and in-hospital mortality. J Gastrointest Surg, 2001, 5 : 21-26. 10. PORTER G. A., PISTERS P. W. T., MANSYUR C. et al. Cost and utilization impact of a clinical pathway for patients undergoing pancreaticoduodenectomy. Ann Surg Oncol, 2000, 7 : 484-489. 11. GORDON T. A., BURLEYSON G. P., TIELSCH J. M., CAMERON J. L. The effects of regionalization on costs and outcome for one general high-risk surgical procedure. Ann Surg, 1995, 221 : 43-49. 12. HOWARD T. J., JONES J. W., SHERMAN S., FOGEL E., LEHMAN G. A. Impact of pancreatic head resection on direct medical costs in patients with chronic pancreatitis. Ann Surg, 2001, 234 : 661-667. 13. COOPERMAN A. M., SCHWARTZ E. T., FADER A., GOLIER F., FELD M. Safety, efficacy, and cost of pancreaticoduodenal resection in a specialized centre based at a community hospital. Arch Surg, 1997, 132 : 744-747. 14. VICKERS S. M., KERBY J. D., SMOOT T. M. et al. Economics of pancreatoduodenectomy in the elderly. Surgery, 1996, 120 : 620-625. 15. HOLBROOK R. F., HARGRAVE K., TRAVERSO W. A prospective cost analysis of pancreatoduodenectomy. Am J Surg, 1996, 171 : 508511.

Cost of Pancreaticoduodenectomy 16. DINDO D., DEMARTINES N., CLAVIEN P. A. Classification of surgical complications : a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg, 2004, 240 : 214-5. 17. BASSI C., DERVENIS C., BUTTURINI G. et al. for the International Study Group on Pancreatic Fistula. Postoperative pancreatic fistula : an international study group (ISGPF) definition. Surgery, 2005, 138 : 8-13. 18. TOPAL B., PEETERS G., VERBERT A., PENNINCKX F. Outpatient laparoscopic cholecystectomy : clinical pathway implementation is efficient and cost effective and increases hospital bed capacity. Surg Endosc, 2007, Epub ahead of print. 19. SCHOKKAERT E., VAN DE VOORDE C. Health care reform in Belgium. Health Econ, 2005, 14 : S25-S39. 20. SOSA J. A., BOWMAN H. M., GORDON T. A. et al. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg, 1998, 228 : 429-38.

377 21. SHRIKHANDE S. V., QURESHI S. S., RAJNEESH N., SHUKLA P. J. Pancreatic anastomoses after pancreaticoduodenectomy : do we need further studies ? World J Surg, 2005, 29 : 1642-9.

B. Topal, M.D., Ph.D. Department of Abdominal Surgery University Hospital Gasthuisberg Herestraat 49 B-3000 Leuven, Belgium Tel. : +3216344265 Fax : +3216344832 E-mail : [email protected]

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