Drivers of Variability in 90-Day Cost for Elective Laminectomy and Fusion for Lumbar Degenerative Disease

Neurosurgery ◽  
2018 ◽  
Vol 84 (5) ◽  
pp. 1043-1049 ◽  
Author(s):  
Ahilan Sivaganesan ◽  
Silky Chotai ◽  
Scott L Parker ◽  
Matthew J McGirt ◽  
Clinton J Devin
Keyword(s):  
Regression Tree ◽  
Length Of Hospital Stay ◽  
Opioid Use ◽  
Tree Model ◽  
Lumbar Degenerative Disease ◽  
Modifiable Factors ◽  
Duration Of Surgery ◽  
Laminectomy And Fusion ◽  
The Cost ◽  
Prospective Longitudinal

Abstract BACKGROUND Considerable variability exists in the cost of surgery following spine surgery for common degenerative spine diseases. This variation in the cost of surgery can affect the payment bundling during the postoperative 90 d. OBJECTIVE To determine the drivers of variability in total 90-d cost for laminectomy and fusion surgery. METHODS A total of 752 patients who underwent elective laminectomy and fusion for degenerative lumbar conditions and were enrolled into a prospective longitudinal registry were included in the study. Total cost during the 90-d global period was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multivariable regression models were built for total 90-d cost. RESULTS The mean 90-d direct cost was $29 295 (range, $28 612-$29 973). Based on our regression tree analysis, the following variables were found to drive the 90-d cost: age, BMI, gender, diagnosis, postop imaging, number of operated levels, ASA grade, hypertension, arthritis, preop and postop opioid use, length of hospital stay, duration of surgery, 90-d readmission, outpatient physical/occupational therapy, inpatient rehab, postop healthcare visits, postop nonopioid pain medication use nonsteroidal antiinflammatory drug (NSAIDs), and muscle relaxant use. The R2 for tree model was 0.64. CONCLUSION Utilizing prospectively collected data, we demonstrate that considerable variation exists in total 90-d cost, nearly 70% of which can be explained by those factors included in our modeling. Risk-adjusted payment schemes can be crafted utilizing the significant drivers presented here. Focused interventions to target some of the modifiable factors have potential to reduce cost and increase the value of care.

scholarly journals Evaluation of the cost-utility of a prescription digital therapeutic for the treatment of opioid use disorder

2021 ◽  
pp. 1-7
Author(s):  
Fulton F. Velez ◽  
Hilary F. Luderer ◽  
Robert Gerwien ◽  
Benjamin Parcher ◽  
Dylan Mezzio ◽  
...  
Keyword(s):  
Opioid Use Disorder ◽  
Cost Utility ◽  
Opioid Use ◽  
The Cost

scholarly journals Review on Perioperative and Oncological Outcomes of Robotic Gastrectomy for Cancer

2021 ◽  
Vol 11 (7) ◽  
pp. 638
Author(s):  
Giuseppe Giuliani ◽  
Francesco Guerra ◽  
Lorenzo De Franco ◽  
Lucia Salvischiani ◽  
Roberto Benigni ◽  
...  
Keyword(s):  
English Language ◽  
Length Of Hospital Stay ◽  
Radical Gastrectomy ◽  
Robotic Gastrectomy ◽  
Relevant Evidence ◽  
Relative Paucity ◽  
Duration Of Surgery ◽  
High Level ◽  
Standard Laparoscopic Surgery

Background. Minimally invasive gastrectomy is currently considered a valid option to treat gastric cancer and is gaining increasing acceptance. Recent reports have suggested that the application of robots may confer some advantages over conventional laparoscopy, but the role of robotic surgery in clinical practice is still uncertain. We aimed to critically review the relevant evidence comparing robotic to standard laparoscopic surgery in performing radical gastrectomy. Methods. The Pubmed/Medline electronic databases were searched through February 2021. Paper conference and the English language was the only restriction applied to our search strategy. Results. According to the existing data, robotic gastrectomy seems to provide some benefits in terms of blood loss, rate of conversion, procedure-specific postoperative morbidity, and length of hospital stay. Robotic gastrectomy is also associated with a longer duration of surgery and a higher economic burden as compared to its laparoscopic counterpart. No significant differences have been disclosed in terms of long-term survivals, while the number of lymph nodes retrieved with robotic gastrectomy is generally higher than that of laparoscopy. Conclusions. The current literature suggests that robotic radical gastrectomy appears as competent as the conventional laparoscopic procedure and may provide some clinical advantages. However, due to the relative paucity of high-level evidence, it is not possible to draw definitive conclusions.

