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A descriptive cost analysis study of cases of right iliac fossa pain
ORIGINAL RESEARCH International Journal of Surgery 11 (2013) 524e528
Contents lists available at SciVerse ScienceDirect
International Journal of Surgery journal homepage: www.theijs.com
Original research
A descriptive cost analysis study of cases of right iliac fossa pain D.A. Healy a, A. Aziz a, M. Wong a, M. Clarke Moloney a, J.C. Coffey a, P.A. Grace a, S. Kinsella b, S.R. Walsh a, * a b
Department of Surgery, University Hospital Limerick, Limerick, Ireland Department of Economics, University of Limerick, Ireland
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 December 2012 Received in revised form 18 April 2013 Accepted 1 May 2013 Available online 13 May 2013
Patients with suspected appendicitis comprise a large proportion of general surgical workload. The resulting healthcare burden is significant when one considers that investigations, observation and surgical procedures are often needed. As no previous study has examined the cost of managing patients with suspected appendicitis, we performed a cost analysis study of management of cases of right iliac fossa (RIF) pain in University Hospital Limerick. Patients who were admitted with right iliac fossa pain from 1st April 2011 to 4th May 2011 were identified prospectively. After discharge, patients’ medical records were reviewed. Costing data collected comprised details on length of stay, number and type of radiological investigations, number and type of blood investigations, medications administered and operations performed. Costs for radiological investigations were obtained from casemix data. Blood investigation costs were obtained from relevant laboratories. Medication costs were obtained from the pharmacy department. Operation costs were based on the cost of equipment combined with cost relating to operating theatre time and recovery unit time. Due to unavailability of data on Irish public hospital bed-day cost, a private hospital provided cost details on this aspect. 94 patients (M ¼ 33, F ¼ 61) were admitted with RIF pain during this time period. 62 underwent surgery. There were 53 appendicectomies performed with 42 (79%) positive for appendicitis on histological analysis. Blood test, radiology, pharmacy, operative and bed-day costs were V1857, V6252, V3517, V184,191 and V152,706 respectively. The total estimated cost was V348,525 (V3708 average per patient). There is a high cost associated with managing suspected appendicitis in Ireland. Strategies to reduce cost include reducing unnecessary admissions and unnecessary operations. Reducing LOS may be another potentially valuable cost saving method. It is imperative that resources are channelled into the provision of accurate costing structures. Ó 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Appendicitis Cost analysis Non-specific abdominal pain Laparoscopic appendicectomy Open appendicectomy Appendectomy
1. Introduction Appendicitis is one of the most common surgical emergencies.1 Patients with right iliac fossa (RIF) pain and suspected appendicitis are one of the most common groups of general surgical admissions. These patients frequently require admission although initial diagnoses are often uncertain. The health system burden attributable to these patients is significant, when one considers that investigations and a period of observation are frequently needed, with a surgical procedure following in certain cases. While several previous studies,2e15 including a Cochrane review,16 have
* Corresponding author. Tel.: þ353 61 234920; fax: þ353 61 233778. E-mail addresses: [email protected], [email protected] (S.R. Walsh).
examined the cost of managing patients with appendicitis, there has been no previous study on the cost of managing patients who are admitted with suspected appendicitis. Determining the cost of managing these patients is important in order to guide future resource allocation and research directions. Knowing the cost becomes important also when we consider that many patients with suspected appendicitis subsequently are found to have benign and self-limiting disease that would not have necessitated admission if a clear diagnosis had been known. Theoretical ways to reduce cost include achieving early diagnosis with subsequent prompt discharge for those without serious disease and urgent surgical intervention for those with serious disease. With the budgetary problems of managing suspected appendicitis in mind, we performed a prospective cost analysis study of management of cases of RIF pain in the setting of a tertiary referral teaching hospital in Ireland.
1743-9191/$ e see front matter Ó 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijsu.2013.05.001
ORIGINAL RESEARCH D.A. Healy et al. / International Journal of Surgery 11 (2013) 524e528 Table 1 Summary of total costs displayed in five components.
