Abstract
INTRODUCTION
Little is known regarding the impact of the minimally invasive approach to distal pancreatectomy (DP) on the aggregate costs of care for patients undergoing DP.
METHODS
We queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing elective laparoscopic (LDP) or open distal pancreatectomy (ODP) between 2012 and 2014. Multivariable regression (MVR) was used to evaluate postoperative outcomes including readmissions to 90 days following DP.
RESULTS
A total of 267 (11%) patients underwent LDP; 2,214 (89%) underwent ODP. On MVR, patients undergoing LDP had a decreased odds risk of having any severe adverse outcome (OR 0.73, 95% CI [0.54, 0.97]), prolonged LOS (OR 0.49, 95% CI [0.30, 0.79]), and of being in the highest quartile for aggregate costs of care (OR 0.46, 95% CI [0.32, 0.66]) relative to those undergoing ODP. Patients undergoing LDP had a lower average 90-day aggregate cost of care than those undergoing ODP when procedures were performed in high-volume (-$16,153, 95% CI: [-$23,342, -$8,964]) centers.
CONCLUSION
Patients undergoing LDP have a lower risk of severe adverse outcomes, prolonged overall LOS, and lower associated costs of care relative to those undergoing ODP. This association is independent of hospital volume.
Keywords: healthcare economics, benign and malignant pancreatic tumors, cost-volume, laparoscopic surgery
TOC Statement
We aimed to examine the cost of care for patients undergoing distal pancreatectomy by surgical approach. The significance of this finding is that the laparoscopic approach is associated with significant cost savings only in high volume centers.
INTRODUCTION
The United States (U.S.) health care spending grew 4% in 2017 alone, reaching $3.5 trillion or $10,739 per person and accounting for 18% of the national gross domestic product (GDP). (1) In 2015, 32% of the national healthcare expenditures went toward hospital-based care and 20% toward physician and clinical services. (1) Healthcare providers are under ever increasing pressure to deliver value to patients by containing costs while continuing to provide high-quality clinical outcomes.
Distal pancreatectomy (DP) is a complicated surgical procedure which can be lifesaving but carries a significant risk of postoperative complication. The index procedure and hospitalization themselves are costly. Complications and related admissions and ancillary procedures necessary to manage complications frequently result in substantial increases in the costs of care. Because of the potential to save lives and the high costs of care associated with both the index operation and its postoperative complications, distal pancreatectomy by nature represents a unique opportunity to significantly improve value for patients.
Previous studies have evaluated the impact of variations in several technical approaches to the DP on postoperative complication rates, rates of readmission and lengths of stay. (2–4) These have included studies comparing minimally invasive methods to open procedures, use of staplers and different energy devices to divide the pancreatic parenchyma, use of endoscopic stenting to manage pancreatic fistula and application of sealants to prevent fistula. Few of these studies evaluate the impact of different technical approaches to distal pancreatectomy on the costs of care for patients undergoing DP. In the current study, we use the Healthcare Cost and Utilization Project State Inpatient Database (HCUP-SID) to examine differences in aggregate costs of care associated with laparoscopic and open approaches to DP with results stratified by hospital volume.
METHODS
Data Source
The Healthcare Cost and Utilization Project State Inpatient Database (HCUP-SID) was used to identify patients undergoing elective laparoscopic (LDP) or open (ODP) distal pancreatectomy in Florida (FL), Maryland (MD), Massachusetts (MA), New York (NY), and Washington (WA) between 2012 and 2014. HCUP is an administrative dataset composed of a family of healthcare databases developed through a Federal-State-Industry partnership sponsored by the Agency for Healthcare Research and Quality (AHRQ). Each SID captures all inpatient discharges at non-federal facilities for the respective state, regardless of primary payer. The SID includes patient-level demographic data as well as Charlson comorbidity score, admitting diagnosis, procedures performed during the admission, hospital volume for the procedure. The SID also captures readmissions following discharges and all associated procedure performed during those readmissions for any subsequent year of data that are made available by HCUP.
