Cost Consequences of Age and Comorbidity in Accelerated Postoperative Discharge After Colectomy.
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ABSTRACT:
SUBMITTER: De Roo AC
PROVIDER: S-EPMC8994054 | biostudies-literature | 2022 May
REPOSITORIES: biostudies-literature
Publications
Cost Consequences of Age and Comorbidity in Accelerated Postoperative Discharge After Colectomy.
De Roo Ana C AC Shubeck Sarah P SP Cain-Nielsen Anne H AH Norton Edward C EC Regenbogen Scott E SE
Diseases of the colon and rectum 20220501 5
<h4>Background</h4>Prospective payment models have incentivized reductions in length of stay after surgery. The benefits of abbreviated postoperative hospitalization could be undermined by increased readmissions or postacute care use, particularly for older adults or those with comorbid conditions.<h4>Objective</h4>The purpose of this study was to determine whether hospitals with accelerated postsurgical discharge accrue total episode savings or incur greater postdischarge payments among patient ...[more]
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Project description:BackgroundAlthough early discharge after colectomy has garnered significant interest, contemporary, large-scale analyses are lacking.ObjectiveThe present study utilized a national cohort of patients undergoing colectomy to examine costs and readmissions following early discharge.MethodsAll adults undergoing elective colectomy for primary colon cancer were identified in the 2016-2019 Nationwide Readmissions Database. Patients with perioperative complications or prolonged length of stay (>8 days) were excluded to enhance cohort homogeneity. Patients discharged by postoperative day 3 were classified as Early, and others as Routine. Entropy balancing and multivariable regression were used to assess the risk-adjusted association of early discharge with costs and non-elective readmissions. Importantly, we compared 90-day stroke rates to examine whether our results were influenced by preferential early discharge of healthier patients.ResultsOf an estimated 153,996 patients, 45.5% comprised the Early cohort. Compared to Routine, the Early cohort was younger and more commonly male. Patients in the Early group more commonly underwent left-sided colectomy and laparoscopic operations. Following multivariable adjustment, expedited discharge was associated with a $4,500 reduction in costs as well as lower 30-day (adjusted odds ratio [AOR] 0.74, p<0.001) and 90-day non-elective readmissions (AOR 0.74, p<0.001). However, among those readmitted within 90 days, Early patients were more commonly readmitted for gastrointestinal conditions (45.8 vs 36.4%, p<0.001). Importantly, both cohorts had comparable 90-day stroke rates (2.2 vs 2.1%, p = 0.80).ConclusionsThe present work represents the largest analysis of early discharge following colectomy for cancer and supports its relative safety and cost-effectiveness.
| S-EPMC10871523 | biostudies-literature
Project description:BackgroundUlcerative colitis (UC) patients failing medical management require colectomy. This study compares risk estimates for predictors of postoperative complication derived from administrative data against that of chart review and evaluates the accuracy of administrative coding for this population.MethodsHospital administrative databases were used to identify adults with UC undergoing colectomy from 1996-2007. Medical charts were reviewed and regression analyses comparing chart versus administrative data were performed to assess the effect of age, emergent operation, and Charlson comorbidities on the occurrence of postoperative complications. Sensitivity, specificity, and positive/negative predictive values of administrative coding for identifying the study population, Charlson comorbidities, and postoperative complications were assessed.ResultsCompared to chart review, administrative data estimated a higher magnitude of effect for emergent admission (OR 2.52 [95% CI: 1.80-3.52] versus 1.49 [1.06-2.09]) and Charlson comorbidities (OR 2.91 [1.86-4.56] versus 1.50 [1.05-2.15]) as predictors of postoperative complications. Administrative data correctly identified UC and colectomy in 85.9% of cases. The administrative database was 37% sensitive in identifying patients with???1Charlson comorbidity. Restricting analysis to active comorbidities increased the sensitivity to 63%. The sensitivity of identifying patients with at least one postoperative complication was 68%; restricting analysis to more severe complications improved the sensitivity to 84%.ConclusionsAdministrative data identified the same risk factors for postoperative complications as chart review, but overestimated the magnitude of risk. This discrepancy may be explained by coding inaccuracies that selectively identifying the most serious complications and comorbidities.
