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Background: TRICARE military beneficiaries are increasingly referred for major surgeries to civilian hospitals under "purchased care." This loss of volume may have a negative impact on the readiness of surgeons working in the "direct-care" setting at military treatment facilities and has important implications under the volume-quality paradigm. The objective of this study is to assess the impact of care source (direct versus purchased) and surgical volume on perioperative outcomes and costs of colorectal surgeries., Methods: We examined TRICARE claims and medical records for 18- to 64-year-old patients undergoing major colorectal surgery from 2006 to 2015. We used a retrospective, weighted estimating equations analysis to assess differences in 30-day outcomes (mortality, readmissions, and major or minor complications) and costs (index and total including 30-day postsurgery) for colorectal surgery patients between purchased and direct care., Results: We included 20,317 patients, with 24.8% undergoing direct-care surgery. Mean length of stay was 7.6 vs 7.7 days for direct and purchased care, respectively (P = .24). Adjusted 30-day odds between care settings revealed that although hospital readmissions (odds ratio 1.40) were significantly higher in direct care, overall complications (odds ratio 1.05) were similar between the 2 settings. However, mean total costs between direct and purchased care differed ($55,833 vs $30,513, respectively). Within direct care, mean total costs ($50,341; 95% confidence interval $41,509-$59,173) were lower at very high-volume facilities compared to other facilities ($54,869; 95% confidence interval $47,822-$61,916)., Conclusion: Direct care was associated with higher odds of readmissions, similar overall complications, and higher costs. Contrary to common assumptions regarding volume and quality, higher volume in the direct-care setting was not associated with fewer complications., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: There is controversy regarding the widespread uptake of robotic surgery across several surgical disciplines. While it has been shown to confer clinical benefits such as decreased blood loss and shorter hospital stays, some argue that the benefits of this technology do not outweigh its high cost. We performed a retrospective insurance-based analysis to investigate how undergoing robotic surgery, compared to open surgery, may impact the time in which an employed individual returns to work after undergoing major surgery., Methods: We identified a cohort of US adults with employer-sponsored insurance using claims data from the MarketScan database who underwent either open or robotic radical prostatectomy, hysterectomy/myomectomy, and partial colectomy from 2012 to 2016. We performed multiple regression models incorporating propensity scores to assess the effect of robotic vs. open surgery on the number of absent days from work, adjusting for demographic characteristics and baseline absenteeism., Results: In a cohort of 1157 individuals with employer-sponsored insurance, those undergoing open surgery, compared to robotic surgery, had 9.9 more absent workdays for radical prostatectomy (95%CI 5.0 to 14.7, p < 0.001), 25.3 for hysterectomy/myomectomy (95%CI 11.0-39.6, p < 0.001), and 29.8 for partial colectomy (95%CI 14.8-44.8, p < 0.001) CONCLUSION: For the three major procedures studied, robotic surgery was associated with fewer missed days from work compared to open surgery. This information helps payers, patients, and providers better understand some of the indirect benefits of robotic surgery relative to its cost.