Study Population
The analysis cohort included adult patients 18 years or older that were discharged from hospitals within their respective states after having undergone either an LDP or ODP. Patients were first identified as individuals having undergone DP for benign or malignant disease based on International Classification of Diseases, Ninth Revision (ICD-9) codes (157.1 body of pancreas, 157.2 tail of pancreas, 157.4 islets of Langerhans, 157.8 other specified sites of pancreas,157.9 pancreas part unspecified, 577.1 chronic pancreatitis, 577.2 cyst and pseudocysts of pancreas, 577.8 other specified disease of pancreas, 577.9 unspecified disease of pancreas, 211.6 pancreas except islets of Langerhans, 211.7 islets of Langerhans). This group was further divided by procedure type into two cohorts (those undergoing laparoscopic distal pancreatectomy and those undergoing open distal pancreatectomy) by a secondary search from the distal pancreatectomy cohort that underwent a surgical procedure based on ICD-9 codes (52.52 distal pancreatectomy,17.4 −17.43 robotic-assisted, 54.21 laparoscopic). 252 patients underwent conversion from laparoscopic to open DP. Given dataset limitations, we were unable to identify the reason for a conversion from laparoscopic to open DP. We could not identify if a conversion occurred as a part of a plan (diagnostic laparoscopy to rule out carcinomatosis followed by open DP) or as a result of an untoward intraoperative event. For this reason, we could not perform an intent to treat analysis and, to avoid related bias, we have elected to exclude patients undergoing a conversion from laparoscopic to open DP from the dataset.
Study Design
This was a retrospective cohort study of patients undergoing distal pancreatectomy between 2012 and 2014. We intended to examine the association between surgical approach and aggregate in-hospital costs of care including costs associated with the index procedure, index admission and all readmissions up to 90 days following the index operation. Cost data were obtained using HCUP total charges variable multiplied by a hospital-specific cost to charge ratio (CCR). The CCR is developed using standardized information on all-payer inpatient cost and charges reported by hospitals to the Centers for Medicare and Medicaid.
We also evaluated the association between surgical approach and rates of postoperative morbidity, readmission and aggregate postoperative lengths of stay (LOS) including readmissions to 90 days following the index operation. The postoperative complications that were evaluated included myocardial infarction (MI), pulmonary embolism (PE) and sepsis. The overall LOS included all readmission to 90 days post index procedure, and prolonged LOS was defined as a having an overall LOS greater than the 75% percentile for the entire DP population.
Statistical Analysis
Baseline characteristics are presented as means with standard deviations, medians, and interquartile ranges, or counts and percentages. Variables included in univariate and multivariable analyses were determined a priori using best variable subsets. Candidate variables included: age, gender, insurance type, race/ethnicity, Charlson comorbidity index (CCI), pathology (benign vs. malignant), annual hospital DP volume broken into terciles low (<6 DPs/year), moderate (>6 and <41 DPs/year), and high volume (>41 DP’s/year) and overall LOS including all readmissions to 90 days post procedure. Unadjusted comparisons of two or more proportions were performed using a chi-squared test. Continuous variables were compared using t-tests or Wilcoxon rank sum tests as appropriate. Multivariable regression (MVR) was used to evaluate the association between surgical approach and rates of postoperative complication (PE, MI, and sepsis), LOS and aggregate costs of care including readmissions to 90 days following DP. All analyses were performed using STATA 14 software (College Station, TX). This study was evaluated and approved by the Institutional Review Board at Loyola University Chicago.
