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The purpose of this analysis was to assess the burden of Clostridium difficile infection in the hospitalized pediatric surgical population and to characterize its influence on the costs of care.There were 313,664 patients age 1-18 years who underwent a general thoracic or abdominal procedure in the Kids' Inpatient Database during 2003, 2006, 2009, and 2012. Logistic regression was used to model factors associated with the development of C difficile infection. A propensity score-matching analysis was performed to evaluate the influence of C difficile infection on mortality, duration of stay, and costs in similar patient cohorts. Population weights were used to estimate the national excess burden of C difficile infection on these outcomes.The overall prevalence of C difficile infection in the sampled cohort was 0.30%, with an increasing trend of C difficile infection over time in non-children's hospitals (P .001). C difficile infection was associated with younger age, nonelective procedures, increasing comorbidities, and urban teaching hospital status (P .001). An estimated 1,438 children developed C difficile infection after operation. After propensity score matching, the mean excess duration of stay and costs attributable to C difficile infection were 5.8 days and $12,801 (P .001), accounting for 8,295 days spent in the hospital and $18.4 million (2012 USD) in spending annually.C difficile infection is a relatively uncommon but costly complication after pediatric operative procedures. Given the increasing trend of C difficile infection among hospitalized surgical patients, there is substantial opportunity for reduction of inpatient burden and associated costs in this potentially preventable nosocomial infection.

Background Little is known about costs associated with differentiated thyroid cancer (DTC) and follow-up care. This study used data from the Surveillance Epidemiology and End Results (SEER) database to examine cumulative costs attributable to disease stage and treatment options of DTC in elderly patients over 5 years. Methods We identified 2,823 patients aged >65 years with DTC and 5,646 noncancer comparison cases from SEER Medicare data between 1995 and 2005. Cumulative costs were obtained by estimating average costs/patient in each month up to 60 months after diagnosis. We performed multivariate analyses of costs by fitting each monthly cost to linear models, controlling for demographics and comorbidities. Marginal effects of covariates were obtained by summing coefficients over 60 months. Results Cumulative costs were $17,669/patient the first year and $48,989/patient 5 years after diagnosis. Regional disease was associated with higher costs at 1 year ($9,578) and 5 years ($8,902). Distant disease was associated with 1-year costs of $28,447 and 5-year costs of $20,103. Patients undergoing surgery and radiation had a decrease in cost of $722 at 5 years. Conclusion DTC in the elderly is associated with significant economic burden largely attributable to patient demographics, stage of disease, and treatment modalities.

Standard of care for patients with advanced gastric cancer includes administration of neoadjuvant chemotherapy (NAC) before resection. This study assesses the pattern of use and impact of NAC on perioperative outcomes in US medical centers.Using the American College of Surgeons National Cancer Database, 16,128 patients underwent gastrectomy for cancer from 2003 to 2012. Treatment groups were categorized as NAC or no NAC (ie, adjuvant chemotherapy and surgery only). Univariate and multivariate analyses were performed to estimate trends in utilization and impact of treatment on perioperative outcomes.Of patients undergoing gastrectomy, 36.6% received NAC and 63.4% did not receive chemotherapy in the neoadjuvant setting. Patients who received NAC were more frequently younger, male, white, privately insured, with fewer comorbidities, and treated at an academic center (all P.0001). After controlling for demographics, comorbidities, and tumor-related factors, patients who received NAC had a postoperative duration of stay 0.43 days shorter than patients who did not receive chemotherapy (5.79 vs 6.22 days; P = .050). They had a 36% lower odds of 30-day mortality (odds ratio, 0.64, P.0001) but nonsignificant lower odds of 90-day mortality. Use of NAC increased annually, with the greatest increases seen in academic facilities and in the Northeast and North Central United States.With concerns regarding the toxicity of NAC, these findings suggest that NAC is not associated with worse postoperative outcomes. In light of evidence touting the benefits of NAC, its adoption as a component in the multimodality care of gastric cancer is slowly increasing, although use of NAC remains poor overall.

The purpose of this study was to estimate the costs associated with the most common complications of the ileal pouch anal anastomosis (IPAA) and identify factors that predispose to them.Hospital costs of 135 patients undergoing the IPAA were combined with information abstracted from charts. Logistic and linear regression modeling were used to estimate the marginal costs for the most common IPAA complications and determine factors predisposing to their occurrence.The average overall cost for the IPAA was $20,865. Just more than half (53%) of patients experienced complications, the 3 most common being small-bowel obstruction (24.4%), pelvic/abdominal sepsis (6.7%), and dehydration (5.9%). The average cost to treat an episode of small-bowel obstruction was $6709. Treatment of pelvic/abdominal sepsis averaged $9268 per occurrence, whereas dehydration averaged $4860. Steroid use3 months before colectomy significantly increased the risk for any complication (P =.02). No factors were found to be good predictors of bowel obstruction. However, age42 years and low patient hematocrit were significant predictors of dehydration as a complication (P.05). Trending toward significance were urgent operation and weight loss greater than 5%.The most common complications of the IPAA are small-bowel obstruction, pelvic/abdominal sepsis, and dehydration. Complications were responsible for approximately 44% of the overall cost of an IPAA. Factors that increase risk of IPAA complications are steroid use, low hematocrit, age42 years, nonelective procedures, and preoperative weight loss.