Stereotactic Electroencephalography Is Associated With Reduced Pain and Opioid Use When Compared with Subdural Grids: A Case Series

2021 ◽  
Author(s):  
Jonathan P Scoville ◽  
Evan Joyce ◽  
Joshua Hunsaker ◽  
Jared Reese ◽  
Herschel Wilde ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Chart Review ◽  
Statistical Tests ◽  
Case Series ◽  
Length Of Hospital Stay ◽  
Retrospective Chart Review ◽  
Opioid Use ◽  
Pain Scores ◽  
Surgical Methods ◽  
Significant Difference

Abstract BACKGROUND Minimally invasive surgery (MIS) has been shown to decrease length of hospital stay and opioid use. OBJECTIVE To identify whether surgery for epilepsy mapping via MIS stereotactically placed electroencephalography (SEEG) electrodes decreased overall opioid use when compared with craniotomy for EEG grid placement (ECoG). METHODS Patients who underwent surgery for epilepsy mapping, either SEEG or ECoG, were identified through retrospective chart review from 2015 through 2018. The hospital stay was separated into specific time periods to distinguish opioid use immediately postoperatively, throughout the rest of the stay and at discharge. The total amount of opioids consumed during each period was calculated by transforming all types of opioids into their morphine equivalents (ME). Pain scores were also collected using a modification of the Clinically Aligned Pain Assessment (CAPA) scale. The 2 surgical groups were compared using appropriate statistical tests. RESULTS The study identified 43 patients who met the inclusion criteria: 36 underwent SEEG placement and 17 underwent craniotomy grid placement. There was a statistically significant difference in median opioid consumption per hospital stay between the ECoG and the SEEG placement groups, 307.8 vs 71.5 ME, respectively (P = .0011). There was also a significant difference in CAPA scales between the 2 groups (P = .0117). CONCLUSION Opioid use is significantly lower in patients who undergo MIS epilepsy mapping via SEEG compared with those who undergo the more invasive ECoG procedure. As part of efforts to decrease the overall opioid burden, these results should be considered by patients and surgeons when deciding on surgical methods.

scholarly journals Perioperative Gabapentin Does Not Reduce Postoperative Delirium in Older Surgical Patients

2017 ◽  
Vol 127 (4) ◽  
pp. 633-644 ◽  
Author(s):  
Keyword(s):  
Postoperative Pain ◽  
Postoperative Delirium ◽  
Intervention Group ◽  
Group Versus ◽  
Length Of Hospital Stay ◽  
Treated Group ◽  
Assessment Method ◽  
Hospital Length Of Stay ◽  
Control Group ◽  
Opioid Use

Abstract Background Postoperative pain and opioid use are associated with postoperative delirium. We designed a single-center, randomized, placebo-controlled, parallel-arm, double-blinded trial to determine whether perioperative administration of gabapentin reduced postoperative delirium after noncardiac surgery. Methods Patients were randomly assigned to receive placebo (N = 347) or gabapentin 900 mg (N = 350) administered preoperatively and for the first 3 postoperative days. The primary outcome was postoperative delirium as measured by the Confusion Assessment Method. Secondary outcomes were postoperative pain, opioid use, and length of hospital stay. Results Data for 697 patients were included, with a mean ± SD age of 72 ± 6 yr. The overall incidence of postoperative delirium in any of the first 3 days was 22.4% (24.0% in the gabapentin and 20.8% in the placebo groups; the difference was 3.20%; 95% CI, 3.22% to 9.72%; P = 0.30). The incidence of delirium did not differ between the two groups when stratified by surgery type, anesthesia type, or preoperative risk status. Gabapentin was shown to be opioid sparing, with lower doses for the intervention group versus the control group. For example, the morphine equivalents for the gabapentin-treated group, median 6.7 mg (25th, 75th quartiles: 1.3, 20.0 mg), versus control group, median 6.7 mg (25th, 75th quartiles: 2.7, 24.8 mg), differed on the first postoperative day (P = 0.04). Conclusions Although postoperative opioid use was reduced, perioperative administration of gabapentin did not result in a reduction of postoperative delirium or hospital length of stay.

scholarly journals Opioid Overprescription in Adolescents and Young Adults Undergoing Hip Arthroscopy

2021 ◽  
Vol 9 (7_suppl3) ◽  
pp. 2325967121S0005
Author(s):  
Mahad M. Hassan ◽  
Omar F. Rahman ◽  
Zaamin B. Hussain ◽  
Stephane L. Burgess ◽  
Yi-Meng Yen ◽  
...  
Keyword(s):  
Young Adult ◽  
Hip Arthroscopy ◽  
Pain Syndrome ◽  
Adult Patients ◽  
Adolescent And Young Adult ◽  
Bivariate Analysis ◽  
Opioid Use ◽  
Duration Of Surgery ◽  
Opioid Medications ◽  
Arthroscopic Procedures