RESULTS
Univariate Comparison of Demographics, LOS, Mortality, and Costs
4,481 patients underwent DP; 267 (11%) patients underwent LDP and 2,214 (89%) underwent ODP. There were no differences among the two cohorts in age, race/ethnicity, gender, and pathology. Compared to ODP, LDP patients had a higher frequency of private insurance (49% vs. 42%, p<0.01) and were more likely to have procedures performed in high volume centers (35% vs. 23%, p<0.01). Patients undergoing LDP has higher mean CCI (3 vs. 2; p<0.01) than those undergoing ODP. (Table 1) Compared to ODP, LDP patients also had shorter overall LOS (9 days, SD [7] vs. 12 days, SD [14], p<0.01), lower aggregated 90-day costs of care ($29,886 vs. $41,385, p<0.01), and lower frequency of postoperative complications (31% vs. 38%, p = 0.04). There was no difference in in-hospital death between the two groups. (Table 2)
Table 1.
Demographic and pathologic characteristics of patients undergoing distal pancreatectomy*
| Open | Laparoscopic | p | |||
|---|---|---|---|---|---|
| No. patients, n (%) | 2,214 | 89% | 267 | 11% | |
| Age, mean (SD) | 60 | 15 | 62 | 14 | 0.09 |
| Female gender, n (%) | 1219 | 55.1% | 147 | 55.1% | 1.00 |
| Charlson comorbidity index, mean (SD) | 2 | 2 | 3 | 3 | <.01 |
| Race/ethnicity, n (%) | |||||
| White | 1,611 | 72.8% | 205 | 76.8% | 0.27 |
| Black | 215 | 9.7% | 28 | 10.5% | |
| Hispanic | 187 | 8.4% | 17 | 6.4% | |
| Other | 201 | 9.1% | 17 | 6.4% | |
| Insurance type, n (%) | |||||
| Medicare | 992 | 44.8% | 117 | 43.8% | 0.03 |
| Medicaid | 205 | 9.3% | 16 | 6.0% | |
| Private | 922 | 41.6% | 129 | 48.3% | |
| Other | 95 | 4.3% | - | 1.9% | |
| Pathology, n (%) | |||||
| Malignant | 848 | 38.3% | 139 | 52.1% | <.01 |
| Benign | 1,366 | 61.7% | 128 | 47.9% | |
| Annual hospital DP volume, terciles n (%) | |||||
| Low (1–5) | 594 | 26.8% | 49 | 18.4% | <.01 |
| Moderate (6–41) | 1102 | 49.8% | 124 | 46.4% | |
| High (>41) | 518 | 23.4% | 94 | 35.2% | |
Data represents 2012–2014 for Florida, Maryland, Massachusetts, New York, and Washington. Length of stay (LOS); distal pancreatectomy (DP). Cells left blank due to data use agreement restrictions
Table 2.
Postoperative outcomes of patients undergoing distal pancreatectomy*
| Open | Laparoscopic | p | |||
|---|---|---|---|---|---|
| Overall morbidity ‡ n (%) | 833 | 37.6% | 83 | 31.1% | 0.04 |
| Total LOS, mean (SD) | 12 | 14 | 9 | 7 | <.01 |
| 90-day readmission, n (%) | 613 | 27.7% | 61 | 22.8% | 0.09 |
| In-hospital death, n (%) | 28 | 1.3% | 3 | 1.1% | 0.85 |
| 90-day cost of care, mean (SD) | $41,385 | $53,617 | $29,886 | $25,039 | <.01 |
Data represents 2012–2014 for Florida, Maryland, Massachusetts, New York, and Washington. Length of stay (LOS).
Overall morbidity includes pulmonary embolism, myocardial infarction, and sepsis.
Multivariable Analysis of Postoperative Complications
We examined the postoperative outcomes for patients undergoing LDP compared to ODP to identify factors which may impact the in-hospital 90-day cost of care. On univariate analysis patients undergoing LDP were less likely to have postoperative complications (PE, MI, and sepsis), had shorter LOS, and lower 90-day aggregate cost compared to ODP. On MVR, adjusted for age, gender, race/ethnicity, malignant pathology, insurance type, CCI and hospital volume, LDP was associated with a lower odds risk of overall postoperative morbidity (OR 0.73, 95% CI [0.55, 0.97]) and prolonged LOS (OR 0.49, 95% CI [0.30, 0.79]) compared to ODP. There were no statistical differences between the two cohorts in PE, MI, sepsis and 90-day readmissions (p > 0.05). (Table 3)
Table 3.