525
The primary objective was to determine the cost of managing consecutive patients who were admitted to University Hospital Limerick (UHL) with RIF pain over a 5 week period from April 2011 to May 2011. Our secondary aim was to examine relationships between cost and gender, age, operation type (non-operated, diagnostic laparoscopy, laparoscopic appendicectomy or open appendicectomy) and appendicitis severity (based on histology reports of normal, inflamed or perforated specimens).
patient needed surgery, the on-call team of that day performed the surgery and managed the patient post-operatively. After discharge, patients’ medical notes were reviewed. Computerised laboratory and radiology databases were also interrogated and data were entered into an electronic spreadsheet. Data were obtained on number and type of blood and radiological investigations, amount of medications used, length of hospital stay (LOS) and whether or not surgery was performed. If surgery was performed, the type and length of procedure was documented. The costs of these components of care were obtained where possible from relevant departments. Histology results were obtained and used to determine definitive diagnoses. The haematology, biochemistry and serology laboratories provided figures for the cost of blood tests. The cost figures for the haematology and biochemistry tests were solely the reagent costs and did not account for staffing, building and other running costs (an accurate costing structure which accounts for all fixed and variable costs in these departments was not available). The figure for the cost of a C-reactive protein (CRP) assay included both fixed and variable costs. The casemix department provided information on the cost of radiological investigations which are specific to University Hospital Limerick radiology department. They are calculated on an annual basis by trained Irish healthcare service casemix staff and include all costs relating to radiological investigations divided by the number of investigations per year (capital costs and depreciation are not included). For ultrasound (USS) and computed tomography (CT) examinations, we additionally incorporated reporting fees based on figures obtained from an Irish health insurance company (VHI). Using this method, costs were as follows: plain radiographs e V64; USS examinations e V177; CT examinations e V303. The pharmacy department provided details on the cost of medications. Individual drug costs were not available due to a confidentiality agreement between the hospital pharmacy and suppliers. However, the pharmacy provided a cumulative figure for the overall cost to the hospital for the drugs used. This figure did not include costs related to staffing and pharmacy departmental running costs. For simplicity, medication costs were divided into three categories (analgesic medications, anaesthetic medications and general medications), thereby allowing a degree of individualisation of costs. Operation costs were derived by adding the costs of the equipment, operating theatre time cost and post anaesthesia care unit (PACU) cost. We used 2010 operating theatre time cost of $30 per minute17 as a measure of operative time cost. This per minute rate was converted to a corresponding 2011 value via Consumer Price Index (CPI) conversion18 and subsequently to Euro based on an average 2011 conversion rate of V0.7190 per US dollar.19 This resulted in an operating theatre per minute cost of V22.29. We assumed that patients spend 30 min in the PACU, corresponding to V58.56. This is based on published PACU costing data20 with CPI and Euro conversions. Regarding length of stay costs, the casemix department provided a nationwide average figure of V1356 per hospital bed-day for Ireland, which reflects the total overall average cost of medical care per day in Ireland and so is not relevant to this study. As a substitute, we searched for costing details from the private sector. Mount Carmel Hospital (a private hospital in Dublin) quoted a semi-private bed day cost of V533.94 and a private bed-day cost of V678.43, which reflects solely length of stay. For the current study, we used the semi-private figure as the bed-day cost, accepting that this is prone to some inaccuracy. Statistical analyses were performed with Minitab version 16. Descriptive statistics and boxplots were used to summarise costs. Students t test and one way analysis of variance (ANOVA) (with Tukey multiple comparison testing) were used to examine differences in mean costs. For all tests, significance was set at 0.05.
3. Methods
4. Results
All patients who were admitted under the on-call surgical team with RIF pain from 1st April to 4th May 2011 were eligible for inclusion. There were no exclusion criteria. RIF pain was defined as abdominal pain with RIF tenderness on assessment by the admitting surgical team member. Eligible patients were identified prospectively by liaising with the on-call surgical team on a daily basis. All decisions regarding management were made by the on-call team. If it was decided that a
94 patients (M ¼ 33, F ¼ 61) were admitted with RIF pain during this time period. 71 patients were under 30 years of age. 62 patients underwent surgery of whom 14 patients underwent open appendicectomy, 39 underwent laparoscopic appendicectomy (with 3 open conversions) and nine underwent diagnostic laparoscopy.
Cost component
Total cost
Blood tests Radiology Medications Operative costs Hospital stay Total cost Average cost
V1857 V6252 V3517 V184,191 V152,707 V348,525 V3708
Summary of total costs displayed according to operation type 10000
Total cost
8000
6000
4000
2000
0 DL(n= 9)
LA(n= 39) non-operated(n= 32) Operation type
OA(n= 14)
DL–diagnostic laparoscopy; LA – laparoscopic appendicectomy; OA – open appendicectomy.
