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"General Surgery economics."
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Development and transferability of a cost-effective laparoscopic camera navigation simulator
Laparoscopic camera navigation (LCN) is vital for the successful performance of laparoscopic operations, yet little time is spent on training. This study aimed to develop an inexpensive LCN simulator, to design a structured curriculum, and to determine the transferability of skills acquired.
In this study, 0 degrees and 30 degrees LCN simulators were developed for use on a videotrainer platform. Transferability was tested by enrolling 20 medical students in an institutional review board-approved, randomized, controlled, blinded protocol. Subjects viewed a video tutorial and were pretested in LCN on a porcine Nissen model. Procedures were videotaped and the LCN performance was scored by a blinded rater according to the number of standardized verbal cues required and the percentage of time an optimal surgical view (%OSV) was obtained. Procedure time also was recorded. Subjects were stratified and randomized. The trained group practiced on the LCN simulator until competency was demonstrated. The control group received no training. Both groups were posttested on the porcine Nissen model.
The constructed simulators required 35 man hours for development, cost $25 per board for materials, and proved to be durable. The trained group demonstrated significant improvement in verbal cues (p = 0.001), %OSV (p < 0.001), and procedure time (p = 0.001), whereas the control group showed improvement only in verbal cues (p < 0.02). At posttesting, the training group demonstrated significantly better scores for verbal cues (2.1 vs 8.0; p = 0.02) and %OSV (64% vs 45% p = 0.01) than the control group.
These data suggest that the LCN simulator is cost effective and provides trainees with skills that translate to the operating room.
Journal Article
Charitable Platforms in Global Surgery: A Systematic Review of their Effectiveness, Cost-Effectiveness, Sustainability, and Role Training
Objective
This study was designed to propose a classification scheme for platforms of surgical delivery in low- and middle-income countries (LMICs) and to review the literature documenting their effectiveness, cost-effectiveness, sustainability, and role in training. Approximately 28 % of the global burden of disease is surgical. In LMICs, much of this burden is borne by a rapidly growing international charitable sector, in fragmented platforms ranging from short-term trips to specialized hospitals. Systematic reviews of these platforms, across regions and across disease conditions, have not been performed.
Methods
A systematic review of MEDLINE and EMBASE databases was performed from 1960 to 2013. Inclusion and exclusion criteria were defined
a priori
. Bibliographies of retrieved studies were searched by hand. Of the 8,854 publications retrieved, 104 were included.
Results
Surgery by international charitable organizations is delivered under two, specialized hospitals and temporary platforms. Among the latter, short-term surgical missions were the most common and appeared beneficial when no other option was available. Compared to other platforms, however, worse results and a lack of cost-effectiveness curtailed their role. Self-contained temporary platforms that did not rely on local infrastructure showed promise, based on very few studies. Specialized hospitals provided effective treatment and appeared sustainable; cost-effectiveness evidence was limited.
Conclusions
Because the charitable sector delivers surgery in vastly divergent ways, systematic review of these platforms has been difficult. This paper provides a framework from which to study these platforms for surgery in LMICs. Given the available evidence, self-contained temporary platforms and specialized surgical centers appear to provide more effective and cost-effective care than short-term surgical mission trips, except when no other delivery platform exists.
Journal Article
Cost-Effectiveness in Global Surgery: Pearls, Pitfalls, and a Checklist
Introduction
Cost-effectiveness analysis can be a powerful policy-making tool. In the two decades since the first cost-effectiveness analyses in global surgery, the methodology has established the cost-effectiveness of many types of surgery in low- and middle-income countries (LMICs). However, with the crescendo of cost-effectiveness analyses in global surgery has come vast disparities in methodology, with only 15% of studies adhering to published guidelines. This has led to results that have varied up to 150-fold.
Methods
The theoretical basis, common pitfalls, and guidelines-based recommendations for cost-effectiveness analyses are reviewed, and a checklist to be used for cost-effectiveness analyses in global surgery is created.