Adjusted* odds risk of post-operative morbidity, readmission, and prolonged LOS for laparoscopic relative to open distal pancreatectomy
| OR | 95% CI | ||
|---|---|---|---|
| Postoperative morbidity | |||
| PE | 0.93 | 0.21 | 4.13 |
| MI | - | - | - |
| Sepsis | 0.59 | 0.30 | 1.15 |
| Severe Adverse Outcome+ | 0.73 | 0.54 | 0.97 |
| 30-day readmission | 0.80 | 0.59 | 1.09 |
| 90-day readmission | 0.93 | 0.69 | 1.34 |
| Prolonged LOS** | 0.49 | 0.30 | 0.79 |
Adjusted for age, gender, malignancy, Charlson index, race, insurance, volume and procedure type.
Severe Adverse Outcome includes cases where a patient developed a postoperative pulmonary embolism (PE), myocardial infarction (MI), Sepsis.
Prolonged LOS defined as greater than 75% of the overall length of stay (LOS).
Multivariable Comparison of High-Cost Outliers
Next, we examined the risk factors associated with being a high-cost outlier following a DP. To qualify as a high cost outlier aggregate costs of care including all readmissions to 90 days post index procedure that had to be greater than those for the 75% percentile for the DP population. We aimed to identify any associations between being a high-cost outlier, surgical approach, and hospital volume. We performed an analysis adjusted for the following variables: age, gender, race/ethnicity, malignant pathology, CCI, insurance type, procedure approach, and hospital volume. The risk factors associated with being a high cost outlier included the following: advanced age (OR 1.00, 95% CI [1.00,1.02]), male gender (OR 1.64, 95% CI [1.35,1.98]), CCI score (OR 1.25, 95% CI [1.19, 1.31]), Black race (OR1.56, 95% CI [1.14, 2.13]), and Medicaid insurance (OR 1.54, 95% CI [1.09, 2.18]). Compared to ODP, LDP patients had a significantly lower odds risk of being in the highest quartile of costs (OR 0.46, 95% CI [0.32, 0.66]). There was no significant association between hospital volume and the risk of being a high-cost outlier. (Table 4)
Table 4.
Adjusted odds risk of being a high cost outlier following distal pancreatectomy*
| OR | 95 % CI | ||
|---|---|---|---|
| Age, (per year) | 1.01 | 1.00 | 1.02 |
| Male gender | 1.64 | 1.35 | 1.98 |
| Charlson comorbidity index | 1.25 | 1.19 | 1.31 |
| Malignant pathology | 2.18 | 1.69 | 2.82 |
| Race/ethnicity | |||
| White (reference) | |||
| Black | 1.56 | 1.14 | 2.13 |
| Hispanic | 0.96 | 0.66 | 1.38 |
| Other | 1.14 | 0.82 | 1.60 |
| Insurance type | |||
| Private (reference) | |||
| Medicare | 1.05 | 0.81 | 1.36 |
| Medicaid | 1.54 | 1.09 | 2.18 |
| Other | 1.38 | 0.85 | 2.22 |
| Surgical approach | |||
| Open (reference) | |||
| Laparoscopic | 0.46 | 0.32 | 0.66 |
| Annual hospital DP volume, (terciles) | |||
| Low (1–5) | 1.05 | 0.79 | 1.39 |
| Moderate (6–41) | 1.20 | 0.94 | 1.54 |
| High (>41), (reference) | |||
Adjusted for age, gender, malignancy, Charlson comorbidity index, race/ethnicity, insurance type, hospital volume, and procedure type.