Fig. 1. Boxplot of costs (in euro) displayed according to operation type, including patients who had no operation.
2. Aim
Table 2 Summary cost data (in euro) when patients are divided into groups based on operation type e open/laparoscopic appendicectomy, diagnostic laparoscopy and non e operated. 95% confidence intervals were calculated using one-way ANOVA testing. p < 0.001 ANOVA.
ANOVA e analysis of variance; CI e confidence intervals; DL e diagnostic laparoscopy; LA e laparoscopic appendicectomy; none e no operation; OA e open appendicectomy; SD e standard deviation.
ORIGINAL RESEARCH 526
D.A. Healy et al. / International Journal of Surgery 11 (2013) 524e528
Summary of total costs displayed according to gender
10000
10000
8000
8000 total cost in Euro
total cost in Euro
Summary of total costs displayed according to disease severity
6000
4000
2000
6000
4000
2000
0
0 app(n= 36)
DL only(n= 9)
non-operated(n= 32) normal(n= 11)
female(n= 61)
perf(n= 6)
histology
App – appendicitis; DL – diagnostic laparoscopy; perf − perforation.
Fig. 2. Boxplot displaying costs in euro according to whether patients had no operation, diagnostic laparoscopy only, removal of a histologically normal appendix, removal of an appendix with simple appendicitis or removal of a perforated appendix.
There were 53 appendicectomies performed with 42 (79%) positive for appendicitis on histological analysis (36 uncomplicated appendicitis, 6 perforated appendicitis). The total number of hospital bed days used was 286 days (186 days in the operated group and 100 in the non-operated group). Table 1 outlines the contribution of each of the five cost components to the total cost (blood test costs e V1857; radiological costs e V6252; medication costs e V3517; surgical costs e V184,191; hospital bed costs e V152,707; total cost e V348,525). Fig. 1 and Table 2 summarise costs using operation type as the distinguishing feature (open appendicectomy, laparoscopic appendicectomy, diagnostic laparoscopy and no operation). The Tukey method for multiple comparison testing showed that patients who had no operation incurred significantly lower costs and that there was no significant cost difference between patients who had operations. Fig. 2 and Table 3 summarise costs by categorising patients based on histology results (normal appendix, acute appendicitis, perforated appendicitis) and also includes those who underwent diagnostic laparoscopy without appendicectomy and those who had no operation. The Tukey method for multiple comparison testing showed that significantly lower costs were seen in the non-operated group. Costs incurred by patients who had uncomplicated appendicitis, diagnostic laparoscopy or removal of a normal appendix were not significantly different although cases of perforated appendicitis incurred significantly more cost than cases of uncomplicated appendicitis. When costs were examined according to patients’ gender, no differences were seen (p ¼ 0.53)
male(n= 33) gender
Fig. 3. Boxplot of costs in euro displayed according to gender of patients.
(Fig. 3 and Table 4). Age was positively correlated with cost (Pearson’s r ¼ 0.225; p ¼ 0.03) (Fig. 4). 5. Discussion The present study found that the estimated total hospital cost for managing 94 consecutive patients with RIF pain was V348,524 with an average cost per patient of V3708. Operative cost was the single biggest contributor to cost at 52.8% of the total cost. This is the first study that attempted to determine the hospital costs associated with managing all cases of RIF pain, irrespective of the final diagnosis. The calculated cost of management of cases of suspected appendicitis in our institution is comparable to the appendicectomy cost in most of the studies mentioned in the introduction. We feel that is important to emphasise that cost conclusions should be formed based on contemporary studies performed in one’s own country or in countries with similar healthcare systems. This particularly true for common conditions such as appendicitis (as has been highlighted before16) as healthcare system differences may limit generalisability. Though we think that the internal validity of the current study is high, it is possible that our low reliance on imaging and blood testing could limit extrapolation of our results to centres that use more pre-operative investigations (this low reliance on investigations may also be reflected in our relatively high negative appendicectomy rate, though reasons for this are beyond the scope of this study). For this cost analysis, we focused on five key components of patient care e number and cost of blood tests, number and costs of radiological tests, amount of medications used, operative costs and length of hospital stay. We did not intend this to be an exhaustive
Table 3 Summary cost data (in euro) when patients are divided into groups e non-operated, diagnostic laparoscopy only, normal appendix removed, simple appendicitis, perforated appendicitis. 95% confidence intervals were calculated using one-way ANOVA testing. p < 0.001 ANOVA.