Background: Most hospitals in the United States are reimbursed for colectomy via a bundled payment based on the diagnosis-related group assigned. Enhanced recovery after surgery programs have been shown to improve the value of colorectal surgery, but little is known about the granular financial tradeoffs required at individual hospitals., Objective: The purpose of this study is to analyze the index-hospitalization impact on specific cost centers associated with enhanced recovery after surgery implementation for diagnosis-related groups commonly assigned to patients undergoing colon resections., Design: We performed a single-institution retrospective, nonrandomized, preintervention (2013-2014) and postintervention (2015-2017) analysis of hospital costs., Setting: This study was conducted at an academic medical center., Patients: A total of 1297 patients with diagnosis-related group 330 (colectomy with complications/comorbidities) and 331 (colectomy without complications/comorbidities) were selected., Main Outcome Measures: The primary outcome was total index-hospitalization cost. Secondary outcomes included specific cost center expenses., Results: Total median cost for diagnosis-related group 330 in the pre-enhanced recovery after surgery group was $24,111 ($19,285-$28,658) compared to $21,896 ($17,477-$29,179) in the enhanced recovery after surgery group, p = 0.01. Total median cost for diagnosis-related group 331 in the pre-enhanced recovery after surgery group was $19,268 ($17,286-$21,858) compared to $18,444 ($15,506-$22,847) in the enhanced recovery after surgery group, p = 0.22. When assessing cost changes after enhanced recovery after surgery implementation for diagnosis-related group 330, operating room costs increased (p = 0.90), nursing costs decreased (p = 0.02), anesthesia costs increased (p = 0.20), and pharmacy costs increased (p = 0.08). For diagnosis-related group 331, operating room costs increased (p = 0.001), nursing costs decreased (p < 0.001), anesthesia costs increased (p = 0.03), and pharmacy costs increased (p = 0.001)., Limitations: This is a single-center study with a pre- and postintervention design., Conclusions: The returns on investment at the hospital level for enhanced recovery after surgery implementations in colorectal surgery result largely from cost savings associated with decreased nursing expenses. These savings likely offset increased spending on operating room supplies, anesthesia, and medications. See Video Abstract at http://links.lww.com/DCR/B204. IMPACTO DE LA IMPLEMENTACIÓN DEL PROTOCOLO DE RECUPERACIÓN MEJORADA DESPUÉS DE CIRUGÍA EN EL COSTO DE LA HOSPITALIZACIÓN ÍNDICE EN CENTROS ESPECÍFICOS: La mayoría de los hospitales en los Estados Unidos son reembolsados por la colectomía a través de un paquete de pago basado en el grupo de diagnóstico asignado. Se ha demostrado que los programas de recuperación después de la cirugía mejoran el valor de la cirugía colorrectal, pero se sabe poco sobre las compensaciones financieras granulares que se requieren en los hospitales individuales.El objetivo de este estudio es analizar el impacto del índice de hospitalización en centros de costos específicos asociados con la implementación de RMDC para grupos relacionados con el diagnóstico comúnmente asignados a pacientes que se someten a resecciones de colon.Realizamos un análisis retrospectivo, no aleatorio, previo (2013-2014) y posterior a la intervención (2015-2017) de los costos hospitalarios de una sola institución.Centro médico académico.Un total de 1. 297 pacientes con diagnóstico relacionado con el grupo 330 (colectomía con complicaciones/comorbilidades) y 331 (colectomía sin complicaciones/comorbilidades).El resultado primario fue el índice total de costos de hospitalización. Los resultados secundarios incluyeron gastos específicos del centro de costos.El costo medio total para el grupo relacionado con el diagnóstico de 330 en el grupo de recuperación pre-mejorada después de la cirugía fue de $24,111 ($19,285- $28,658) en comparación con $21,896 ($17,477- $29,179) en el grupo de recuperación mejorada después de la cirugía, p = 0.01. El costo medio total para DRG 331 en el grupo de recuperación pre-mejorada después de la cirugía fue de $19,268 ($17,286- $21,858) en comparación con $18,444 ($15,506-$22,847) en el grupo de recuperación mejorada después de la cirugía, p = 0.22. Al evaluar los cambios en los costos después de una recuperación mejorada después de la implementación de la cirugía para el grupo 330 relacionado con el diagnóstico, los costos de la sala de operaciones aumentaron (p = 0.90), los costos de enfermería disminuyeron (p = 0.02) los costos de anestesia aumentaron (p = 0.20) y los costos de farmacia aumentaron (p = 0.08). Para el grupo 331 relacionado con el diagnóstico, los costos de la sala de operaciones aumentaron (p = 0.001), los costos de enfermería disminuyeron (p < 0.001) los costos de anestesia aumentaron (p = 0.03) y los costos de farmacia aumentaron (p = 0.001).Este es un estudio de un solo centro con un diseño previo y posterior a la intervención.El retorno de la inversión a nivel hospitalario para una recuperación mejorada después de la implementación de la cirugía en la cirugía colorrectal se debe en gran parte al ahorro de costos asociado con la disminución de los gastos de enfermería. Es probable que estos ahorros compensen el aumento de los gastos en suministros de quirófano, anestesia y medicamentos. Consulte Video Resumen en http://links.lww.com/DCR/B204. (Traducción-Dr. Gonzalo Hagerman).