90-day Cost by Hospital Volume and approach
Finally, we attempted to define the relationship between hospital DP volume, surgical approach, and costs of care. Our hypothesis was that in hospitals performing a high volume of DP, the laparoscopic approach would be associated with lower aggregate costs of care than the open approach. On MVR analysis adjusted for male gender, race/ethnicity, CCI, insurance type, malignant pathology, and age, patients undergoing LDP compared to ODP stratified by hospital volume, we found in high-volume centers (>41 DP’s/year) the laparoscopic approach resulted in lower cost than the open approach with risk-adjusted savings of -$16,153 (95% CI: [-$23,342, - $8,964]). In low (1–5 DPs/year) and moderate (>6 and <41 DPs/year) volume centers there was no difference in the cost of care between laparoscopic and open approaches to a distal pancreatectomy. (Table 5)
Table 5.
Adjusted difference between aggregate costs of care for laparoscopic distal pancreatectomy and those for open distal pancreatectomy by facility volume*
| Unadjusted | Adjusted | |||||
|---|---|---|---|---|---|---|
| Cost | 95% CI | Cost | 95% CI | |||
| Number of cases per year, terciles | ||||||
| Low (1–5) | −$8,436 | −$27,046 | $10,174 | −$3,118 | −$21,806 | $15,570 |
| Moderate (6–41) | −$10,119 | −$19,697 | −$542 | −$9,444 | −$18,890 | $0.77 |
| High (>41) | −$14,234 | −$21,515 | −$6,954 | −$16,153 | −$23,342 | −$8,964 |
Adjusted for male gender, race/ethnicity, Charlson comorbidity index, insurance type, malignancy, and age.
DISCUSSION
Pancreatic resections are technically complex, operations which have high rates of postoperative morbidity. Very few studies to date have evaluated innovations in care for patients undergoing pancreatic resection from the perspective of the value proposition in healthcare. By nature, these operations are associated with high costs of care and have meaningful opportunities to provide value to patients by improving postoperative clinical outcomes in ways that are cost- effective. In this study, we aimed to examine the economic impact of applying the minimally invasive approach to distal pancreatectomy by comparing the aggregate costs of care for patients undergoing LDP to a contemporaneous cohort of patients undergoing ODP. Our results revealed several interesting findings. In our adjusted analysis, compared to ODP, patients undergoing LDP had identical rates of PE, MI, and sepsis but had a lower risk of having a prolonged LOS, a severe adverse outcome, and of being in the highest quartile of cost. LDP patients had lower average aggregate costs of care when performed in high-volume centers whereas in low to moderate centers cost was neutral when compared to ODP. These findings suggest that the laparoscopic approach is inherently cost neutral when compared to the open approach, but with experience, the fixed expense can be overcome to the point that the laparoscopic approach adds value to patients with pathology in the pancreatic tail maintaining outcome quality but providing the outcome in a less costly manner.