Results
Common pitfalls in global surgery cost-effectiveness analyses fall into five categories: the analytic perspective, cost measurement, effectiveness measurement, probability estimation, valuation of the counterfactual, and heterogeneity and uncertainty. These are reviewed in turn, and a checklist to avoid these pitfalls is developed.
Conclusion
Cost-effectiveness analyses, when done rigorously, can be very useful for the development of efficient surgical systems in LMICs. This review highlights the common pitfalls in these analyses and methods to avoid these pitfalls.
Journal Article
Large Variations In Medicare Payments For Surgery Highlight Savings Potential From Bundled Payment Programs
Payers are considering bundled payments for inpatient surgery, combining provider reimbursements into a single payment for the entire episode. We found that current Medicare episode payments for certain inpatient procedures varied by 49-130 percent across hospitals sorted into five payment groups. Intentional differences in payments attributable to such factors as geography or illness severity explained much of this variation. But after adjustment for these differences, per episode payments to the highest-cost hospitals were higher than those to the lowest-cost facilities by up to $2,549 for colectomy and $7,759 for back surgery. Postdischarge care accounted for a large proportion of the variation in payments, as did discretionary physician services, which may be driven in turn by variations in surgeons' practice styles. Our study suggests that bundled payments could yield sizable savings for payers, although the effect on individual institutions will vary because hospitals that were relatively expensive for one procedure were often relatively inexpensive for others. More broadly, our data suggest that many hospitals have considerable room to improve their cost efficiency for inpatient surgery and should look for patterns of excess utilization, particularly among surgical specialties, other inpatient specialist consultations, and various types of postdischarge care. Adapted from the source document.
Journal Article
High value care education in general surgery residency programs: A multi-institutional needs assessment
The ACGME mandates that residency programs provide training related to high value care (HVC). The purpose of this study was to explore HVC education in general surgery residency programs.
An electronic survey was distributed to general surgery residents in geographically diverse programs.
The response rate was 29% (181/619). Residents reported various HVC components in their curricula. Less than half felt HVC is very important for their future practice (44%) and only 15% felt confident they could lead a QI initiative in practice. Only 20% of residents reported participating in a root cause analysis and less than one-third of residents (30%) were frequently exposed to cost considerations.
Few residents feel prepared to lead quality improvement initiatives, have participated in patient safety processes, or are aware of patients’ costs of care. This underscores the need for improved scope and quality of HVC education and establishment of formal curricula.
•QI and patient safety curricula are established in general surgery residency programs.•Patient experience and cost-conscious care curricula are in their infancy.•Residents report poor exposure to cost-conscious care education.•Only 15% of residents feel able to lead a quality improvement project in practice.•Surgical educators must collaborate to develop a high-value care curriculum.
Journal Article
Is implementation of robotic-assisted procedures in acute care general surgery cost-effective?
Over the past 2 decades, the use and importance of robotic surgery in minimally invasive surgery has increased. Across various surgical specialties, robotic technology has gained popularity through its use of 3D visualization, optimal ergonomic positioning, and precise instrument manipulation. This growing interest has also been seen in acute care surgery, where laparoscopic procedures are used more frequently. Despite the growing popularity of robotic surgery in the acute care surgical realm, there is very little research on the utility of robotics regarding its effects on health outcomes and cost-effectiveness. The current literature indicates some value in utilizing robotic technology in specific urgent procedures, such as cholecystectomies and incarcerated hernia repairs; however, the high cost of robotic surgery was found to be a potential barrier to its widespread use in acute care surgery. This narrative literature review aims to determine the cost-effectiveness of robotic-assisted surgery (RAS) in surgical procedures that are often done in urgent settings: cholecystectomies, inguinal hernia repair, ventral hernia repair, and appendectomies.
Journal Article
Rural and urban differences in treatment status among children with surgical conditions in Uganda
In low and middle-income countries, approximately 85% of children have a surgically treatable condition before the age of 15. Within these countries, the burden of pediatric surgical conditions falls heaviest on those in rural areas. The objective of the current study was to evaluate the relationship between rurality, surgical condition and treatment status among a cohort of Ugandan children.