| S-EPMC3432603 | biostudies-literature
Project description:Although the elderly population is increasing rapidly, little information is available regarding how the risk of postoperative mortality and morbidity increases when combined with age and comorbidity burden in patients undergoing musculoskeletal tumor surgery.We evaluated the effect of age and comorbidity burden on the (1) postoperative complication rate and (2) in-hospital mortality rate after musculoskeletal tumor surgery.We identified 5716 patients undergoing musculoskeletal tumor surgery during 2007 to 2012 using a Japanese national inpatient database. Logistic regression analyses were performed to examine the relationships of various factors with the rates of mortality and morbidity.The postoperative complication rate (6.7%) was associated with male sex (p = 0.033), age 80 years or older (p = 0.001), tumor located in the lower extremity (p = 0.001) or trunk (p = 0.019), Charlson Comorbidity Index of 4 or greater (p < 0.001), blood transfusion (p < 0.001), and duration of anesthesia of 240 minutes or longer (p < 0.001). The in-hospital mortality (0.8%) was related to the Charlson Comorbidity Index of 4 or greater (p < 0.001), blood transfusion (p < 0.001), and high hospital volume (p = 0.016). The morbidity (21.6%; OR, 3.29; p < 0.001) and mortality (4.1%; OR, 5.95; p < 0.001) in patients 80 years or older with a Charlson Comorbidity Index of 4 or greater was increased three and six times, respectively, compared with patients 64 years or younger with no comorbidity.We found that age and comorbidity burden together greatly increased the risk of morbidity and mortality. Our study showed quantitative evidence that will assist physicians in assessing perioperative risk accurately and provide a more informative explanation to elderly patients undergoing musculoskeletal tumor surgery.Level IV, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.
| S-EPMC4397778 | biostudies-other
Project description:BackgroundFirst postoperative day drain fluid amylase (DFA1) <5000 U/L is commonly used for early drain removal. We manage patients with risk-stratified pancreatectomy care pathways determined preoperatively by risk for postoperative pancreatic fistula. We hypothesized that preoperative risk stratification would yield unique DFA1/DFA3 cutoffs for safe early drain removal.MethodsPatients with DFA1/DFA3 values after pancreaticoduodenectomy or distal pancreatectomy were identified. Patients were risk stratified as "low-risk pancreaticoduodenectomy," "high-risk pancreaticoduodenectomy," or "distal pancreatectomy." Receiver operator characteristic analyses yielded clinically relevant sensitivity thresholds for International Study Group on Pancreatic Surgery grade B/C postoperative pancreatic fistulas.ResultsFrom October 2016 to April 2018, 174 patients were preoperatively stratified as low-risk pancreaticoduodenectomy (n = 78, 45%), high-risk pancreaticoduodenectomy (n = 51, 29%), and distal pancreatectomy (n = 45, 26%). B/C postoperative pancreatic fistulas developed in 3% (n = 2) of low-risk pancreaticoduodenectomies, 37% (n = 19) of high-risk pancreaticoduodenectomies, and 24% (n = 11) of distal pancreatectomies (low- vs high-risk pancreaticoduodenectomy P < .001, low-risk pancreaticoduodenectomy versus distal pancreatectomy P = .004, high-risk pancreaticoduodenectomy versus distal pancreatectomy P = .25). B/C postoperative pancreatic fistulas occurred in 16% (n = 21) pancreaticoduodenectomy patients (high- + low-risk pancreaticoduodenectomy), and B/C postoperative pancreatic fistulas were excluded in pancreaticoduodenectomy with 100% sensitivity if DFA1 ≤ 136 or DFA3 ≤ 93. DFA1 < 5000 excluded B/C postoperative pancreatic fistulas with only 57% sensitivity after pancreaticoduodenectomy. Exclusion of B/C postoperative pancreatic fistulas occurred with 100% sensitivity if DFA1 ≤ 661 or DFA3 ≤ 141 in low-risk pancreaticoduodenectomy patients, DFA1 ≤ 136 or DFA3 ≤ 93 in high-risk pancreaticoduodenectomy patients, and DFA1 < 49 or DFA3 < 26 in distal pancreatectomy patients.ConclusionPreoperative risk stratification results in unique DFA1/DFA3 thresholds to exclude B/C postoperative pancreatic fistulas, thus allowing for safe drain removal and potential for accelerated discharge. Rather than applying generic DFA cutoffs based on national databases, we propose institution-specific DFA1 and DFA3 values tailored to 3 replicable postoperative pancreatic fistula-risk pathways.