Studies evaluating the relationship between 90-day costs and surgical approach in pancreatectomy are limited. Our principal finding suggests that the in-hospital 90-day costs for patients undergoing LDP in high-volume centers are less than that for patients undergoing ODP. A recent study by Ricci et al. found that patients undergoing LDP had similar postoperative complication rates and length of stay compared to ODP. (5) The only difference noted between the two groups was that the laparoscopic group had an earlier return of bowel function and had a higher probability of being cost-effective. (5) The results of the Ricci et al. study are comparable to our postoperative complications although we found the LDP compared to the ODP approach was associated with a shorter LOS and was more cost-effective in high volume centers. A study evaluating the cost in patients undergoing pancreaticoduodenectomy (PD) in high volume centers by Tran et al. found that patients undergoing an LDP in high-volume centers had lower costs ($76,572 vs. $106,367, p<.01) of care compared to patients undergoing OPD when comparing clinical outcomes at 30 days post procedure. (6)
In a national randomized comparison of clinical outcomes for laparoscopic and open distal pancreatectomy, De Rooji et al., found that 90-day costs were lower in patients undergoing LDP compared to ODP. This study was based in the Netherlands with a patient population that is considerably more homogeneous than the population in our study and involves a single-payer healthcare system. The findings in that study may or may not be generalizable to populations with more heterogenous demographics and health systems that have fee-for-service reimbursement structures. (7) In a recent study using the Truven dataset and examining 693 patients who underwent distal pancreatectomies, Fisher et al. found that LDP was associated with 90-day cost savings compared to OPD. Because of limitations of that dataset, the authors were not able to stratify by hospital volume or to study weather variation in complication rate was a potential driver of cost savings. Both of these variables are tracked in a meaningful way in the HCUP dataset and using the HCUP dataset has allowed us to comment on the way in which these variables contribute to costs of care. (8) In the current work, we found similar cost savings associated with the laparoscopic approach in distal pancreatectomy. The advantage of our paper over the others is that we have evaluated clinical outcomes and costs to 90 days following the index procedure. Also, we stratified our results by hospital volume which has not been done in previous studies. Patients undergoing pancreatectomy not infrequently accrue costs related to their complications for considerably longer than 30 days following the index procedure. There is very little in the literature regarding costs of care and drivers of value in hepatobiliary surgery. The advantage of using HCUP is that there is information from a broad population, a crosssection of payers and providers and includes some data on complication rates. There are always limitations to use of any large dataset for research but, recognizing these, we believe the observation of lower complication rates among the laparoscopic DP cohort and lower associated costs of care is valid and meaningful. We are and will increasingly be, asked, as treating physicians, to deliver value to patients. Value in health care is probably best defined as quality per unit cost. Our results demonstrate that the laparoscopic method for distal pancreatectomy adds value and should be utilized preferentially to open distal pancreatectomy. For this reason, our result is likely more representative of the potential cost savings associated with the laparoscopic approach than prior studies.
The underlying reasons for the cost savings associated with LDP are not readily apparent. We believe that the cost savings realized by LDP in high volume centers are due in part to cost advantages that are achieved by economies of scale: as the number of procedures increases, the operators become more efficient with resources. High volume surgeons likely have shorter operative times and use fewer disposable instruments (fewer staple loads, sutures, etc.) to do the procedures than do low volume surgeons. (9) Other studies have noted that high volume centers are more effective at rescuing patients from complications. (10, 11) It is difficult to measure that type of an effect in HCUP because there are limited hospital-specific variables to evaluate this association, but it is possible that a better ability to rescue also contributes to lower costs at high volume centers. Regardless of the underlying cause, the cost savings in high volume centers is positive and would suggest that centralizing pancreatic surgical care to high volume centers (regionally or locally) may lead to better value in the care of these patients.
We found that the laparoscopic approaches to distal pancreatectomy is associated with a lower risk of developing postoperative complications. This observation is similar to prior studies which in general identify an association between the laparoscopic approach and lower rates of postoperative morbidity, lower blood loss and lower rates of delayed gastric emptying. (1, 5, 12–18) A meta-analysis, Venkat et al. identified that LDP was associated with lower blood loss and no significant difference in operative time, margin positivity, the incidence of postoperative pancreatic fistula, or mortality compared to ODP. (15) Our own previous evaluation of postoperative outcomes has demonstrated that the laparoscopic approach is associated with less severe adverse postoperative outcomes. (19) Our current study is unique in that we were able to validate that the laparoscopic approach has better outcomes to 90-days from the index surgery. We were not able to evaluate complications by hospital volume because there was a relatively low incidence of postoperative complication. The HCUP dataset without question captures fewer complications that we would expect to find by a thorough retrospective chart review or in using the pancreas procedure target NSQIP dataset.