Background: The United States is in the middle of an opioid epidemic. Gastrointestinal surgery has been ranked in the top 3 surgical subspecialties for highest opioid prescribing., Objective: The goal of this study is to determine the rate of and risk factors for prolonged opioid use following colectomy., Design: This study utilized data (2015-2017) from the American College of Surgeons National Surgical Quality Improvement Program from 5 institutions., Settings: This study was conducted at 2 academic and 3 community hospitals., Patients: Included were 1243 patients who underwent colectomy., Main Outcome Measures: The primary outcome was rate of prolonged opioid use defined as a new opioid prescription 90 to 180 days postoperatively., Results: A total of 132 (10.6%) patients were prolonged opioid users. In univariate analysis, patients who were prolonged opioid users were significantly more likely to have had more than one opioid prescription in the prior year, to have a higher ASA classification, to undergo an open procedure, to have an ostomy created, and to be discharged with a high quantity of opioids (all p < 0.05). Prolonged opioid users were significantly more likely to have a complication (p = 0.007) or readmission (p = 0.003) within 30 days of the index procedure. In multivariable analysis, prior opioid use (OR, 2.6; 95% CI, 1.6-4.2; p < 0.001), ostomy creation (OR, 2.1; 95% CI,1.2-3.7; p = 0.01), higher quantity of opioid prescription at discharge (OR, 1.9; 95% CI,1.1-3.3; p = 0.03), higher ASA classification (OR, 1.7; 95% CI, 1.1-2.6; p = 0.02), and hospital readmission (OR, 2.0; 95% CI, 1.2-3.4; p = 0.01) were independent predictors of prolonged opioid use., Limitations: This study is a retrospective review, and all variables related to prolonged opioid use are not collected in the data., Conclusions: A significant proportion of patients undergoing colectomy become prolonged opioid users. We have identified risk factors for prolonged postoperative opioid use, which may allow for improved patient education and targets for intervention preoperatively, as well as implementation of programs for monitoring and cessation of opioid use in the postoperative period. See Video Abstract at http://links.lww.com/DCR/A973. PREDICTORES DEL USO PROLONGADO DE OPIOIDES DESPUÉS DE LA COLECTOMÍA: Los Estados Unidos se encuentran en medio de una epidemia de opioides. La cirugía gastrointestinal ha sido clasificada entre las tres subespecialidades quirúrgicas principales para la prescripción más alta de opioides., Objetivo: El objetivo de este estudio es determinar la tasa y los factores de riesgo para el uso prolongado de opioides después de la colectomía. DISEÑO:: Este estudio utilizó datos (2015-2017) del Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Americano de Cirujanos de cinco instituciones., Marco: Dos hospitales académicos y tres comunitarios., Pacientes: 1,243 pacientes sometidos a una colectomía., Medidas De Resultado Principales: El resultado primario fue la tasa de uso prolongado de opioides, definida como una nueva receta de opioides entre 90 y 180 días después de la operación., Resultados: Un total de 132 (10.6%) pacientes fueron usuarios de opioides por tiempo prolongado. En el análisis univariado, los pacientes que eran usuarios prolongados de opioides tenían una probabilidad significativamente mayor de haber tenido más de una receta de opioides en el año anterior, tenían una clasificación más alta de la Asociación Americana de Anestesiólogos, se sometieron a un procedimiento abierto, se les creó una ostomía y se les dio de alta con una cantidad grande de opioides (todos p < 0.05). Los usuarios de opioides prolongados fueron significativamente más propensos a tener una complicación (p = 0.007) o readmisión (p = 0.003) dentro de los 30 días del procedimiento índice. En el análisis multivariado, el uso previo de opioides (OR, 2.6; IC 95%, 1.6-4.2; p < 0.001), creación de ostomía (OR, 2.1; IC 95%, 1.2-3.7; p = 0.01), mayor cantidad de prescripción de opioides al dar de alta (OR, 1.9; IC 95%, 1.1-3.3; p = 0.03), clasificación más alta de la Asociación Americana de Anestesiólogos (OR, 1.7; IC 95%, 1.1-2.6; p = 0.02) y reingreso hospitalario (OR, 2.0; IC del 95%, 1.2-3.4, p = 0.01) fueron predictores independientes del uso prolongado de opioides., Limitaciones: Este estudio es una revisión retrospectiva y todos los variables relacionadas con el uso prolongado de opioides no se colectaron en los datos., Conclusiones: Una proporción significativa de pacientes con colectomía se convierten en usuarios prolongados de opioides. Hemos identificado factores de riesgo para el uso prolongado de opioides postoperatorios, que pueden permitir una mejor educación del paciente y objetivos para la intervención preoperatoria, así como la implementación de programas para la supervisión y cese del uso de opioides en el período postoperatorio. Vea el Video de Resumen en http://links.lww.com/DCR/A973.