| S-EPMC7288221 | biostudies-literature
Project description:Childhood adversity is linked to psychological, behavioral, and physical health problems, including obesity and cardiometabolic disease. Epigenetic alterations are one pathway through which the effects of early life stress and adversity might persist into adulthood. Epigenetic mechanisms have also been proposed to explain why cardiometabolic health can vary greatly between individuals with similar Body Mass Index (BMIs). We evaluated two independent cross-sectional cohorts of adults without known medical illness, one of which explicitly recruited individuals with early life stress (ELS) and control participants (n = 195), and the other a general community sample (n = 477). In these cohorts, we examine associations between childhood adversity, epigenetic aging, and metabolic health. Childhood adversity was associated with increased GrimAge Acceleration (GAA) in both cohorts, both utilizing a dichotomous yes/no classification (both p < 0.01) as well as a continuous measure using the Childhood Trauma Questionnaire (CTQ) (both p < 0.05). Further investigation demonstrated that CTQ subscales for physical and sexual abuse (both p < 0.05) were associated with increased GAA in both cohorts, whereas physical and emotional neglect were not. In both cohorts, higher CTQ was also associated with higher BMI and increased insulin resistance (both p < 0.05). Finally, we demonstrate a moderating effect of BMI on the relationship between GAA and insulin resistance where GAA correlated with insulin resistance specifically at higher BMIs. These results, which were largely replicated between two independent cohorts, suggest that interactions between epigenetics, obesity, and metabolic health may be important mechanisms through which childhood adversity contributes to long-term physical and metabolic health effects.
| S-EPMC11365810 | biostudies-literature
Project description:Comorbidities had considerable effects on the development of postoperative ileus (POI). The primary aim of the present study was to determine the influence of the age-adjusted Charlson comorbidity index (ACCI) score on the risk of prolonged POI in patients with colorectal cancer who underwent surgical resection. Using the electronic Hospitalization Summary Reports, we identified 11,397 patients with colorectal cancer who underwent surgical resection from 2013 through 2015. Logistic regression models were applied to evaluate the effect of the ACCI score on the risk of prolonged POI. The ACCI score had a positive graded association with the risk of prolonged POI in both colon and rectal cancer (P for trend < 0.05). Among patients with rectal cancer, after adjusting for potential confounders, those with an ACCI score of 4-5 had a 108% higher risk of prolonged POI than those with an ACCI score of 0-1 (odds ratio [OR], 2.08; 95% confidence interval [CI], 1.09-3.98), and those with an ACCI score of ≥ 6 had a 130% higher risk (OR, 2.30; 95% CI, 1.08-4.89). Among patients with colon cancer, those with an ACCI score of ≥ 6 had a 47% greater risk of prolonged POI than those with an ACCI score of 0-1 (OR, 1.47; 95% CI, 1.07-2.02). These findings suggested that a higher ACCI score was an independent predictor of the development of prolonged POI.