There are several limitations to this study. These limitations have been discussed in greater detail prior publications. (20, 21) It is a retrospective review of an administrative dataset. We cannot definitively control or adjust for the selection biases that are inherent in these datasets. There is also a significant potential for omitted variable bias. The administrative dataset does not contain detailed clinical information on many physiologic and pathologic measures which may contribute to patient selection for different interventions, determine outcomes and affect costs of care. The dataset does not offer granular detail on several postoperative complications that are relevant, the most notable being a pancreatic fistula. The dataset does capture procedures used to manage complications (IR drain placement, ICU admission, intubation, ventilation, return to the operating room). Those procedures and associated costs are included in the analysis. Given dataset limitations, we were unable to perform an intent to treat analyses. Surgeon procedure volume is not tracked as a variable in HCUP. Because of this, we were only able to adjust for hospital volume. HCUP CCR cost data does not include professional (physician) fees, actual payments received, post-discharge outpatient fees. Further, HCUP does not include actual payments made to hospitals. Costs are, instead, derived by applying the cost to charge ratios to the charges reported by the hospitals. The dataset does not track all complication types and cannot be directly linked to specific clinical activities. Given these limitations, future studies exploring cost using more granular multi-institutional cost data may add substantially to our understanding of the relationship between surgical approach and costs of care for these patients.
CONCLUSION
Patients undergoing LDP have a lower risk of severe adverse outcomes, prolonged overall LOS and lower associated costs of care relative to those undergoing ODP. This association is independent of hospital volume. This finding suggests that high volume centers develop efficiencies of scale that allow them to realize aggregate cost savings when utilizing laparoscopic approaches to DP and also suggest that the laparoscopic approach adds value beyond that provided by the open approach to DP for patients with pathology in the pancreatic tail
Acknowledgments
Support: This work is supported by the National Institute of Health 5 T32 GM008750–18 (EE)
Footnotes
Disclosure/Conflict of Interest
The authors have no disclosures.
Meeting Presentation: Presented at the 14th Annual Academic Surgical Congress in Houston, TX on February 7, 2019.
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
REFERENCES
- 1.NHE-Fact-Sheet 2018 [updated 12/06/2018 3:12 PM. Available from: https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html.
- 2.Baker MS, Bentrem DJ, Ujiki MB, Stocker S, Talamonti MS. Adding days spent in readmission to the initial postoperative length of stay limits the perceived benefit of laparoscopic distal pancreatectomy when compared with open distal pancreatectomy. The American Journal of Surgery. 2011;201(3):295–300. [DOI] [PubMed] [Google Scholar]
- 3.Sharpe SM, Talamonti MS, Wang E, Bentrem DJ, Roggin KK, Prinz RA, et al. The laparoscopic approach to distal pancreatectomy for ductal adenocarcinoma results in shorter lengths of stay without compromising oncologic outcomes. The American Journal of Surgery. 2015;209(3):557–63. [DOI] [PubMed] [Google Scholar]
- 4.Baker MS, Bentrem DJ, Ujiki MB, Stocker S, Talamonti MS. A prospective single institution comparison of peri-operative outcomes for laparoscopic and open distal pancreatectomy. Surgery. 2009;146(4):635–45. [DOI] [PubMed] [Google Scholar]