Background: Previous studies have examined factors related to the increased use of opioids after hip arthroscopy in adults. However, few have focused on the adolescent population. Purpose: The purpose of this study was to compare the opioids prescribed to opioids consumed after hip arthroscopic procedures in adolescent and young adult patients, and to determine patient or surgical factors associated with increased postoperative opioid use. Methods: Adolescent and young adult patients who underwent hip arthroscopy and associated arthroscopic interventions between January 2017 and January 2020 were included. Patients with a diagnosed pain syndrome or history of chronic pain, as determined by the patient taking opioid medications prior to surgery, were excluded. Daily postoperative opioid intake was recorded via pain-control logbooks. The outcome of the study was defined as the average total number of opioid tablets consumed postoperatively. Results: Fifty-eight patients returned completed logbooks, 72% of whom were female patients. The average age was 21.30 years (range, 14.9 – 34.2). Most patients (73%) were prescribed 30 oxycodone tablets. The median amount of tablets consumed was 7 (range, 0-41) over a median duration of 7 days (range, 1-22). The median ratio of tablets consumed to prescribed was 20% and the 95th percentile of opioids consumed was 28 tablets. Bivariate analysis showed that patient age at surgery was positively correlated to the total amount of tablets consumed (r=0.28, p=0.04) and to the ratio of tablets consumed to prescribed (r=0.30, p=0.03). Duration of surgery was negatively correlated to the number of days tablets were consumed (r=-0.31, p=0.03). Multivariate analysis showed that patients who were prescribed more than 30 tablets took on average 7.8 more tablets overall compared to those prescribed 30 or fewer tablets (p=0.003), and that for each additional year of age, the ratio of tablets consumed to prescribed increased by 1% (p=0.02). Conclusion: After undergoing hip arthroscopy and associated arthroscopic procedures, adolescents and young adult patients are commonly overprescribed opioids, consuming on average only one-fifth of the tablets prescribed. This finding mirrors trends in the pediatric knee arthroscopy literature and provides an opportunity to reassess current opioid prescribing behaviors in the adolescent and young adult populations. [Table: see text][Table: see text][Table: see text][Table: see text][Table: see text]

Modifiable Factors and Delays Associated with Neonatal Deaths and Stillbirths in Jordan: Findings from Facility-Based Neonatal Death and Stillbirth Audits

2021 ◽  
Author(s):  
Mohammad S. Alyahya ◽  
Yousef S. Khader ◽  
Nihaya A Al-Sheyab ◽  
Khulood K. Shattnawi ◽  
Omar F. Altal ◽  
...  
Keyword(s):  
Cost Of Care ◽  
Delay Model ◽  
Case Review ◽  
Contributing Factors ◽  
Neonatal Deaths ◽  
Staff Members ◽  
Danger Signs ◽  
Modifiable Factors ◽  
Review Form ◽  
The Cost

Objective This study employed the “three-delay” model to investigate the types of critical delays and modifiable factors that contribute to the neonatal deaths and stillbirths in Jordan. Study Design A triangulation research method was followed in this study to present the findings of death review committees (DRCs), which were formally established in five major hospitals across Jordan. The DRCs used a specific death summary form to facilitate identifying the type of delay, if any, and to plan specific actions to prevent future similar deaths. A death case review form with key details was also filled immediately after each death. Moreover, data were collected from patient notes and medical records, and further information about a specific cause of death or the contributing factors, if needed, were collected. Results During the study period (August 1, 2019–February 1, 2020), 10,726 births, 156 neonatal deaths, and 108 stillbirths were registered. A delay in recognizing the need for care and in the decision to seek care (delay 1) was believed to be responsible for 118 (44.6%) deaths. Most common factors included were poor awareness of when to seek care, not recognizing the problem or the danger signs, no or late antenatal care, and financial constraints and concern about the cost of care. Delay 2 (delay in seeking care or reaching care) was responsible for nine (3.4%) cases. Delay 3 (delay in receiving care) was responsible for 81 (30.7%) deaths. The most common modifiable factors were the poor or lack of training that followed by heavy workload, insufficient staff members, and no antenatal documentation. Effective actions were initiated across all the five hospitals in response to the delays to reduce preventable deaths. Conclusion The formation of the facility-based DRCs was vital in identifying critical delays and modifiable factors, as well as developing initiatives and actions to address modifiable factors. Key Points

Behandeling van lumbale discushernia: open versus endoscopische discectomie?

2021 ◽  
Author(s):  
J. SYS ◽  
A. VERVAECKE
Keyword(s):  
Cost Benefit Analysis ◽  
Lumbar Disc ◽  
Length Of Hospital Stay ◽  
Cost Benefit ◽  
Complication Rates ◽  
Patient Morbidity ◽  
Endoscopic Discectomy ◽  
Theoretical Advantage ◽  
Open Versus ◽  
The Cost

Open (micro) discectomie is a routine treatment for patients with a lumbar disc hernia and incapacitating sciatica, resistant to conservative treatment. Alternatively, the full-endoscopic discectomy has been increasingly performed over the past years. While the surgical instrumentation for this approach has improved and the necessary specialized training is widely available, the technique remains challenging for the surgeon and the assumed/theoretical advantage regarding patient morbidity is still unproven. When compared to open (micro) discectomie, the existing literature fails to attribute significant decreases in length of hospital stay or complication rates to the full-endoscopic approach, therefore making the cost-benefit analysis uninteresting due to the higher associated cost. The structural lack of financing of Belgian hospitals leads to intrinsic budgetary limitations which are emphasized if the hospitals have to carry the extra costs related to endoscopic disc surgery themselves.

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