Background: In Ukraine, the 1-year mortality for colorectal cancer is much higher than that seen in high-income countries. We investigated practice patterns of colorectal cancer treatment in a region of Ukraine to account for high mortality rates. Methods: An explanatory sequential mixed methods design was used. Data from patients who underwent surgery for colorectal cancer in Ivano-Frankivsk from 2011 to 2015 were collected via retrospective chart review, and descriptive statistics were calculated. Semi-structured interviews were performed with local practicing surgeons and oncologists until thematic saturation was reached. Results: A total of 960 patients who underwent surgery were identified in the Ivano-Frankivsk region with colon (689) or rectal (271) cancer. 11.7% of patients underwent preoperative CT of the abdomen and pelvis, and only 1.7% underwent CT of the chest. 4.1% of patients underwent a complete preoperative colonoscopy, while 31.0% had incomplete colonoscopies. Postoperatively, 31.1% of patients with stage II colon cancer and 43.9% of patients with stage III colon cancer underwent adjuvant chemotherapy. For patients with stage II and III rectal cancers, 20.9% and 33.3% underwent chemotherapy, while 68.4% and 66.7% underwent radiation therapy, respectively. Fifteen physicians completed interviews. Two major themes emerged regarding physician perceptions on providing colorectal cancer care: lack of resources and systems level issues negatively impacting patient care. Conclusion: In this region in Ukraine, staging practices for colorectal malignancies are inconsistent and inadequate, and adjuvant treatments are varied. This is likely attributable to the lack of resources facing providers and the prohibitively high cost of care to patients. [ABSTRACT FROM AUTHOR]

Background: The rise in deaths attributed to opioid drugs has become a major public health problem in the United States and in the world. Minimally invasive surgery (MIS) is associated with a faster postoperative recovery and our aim was to investigate if the use of MIS was associated with lower odds of prolonged opioid prescriptions after major procedures.Methods: Retrospective study using the IBM Watson Health Marketscan® Commerical Claims and Encounters Database investigating opioid-naïve cancer patients aged 18-64 who underwent open versus MIS radical prostatectomy (RP), partial colectomy (PC) or hysterectomy (HYS) from 2012 to 2017. Propensity weighted logistic regression analyses were used to estimate the independent effect of surgical approach on prolonged opioid prescriptions, defined as prescriptions within 91-180 days of surgery.Results: Overall, 6838 patients underwent RP (MIS 85.5%), 4480 patients underwent PC (MIS 61.6%) and 1620 patients underwent HYS (MIS 41.8%). Approximately 70-80% of all patients had perioperative opioid prescriptions. In the weighted model, patients undergoing MIS were significantly less likely to have prolonged opioid prescriptions in all three surgery types (Odds Ratio [OR] 0.737, 95% Confidence Interval [CI] 0.595-0.914, p = 0.006; OR 0.728, 95% CI 0.600-0.882, p = 0.001; OR 0.655, 95% CI 0.466-0.920, p = 0.015, respectively).Conclusion: The use of the MIS was associated with lower odds of prolonged opioid prescription in all procedures examined. While additional studies such as clinical trials are needed for further confirmation, our findings need to be considered for patient counseling as postoperative differences between approaches do exist. [ABSTRACT FROM AUTHOR]