- 5.Ricci C, Casadei R, Taffurelli G, Bogoni S, D’Ambra M, Ingaldi C, et al. Laparoscopic Distal Pancreatectomy in Benign or Premalignant Pancreatic Lesions: Is It Really More Cost-Effective than Open Approach? J Gastrointest Surg. 2015;19(8):1415–24. [DOI] [PubMed] [Google Scholar]
- 6.Tran TB, Dua MM, Worhunsky DJ, Poultsides GA, Norton JA, Visser BC. An economic analysis of pancreaticoduodenectomy: should costs drive consumer decisions? Am J Surg. 2016;211(6):991–7.e1. [DOI] [PubMed] [Google Scholar]
- 7.de Rooij T, van Hilst J, Vogel JA, van Santvoort HC, de Boer MT, Boerma D, et al. Minimally invasive versus open distal pancreatectomy (LEOPARD): study protocol for a randomized controlled trial. Trials. 2017;18(1):166. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Fisher AV, Fernandes-Taylor S, Schumacher JR, Havlena JA, Wang X, Lawson EH, et al. Analysis of 90-day cost for open versus minimally invasive distal pancreatectomy. HPB (Oxford). 2018. [DOI] [PubMed] [Google Scholar]
- 9.Sullivan A, Sheffrin SM. Economics: Principles in action Upper Saddle River, New Jersey 07458: Pearson Prentice Hall; 2003. [Google Scholar]
- 10.Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and failure to rescue with high-risk surgery. Medical care. 2011:1076–81. [DOI] [PubMed] [Google Scholar]
- 11.Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. New England Journal of Medicine. 2009;361(14):1368–75. [DOI] [PubMed] [Google Scholar]
- 12.Conlon KC, de Rooij T, van Hilst J, Abu Hidal M, Fleshman J, Talamonti M, et al. Minimally invasive pancreatic resections: cost and value perspectives. HPB (Oxford). 2017;19(3):225–33. [DOI] [PubMed] [Google Scholar]
- 13.Rutz DR, Squires MH, Maithel SK, Sarmiento JM, Etra JW, Perez SD, et al. Cost comparison analysis of open versus laparoscopic distal pancreatectomy. HPB (Oxford). 2014;16(10):907–14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Braga M, Pecorelli N, Ferrari D, Balzano G, Zuliani W, Castoldi R. Results of 100 consecutive laparoscopic distal pancreatectomies: postoperative outcome, cost-benefit analysis, and quality of life assessment. Surg Endosc. 2015;29(7):1871–8. [DOI] [PubMed] [Google Scholar]
- 15.Venkat R, Edil BH, Schulick RD, Lidor AO, Makary MA, Wolfgang CL. Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis LWW; 2012. [DOI] [PubMed] [Google Scholar]
- 16.Hilal MA, Hamdan M, Di Fabio F, Pearce NW, Johnson CD. Laparoscopic versus open distal pancreatectomy: a clinical and cost-effectiveness study. Surgical endoscopy. 2012;26(6):1670–4. [DOI] [PubMed] [Google Scholar]
- 17.Kim SC, Park KT, Hwang JW, Shin HC, Lee SS, Seo DW, et al. Comparative analysis of clinical outcomes for laparoscopic distal pancreatic resection and open distal pancreatic resection at a single institution. Surgical endoscopy. 2008;22(10):2261–8. [DOI] [PubMed] [Google Scholar]
- 18.De Rooij T, Klompmaker S, Hilal MA, Kendrick ML, Busch OR, Besselink MG. Laparoscopic pancreatic surgery for benign and malignant disease. Nature reviews Gastroenterology & hepatology. 2016;13(4):227. [DOI] [PubMed] [Google Scholar]
- 19.Baker MS, Sherman KL, Stocker S, Hayman AV, Bentrem DJ, Prinz RA, et al. Defining quality for distal pancreatectomy: does the laparoscopic approach protect patients from poor quality outcomes? Journal of Gastrointestinal Surgery. 2013;17(2):273–80. [DOI] [PubMed] [Google Scholar]
- 20.Eguia E, Cobb AN, Kothari AN, Molefe A, Afshar M, Aranha GV, et al. Impact of the Affordable Care Act (ACA) Medicaid Expansion on Cancer Admissions and Surgeries. Annals of Surgery. 2018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Eguia E, Cobb AN, Kirshenbaum EJ, Afshar M, Kuo PC. Racial and ethnic postoperative outcomes after surgery: the Hispanic paradox. Journal of Surgical Research. 2018;232:88–93. [DOI] [PMC free article] [PubMed] [Google Scholar]