We identified 2176 children from 2315 households throughout Uganda using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey. Children were randomly selected and were included in the study if they were 18 years of age or younger and had a surgical condition. Location of residence, surgical condition, and treatment status was compared among children.
Of the 305 children identified with surgical conditions, 81.9% lived in rural areas. The most prevalent causes of surgical conditions reported among rural and urban children were masses (24.0% and 25.5%, respectively), followed by wounds due to injury (19.6% and 16.4%, respectively). Among children with untreated surgical conditions, 79.1% reside in rural areas while 20.9% reside in urban areas. Among children with untreated surgical conditions, the leading reason for not seeking surgical care among children living in both rural and urban areas was a lack of money (40.6% and 31.4%, respectively), and the leading reason for not receiving care in both rural and urban settings was a lack of money (48.0% and 42.8%, respectively).
Our data suggest that over half of the children with a surgical condition surveyed are not receiving surgical care and a large majority of children with surgical needs were living in rural areas. Future interventions aimed at increasing surgical access in rural areas in low-income countries are needed.
Journal Article
Medicolegal litigation in general surgery: a comparison between England and the United States
Background
Clinical negligence claims represent a significant financial and reputational burden for healthcare systems worldwide. While the United States is often perceived as having a highly litigious medical culture, comparative data between the United Kingdom and United States, especially in general surgery, are limited.
Methods
Data on clinical negligence claims in general surgery were obtained through a Freedom of Information (FOI) request to NHS Resolution for England, covering financial years 2013/2014 to 2021/2022 and national databases from the United States between 2014 and 2022. Only successful claims with awarded damages were included. Population-adjusted annual means, total claim volumes and associated costs were calculated.
Results
England recorded 5829 successful claims in general surgery over 9 years, with an estimated total cost of £873 million. The United States recorded 12 162 successful claims, which adjusted for population equated to 2043 claims, with an estimated adjusted cost of £563 million. England had three times more population-adjusted successful claims than the United States and nearly double the associated costs. The most common cause of successful litigation in England was “failure or delay in treatment”. Only 6.1% of successful claims were attributed to “operator error”.
Conclusions
Despite the United States’ reputation for higher litigation, England had more successful, population-adjusted general surgery claims and costs over the study period. These findings highlight the importance of systemic, cultural and structural differences in how claims are handled and resolved in each healthcare system.
Journal Article
The Importance of Safety-Net Hospitals in Emergency General Surgery
Introduction
Safety-net hospitals provide care to an inherently underprivileged patient population. These hospitals have previously been shown to have inferior surgical outcomes after complex, elective procedures, but little is known about how hospital payer-mix correlates with outcomes after more common, emergent operations.
Methods
The University HealthSystem Consortium database was queried for all emergency general surgery procedures performed from 2009 to 2015. Emergency general surgery was defined as the seven operative procedures recently identified as contributing most to the national burden. Only urgent and emergent admissions were included (
n
= 653,305). Procedure-specific cohorts were created and hospitals were grouped according to safety-net burden. Multivariate analyses were done to study the effect of safety-net burden on hospital outcomes.
Results
For all seven emergency procedures, patients at hospitals with a high safety-net burden were more likely to be young and black (
p
< 0.01 each). Patients at high-burden hospitals had similar severity of illness scores to those at other hospitals. Compared with lower burden hospitals, in-hospital mortality rates at high-burden hospitals were similar or lower in five of seven procedures (
p
= NS or < 0.01, respectively). After adjusting for patient factors, high-burden hospitals had similar or lower odds of readmission in six of seven procedures, hospital length of stay in four of seven procedures, and cost of care in three of seven procedures (
p
= NS or < 0.01, respectively).
Conclusion
Safety-net hospitals provide emergency general surgery services without compromising patient outcomes or incurring greater healthcare resources. These data may help inform the vital role these institutions play in the healthcare of vulnerable patients in the USA.
Journal Article