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Project description:This retrospective cohort study on adults undergoing colectomy from 2010 to 2019 used linked primary (Clinical Practice Research Datalink), and secondary (Hospital Episode Statistics) care data to determine the prevalence of persistent postoperative opioid use following colectomy, stratified by pre-admission opioid exposure, and identify associated predictors. Based on pre-admission opioid exposure, patients were categorised as opioid-naïve, currently exposed (opioid prescription 0-6 months before admission) and previously exposed (opioid prescription within 7-12 months before admission). Persistent postoperative opioid use was defined as requiring an opioid prescription within 90 days of discharge, along with one or more opioid prescriptions 91-180 days after hospital discharge. Multivariable logistic regression analyses were conducted to obtain odds ratios for predictors of persistent postoperative opioid use. Among the 93,262 patients, 15,081 (16.2%) were issued at least one opioid prescription within 90 days of discharge. Of these, 6791 (45.0%) were opioid-naïve, 7528 (49.9%) were currently exposed and 762 (5.0%) were previously exposed. From the whole cohort, 7540 (8.1%) developed persistent postoperative opioid use. Patients with pre-operative opioid exposure had the highest persistent use: 5317 (40.4%) from the currently exposed group; 305 (9.8%) from the previously exposed group; and 1918 (2.5%) from the opioid-naïve group. The odds of developing persistent opioid use were higher among individuals who used long-acting opioid formulations in the 180 days before colectomy than those who used short-acting formulations (odds ratio 3.41 (95%CI 3.07-3.77)). Predictors of persistent opioid use included: previous opioid exposure; high deprivation index; multiple comorbidities; use of long-acting opioids; white race; and open surgery. Minimally invasive surgical approaches were associated with lower odds of persistent opioid use and may represent a modifiable risk factor.
| S-EPMC10953341 | biostudies-literature
Project description:Aim of the studyShort stay processes are incentives to unburden chronically stressed healthcare systems. The aim of this study is to analyze financial implications of day admission (DAS) and outpatient strategies for colon resections in a prospective payment system (PPS) using Diagnosis Related Group (DRG) coding.MethodsConsecutive patients undergoing left and right colonic resections between January 1, 2019 and December 31, 2020 were included. Medico-economic evaluations of the virtual outpatient and day admission surgery groups based on predefined criteria were compared to the identical group of patients who underwent surgery in the actual traditional inpatient setting. In a second step, postoperative complications of the virtual outpatient group were assessed. Cost-revenue analysis was performed using a micro-costing approach including direct medical costs.ResultsOverall (N = 257), 97 (37.7%) colectomies would have been potentially eligible for an outpatient strategy. The global costs of the actual inpatient strategy totaled USD 3 634 392 with a global revenue of USD 3 571 069, corresponding to a cost coverage rate of 98%. The result of the virtual DAS strategy would have been a net loss of USD 15 800 (coverage rate of 99%) due to 4 low length of stay outliers triggering a reimbursement reduction and preventing a positive net result of USD 16 208. The pilot reference outpatient case's revenue and cost amounted to respectively USD 7479 and USD 6911 (cost coverage of 108%).ConclusionFrom both any given hospital and healthcare system point of view, elective outpatient colectomy for selected patients is the most cost-saving option. However, in a prospective payment system implemented to avoid bad incentives, the latter can unintentionally disadvantage best performing hospitals and impede widespread adoption of high-value strategies.