It is unknown how colorectal surgical outcomes in recipients of renal transplants (TXP) compare to the outcomes in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD).Data from the Nationwide Inpatient Sample for 2004 to 2008 were reviewed. International Classification of Diseases (ICD-9) codes identified patients undergoing colorectal surgery who were stratified as having no kidney disease, CKD, ESRD, or TXP. The effects of renal status on mortality, length of hospital stay, and hospital costs were determined.A total of 171,133 patients were identified; 162,986 had no kidney disease, 3,686 had CKD, 1,296 had ESRD, and 3,765 had had TXP. The odds of death after surgery were 43% more likely for patients with CKD, 82% more likely for TXP, and 240% more likely for those with ESRD. TXP resulted in an additional length of hospital stay of 3.4 days, compared to 3.2 days for those with ESRD, and 1.1 days for those with CKD (P.0001). CKD added $4,223 in additional costs, TXP added $8,213, and ESRD added $12,821 (P.0001). TXP demonstrated odds of mortality between those of CKD and ESRD for cardiovascular complications (OR 2.47). Pulmonary complications resulted in the highest odds of mortality for TXP (OR 6.3).After TXP, patients undergoing colorectal surgery have mortality and costs between those of patients with CKD and ESRD, with pulmonary complications remaining high mortality events.

Although much has been written about excess cost and duration of stay (DOS) associated with surgical site infections (SSIs) after cardiothoracic surgery, less has been reported after vascular and general surgery. We used data from the National Surgical Quality Improvement Program (NSQIP) to estimate the total cost and DOS associated with SSIs in patients undergoing general and vascular surgery.Using standard NSQIP practices, data were collected on patients undergoing general and vascular surgery at a single academic center between 2007 and 2009 and were merged with fully loaded operating costs obtained from the hospital accounting database. Logistic regression was used to determine which patient and preoperative variables influenced the occurrence of SSIs. After adjusting for patient characteristics, costs and DOS were fit to linear regression models to determine the effect of SSIs.Of the 2,250 general and vascular surgery patients sampled, SSIs were observed in 186 inpatients. Predisposing factors of SSIs were male sex, insulin-dependent diabetes, steroid use, wound classification, and operative time (P.05). After adjusting for those characteristics, the total excess cost and DOS attributable to SSIs were $10,497 (P.0001) and 4.3 days (P.0001), respectively.SSIs complicating general and vascular surgical procedures share many risk factors with SSIs after cardiothoracic surgery. Although the excess costs and DOS associated with SSIs after general and vascular surgery are somewhat less, they still represent substantial financial and opportunity costs to hospitals and suggest, along with the implications for patient care, a continuing need for cost-effective quality improvement and programs of infection prevention.

Concerns regarding care quality prompted credentialing processes for bariatric "Centers of Excellence" (COE). It is hypothesized that high-volume surgeons and hospitals have better outcomes.This population-based study examines the effect of bariatric surgery volume on mortality in Pennsylvania.Between 1999 and 2003, 14,716 patients having gastric bypass surgery in Pennsylvania hospitals were identified from the Pennsylvania Health Care Cost Containment Council database. Individual surgeons and hospitals were stratified as high (100 cases/yr), medium (50-100 cases/yr), or low volume (50 cases/yr). The relationship between surgeon and hospital volume on length of stay (LOS), in-hospital, and 30-day mortality were examined, adjusting for age, gender, ethnicity, payor, and MedisGroups Admission Severity Group (ASG) score.There were 26-50 low (n = 2,158), 35-54 medium (n = 1,835), and 43-64 high (n = 10,723) volume hospitals in Pennsylvania. The mean volume/hospital increased between 1999 and 2003 (30-120 cases/yr) and in-hospital mortality decreased (0.8-0.2%). Thirty-day mortality (1.15%) was approximately 2 times the in-hospital mortality (0.37%). Male gender (odds ratio [OR] 3.6, P.001), ASG (OR 2.5, P.001), hospital and surgeon volume were associated with increased in-hospital and 30-day mortality. Controlling for other factors, patients treated by low- and medium-volume surgeons (OR 3.7, P = .002; OR 2.8, P = .015) and hospitals (OR 2.3, P = .01; OR 2.44, P = .017) had increased odds of 30-day mortality versus high-volume surgeons and hospitals. LOS was significantly shorter at high-volume hospitals as well.In Pennsylvania, high volume is associated with decreased mortality and LOS. The results support the use of surgical volume in the COE credentialing process.

Background. Although postoperative infections have a significant impact on morbidity and mortality after orthotopic liver transplantation (OLT), less is known about their economic implications. In this study, we sought to identify risk factors and estimate the impact of surgical site infections on 1-year mortality, graft survival, and resource utilization after OLT. Methods. We studied 777 first, single-organ liver transplant recipients from the National Institute of Diabetes and Digestive and Kidney Diseases Liver Transplantation Database. Surgical site infections (n = 292, 37.8%) were defined as bacterial or fungal infections of the liver, intestine, biliary tract, surgical wound, or peritoneum within 1 year of transplantation. A subset of these (n = 159) occurred during the transplant hospitalization and were used to estimate excess charges associated with surgical site infections. Results. Leaks in the choledochojejunostomy (odds ratio [OR] = 7.1, P =.001) and choledochocholedochostomy (OR = 2.5, P =.002), extended operation duration in hours (OR = 1.2, P =.002), serum albumin levels in grams per liters (OR = 0.71, P =.009), ascites (OR = 1.43, P =.037), and administration of OKT3 within 7 days (OR = 1.49, P =.039) significantly increased risk of infection. Surgical site infections did not significantly increase 1-year mortality (88.5% vs 91.5%, P =.19) but significantly increased 1-year graft loss (79.8% vs 86.5%, P =.022). Patients with surgical site infections incurred approximately 24 extra hospital days and $159,967 in excess charges ( P =.0001). Multivariate analysis reduced the estimate of excess charges to $131,276 ( P =.0001). Conclusions. Liver transplant recipients who develop surgical site infection have significantly higher resource utilization requirements than those who do not. These results imply substantial returns to preventative efforts directed at surgical site infections in patients undergoing OLT. (Surgery 2001;130:388-95.)