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Surgeon Variation in Intraoperative Supply Cost for Pancreaticoduodenectomy: Is Intraoperative Supply Cost Associated with Outcomes?

ABSTRACT: BACKGROUND:With increased scrutiny on the quality and cost of health care, surgeons must be mindful of their outcomes and resource use. We evaluated surgeon-specific intraoperative supply cost (ISC) for pancreaticoduodenectomy and examined whether ISC was associated with patient outcomes. STUDY DESIGN:Patients undergoing open pancreaticoduodenectomy between January 2012 and March 2015 were included. Outcomes were tracked prospectively through postoperative day 90, and ISC was defined as the facility cost of single-use surgical items and instruments, plus facility charges for multiuse equipment. Multivariate logistic regression was used to test associations between ISC and patient outcomes using repeated measures at the surgeon level. RESULTS:There were 249 patients who met inclusion criteria. Median ISC was $1,882 (interquartile range [IQR] $1,497 to $2,281). Case volume for 6 surgeons ranged from 18 to 66. Median surgeon-specific ISC ranged from $1,496 to $2,371. Greater case volume was associated with decreased ISC (p < 0.001). Overall, ISC was not predictive of postoperative complications (p = 0.702) or total hospitalization expenditures (p = 0.195). At the surgeon level, surgeon-specific ISC was not associated with the surgeon-specific incidence of severe complication or any wound infection (p > 0.227 for both), but was associated with delayed gastric emptying (p = 0.004) and postoperative pancreatic fistula (p < 0.001). CONCLUSIONS:In a single-institution cohort of 249 pancreaticoduodenectomies, high-volume surgeons tended to be low-cost surgeons. Across the cohort, ISC was not associated with outcomes. At the surgeon level, associations were noted between ISC and complications, but these may be attributable to unmeasured differences in the postoperative management of patients. These findings suggest that quality improvement efforts to restructure resource use toward more cost-effective practice may not affect patient outcomes, although prospective monitoring of safety and effectiveness must be of the utmost concern.

SUBMITTER: Brauer DG

PROVIDER: S-EPMC5742313 | biostudies-literature | 2018 Jan

REPOSITORIES: biostudies-literature

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Surgeon Variation in Intraoperative Supply Cost for Pancreaticoduodenectomy: Is Intraoperative Supply Cost Associated with Outcomes?

Brauer David G DG Ohman Kerri A KA Jaques David P DP Woolsey Cheryl A CA Wu Ningying N Liu Jingxia J Doyle M B Majella MBM Fields Ryan C RC Chapman William C WC Strasberg Steven M SM Hawkins William G WG

Journal of the American College of Surgeons 20171019 1

<h4>Background</h4>With increased scrutiny on the quality and cost of health care, surgeons must be mindful of their outcomes and resource use. We evaluated surgeon-specific intraoperative supply cost (ISC) for pancreaticoduodenectomy and examined whether ISC was associated with patient outcomes.<h4>Study design</h4>Patients undergoing open pancreaticoduodenectomy between January 2012 and March 2015 were included. Outcomes were tracked prospectively through postoperative day 90, and ISC was defi ...[more]

PMID: 29056314

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Project description:ImportanceRisk-adjusted variation in surgeon outcomes has been traditionally explained by surgeon volume and hospital infrastructure, yet it is unclear how a surgeon's operative proficiency directly contributes to their patients' outcomes.ObjectiveTo assess the variation of surgeons' operative proficiency and investigate its association with surgical outcomes.Design, setting, and participantsThis case series was a retrospective analysis of all digit replantations and revascularizations at a single US university medical center between January 2000 and August 2020. Surgeons were assigned a proficiency score based on the expected procedure difficulty and outcomes from a sample of their cases. Surgeon proficiency scores were then used to determine associations with outcomes from subsequent cases. The expected difficulty of each case was calculated using a novel scoring system that applied pooled relative risks from a meta-analysis of risk factors for replantation and revascularization failure.ExposuresDigit replantation and revascularization.Main outcomes and measuresDigit survival at 1-month follow up (case success) and number of complications.ResultsA total of 145 patients and 226 digits were treated by 11 surgeons with training in hand or microsurgery (mean [SD] age, 41.9 [15.2] years; 204 [90%] men); there were 116 replantations and 110 revascularizations. Surgeon proficiency scores ranged from 1.3 to 5.7, with a mean (SD) of 3.4 (1.4). Case success rates among surgeons varied from 20.0% to 90.5%, with a mean (SD) of 64.9%. Higher proficiency scores were associated with fewer case failures: each point increase was associated with 40% decreased odds of failure (odds ratio, 0.60; 95% CI, 0.38-0.94). Every 3-point increase in proficiency score was associated with 1 less complication (effect estimate, -0.29; 95% CI, -0.56 to 0.02). Surgeon proficiency score had a greater association with case failure than surgeon volume (16.7% vs 12.0%). The final model's association with case failure had an area under the receiver operating characteristics curve of 0.93.Conclusions and relevanceOperative proficiency varied widely among practicing surgeons and accounted for 17% of estimative ability for success of digit replantation and revascularization. Greater surgeon proficiency was associated with better outcomes, indicating that the value of surgical care may be optimized by improving surgeon proficiency.

Project description:We aimed to evaluate perioperative outcomes in patients undergoing pancreaticoduodenectomy with or without a cardiac output goal directed therapy (GDT) algorithm. We conducted a multicentre randomised controlled trial in four high volume hepatobiliary-pancreatic surgery centres. We evaluated whether the additional impact of a intraoperative fluid optimisation algorithm would influence the amount of fluid delivered, reduce fluid related complications, and improve length of hospital stay. Fifty-two consecutive adult patients were recruited. The median (IQR) duration of surgery was 8.6 hours (7.1:9.6) in the GDT group vs. 7.8 hours (6.8:9.0) in the usual care group (p = 0.2). Intraoperative fluid balance was 1005mL (475:1873) in the GDT group vs. 3300mL (2474:3874) in the usual care group (p<0.0001). Total volume of fluid administered intraoperatively was also lower in the GDT group: 2050mL (1313:2700) vs. 4088mL (3400:4525), p<0.0001 and vasoactive medications were used more frequently. There were no significant differences in proportions of patients experiencing overall complications (p = 0.179); however, fewer complications occurred in the GDT group: 44 vs. 92 (Incidence Rate Ratio: 0.41; 95%CI 0.24 to 0.69, p = 0.001). Median (IQR) length of hospital stay was 9.5 days (IQR: 7.0, 14.3) in the GDT vs. 12.5 days in the usual care group (IQR: 9.0, 22.3) for an Incidence Rate Ratio 0.64 (95% CI 0.48 to 0.85, p = 0.002). In conclusion, using a surgery-specific, patient-specific goal directed restrictive fluid therapy algorithm in this cohort of patients, can justify using enough fluid without causing oedema, yet as little fluid as possible without causing hypovolaemia i.e. "precision" fluid therapy. Our findings support the use of a perioperative haemodynamic optimization plan that prioritizes preservation of cardiac output and organ perfusion pressure by judicious use of fluid therapy, rational use of vasoactive drugs and timely application of inotropic drugs. They also suggest the need for further larger studies to confirm its findings.

Dataset Information

Surgeon Variation in Intraoperative Supply Cost for Pancreaticoduodenectomy: Is Intraoperative Supply Cost Associated with Outcomes?

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Surgeon Variation in Intraoperative Supply Cost for Pancreaticoduodenectomy: Is Intraoperative Supply Cost Associated with Outcomes?

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