| S-EPMC11439163 | biostudies-literature
Project description:BackgroundParotid gland carcinoma (PGC) is a rare malignant tumor. The purpose of this study was to investigate the role of immune-inflammatory-nutrition indicators and age-adjusted Charlson comorbidity index score (ACCI) of PGC and develop the nomogram model for predicting prognosis.MethodAll patients diagnosed with PGC in two tertiary hospitals, treated with surgical resection, from March 2012 to June 2018 were obtained. Potential prognostic factors were identified by univariate and multivariate Cox regression analyses. The nomogram models were established based on these identified independent prognostic factors. The performance of the developed prognostic model was estimated by related indexes and plots.ResultThe study population consisted of 344 patients with PGC who underwent surgical resection, 285 patients without smoking (82.8%), and 225 patients (65.4%) with mucoepidermoid carcinoma, with a median age of 50.0 years. American Joint Committee on Cancer (AJCC) stage (p < 0.001), pathology (p = 0.019), tumor location (p < 0.001), extranodal extension (ENE) (p < 0.001), systemic immune-inflammation index (SII) (p = 0.004), prognostic nutrition index (PNI) (p = 0.003), ACCI (p < 0.001), and Glasgow prognostic Score (GPS) (p = 0.001) were independent indicators for disease free survival (DFS). Additionally, the independent prognostic factors for overall survival (OS) including AJCC stage (p = 0.015), pathology (p = 0.004), tumor location (p < 0.001), perineural invasion (p = 0.009), ENE (p < 0.001), systemic immune-inflammation index (SII) (p = 0.001), PNI (p = 0.001), ACCI (p = 0.003), and GPS (p = 0.033). The nomogram models for predicting DFS and OS in PGC patients were generated based on these independent risk factors. All nomogram models show good discriminative capability with area under curves (AUCs) over 0.8 (DFS 0.802, and OS 0.825, respectively). Decision curve analysis (DCA), integrated discrimination improvement (IDI), and net reclassification index (NRI) show good clinical net benefit of the two nomograms in both training and validation cohorts. Kaplan-Meier survival analyses showed superior discrimination of DFS and OS in the new risk stratification system compared with the AJCC stage system. Finally, postoperative patients with PGC who underwent adjuvant radiotherapy had a better prognosis in the high-, and medium-risk subgroups (p < 0.05), but not for the low-risk subgroup.ConclusionThe immune-inflammatory-nutrition indicators and ACCI played an important role in both DFS and OS of PGC patients. Adjuvant radiotherapy had no benefit in the low-risk subgroup for PGC patients who underwent surgical resection. The newly established nomogram models perform well and can provide an individualized prognostic reference, which may be helpful for patients and surgeons in proper follow-up strategies.
| S-EPMC11193213 | biostudies-literature
Project description:BackgroundRecent studies have suggested postoperative acute pancreatitis (POAP) as a serious complication after pancreaticoduodenectomy (PD) and have speculated on its possible role in the pathogenesis of postoperative pancreatic fistula (POPF). This study aimed to assess the impact of POAP on post-PD outcomes and fistula risk score (FRS) performance in predicting POAP.MethodsAll PDs at Helsinki University Hospital between 2013 and 2020 were analysed. POAP was defined as a plasma amylase activity greater than the normal upper limit on postoperative day (POD) 1 and stratified as clinically relevant (CR)-POAP once C-reactive protein (CRP) reached or exceeded 180 mg/l, and non-CR-POAP once CRP was less than 180 mg/l on POD 2. The Comprehensive Complication Index (CCI) was used to assess total postoperative morbidity. Different FRSs were assessed using receiver operating characteristic curves.ResultsOf the 508 patients included, POAP occurred in 202 (39.8 per cent) patients, of whom 91 (17.9 per cent) had CR-POAP. The incidence of CR-POPF was 12.6 per cent (64 patients). Patients with non-CR-POAP had a similar morbidity to patients with no POAP (median CCI score 24.2 versus 22.6; P = 0.142), while CCI score was significantly higher (37.2) in patients with CR-POAP (P < 0.001). CR-POAP was associated with increased rates of CR-POPF, delayed gastric emptying, haemorrhage, and bile leak, while non-CR-POAP was associated only with CR-POPF. Ninety-day mortality was 1.6 per cent, 0.9 per cent, and 3.3 per cent in patients with no-POAP, non-CR-POAP, and CR-POAP, respectively. Updated alternative FRS showed the best performance in predicting CR-POAP (area under the curve 0.834).ConclusionCR-POAP was associated with a higher CCI score, suggesting CR-POAP as a distinct entity from non-CR-POAP. FRSs can be used to assess the risk of CR-POAP.
| S-EPMC9039121 | biostudies-literature