ANOVA e analysis of variance; CIs e confidence intervals; DL e diagnostic laparoscopy; SD e standard deviation.
ORIGINAL RESEARCH D.A. Healy et al. / International Journal of Surgery 11 (2013) 524e528 Table 4 Summary cost data (in euro) incurred by male and female patients. Gender
n
Mean
SD
SE mean
Female Male
61 33
3609 3891
2160 1985
277 34
SD e standard deviation; SE e standard error.
and intricately detailed micro-cost analysis but rather a robust snapshot focusing on the key aspects of care that could be altered in order to minimise future costs. It is not surprising that patients who needed surgery and those who had more severe disease incurred more cost. It is also unsurprising that there was no cost difference relating to gender but that older patients tended to incur more costs. There are several limitations that should be highlighted. We found much difficulty in accurately determining individual costs in this study. A figure encompassing fixed and variable costs for haematology and biochemistry tests was not available in our hospital. Rather, these costs were based on equipment and reagent costs. In contrast, the cost for CRP measurement included both fixed and variable costs. Radiology costs were obtained from the hospital casemix21 unit. These figures are obtained annually in our institution by a trained casemix team by calculating the total cost relating to imaging modalities and dividing this by the number of investigations performed in the year. These costs are highly accurate for the annual running costs of the radiology department. However, they do not account for capital costs or depreciation.21 In relation to pharmacy costs, we calculated cost based solely on the fee that the hospital pays to purchase groups of drugs. This “point of sale” method was chosen due to its simplicity as we felt that microcosting medication related expense was not feasible given the relatively low overall cost yet high level of detail. Furthermore, there is no system in place in our institution to allow accurate costing of operations. The way operation equipment cost was calculated in this study is prone to error as it was based on the assumption that similar equipment is always used in similar operations. Our operative theatre time and PACU costs are based on North American figures due to unavailability of alternatives. We used length of stay cost figures from a private hospital (as no public hospital figures were available). This costing estimate proved to be the most difficult costing figure to obtain. Though it is understandable that the Irish public healthcare system does not have reliable figures, this should be a target for the future. Further limitations are that the sample size is small and that the study lacks
temporal cost information e possibly costs are incurred unevenly with increased costs in the initial part of hospital stay. In order for hospitals to increase productivity, individualised and accurate costs should be available for all departments. However, there are enormous difficulties involved in obtaining and maintaining such data. Casemix21 is an internationally accepted system that monitors the activity and costs in hospitals with a focus on different Diagnosis Related Groups (DRGs). This system is operational in 38 Irish hospitals. It focuses on 12 aspects of cost (allied healthcare, coronary care units, emergency departments, intensive care units, imaging, pay, nursing, pathology, pharmacy, theatre, blood related costs, prosthesis related costs) and four aspects of activity (inpatients, day cases, outpatients and emergency department usage) in order to draw evidence based conclusions on the provision of healthcare. Our study focused on certain aspects of the casemix system that could be targeted to reduce cost, but did not focus on several other categories. As budgeting is central to future healthcare provision, it follows that accurate costing data is essential for both definite and suspected diagnoses. In this manner, components of cost can be targeted to reduce overall cost. Casemix teams have a crucial role to play. Based on our suspected appendicitis data, we can suggest several cost reduction strategies. Unnecessary admissions and unnecessary operations should be avoided when possible (early cross sectional imaging before admission is an option). Furthermore, efforts can be made reduce LOS. The approach to reducing LOS should include streamlining theatre access for patients with likely or confirmed appendicitis and expediting discharge (such an approach has lead to successful outpatient management of uncomplicated appendicitis22). 6. Conclusion There is a high cost associated with managing suspected appendicitis in Ireland. Maintaining accurate costing data is of considerable importance for future service provision. We feel that it is important to develop strategies to streamline the management of patients with both suspected and confirmed diagnoses and to keep cost reduction as a central healthcare theme. Ethical approval None. Funding None. Author contribution D Healy e design, data collection, analysis, writing. A Aziz e design, data collection. M Wong e data collection, analysis. M Clarke Moloney e design, data collection, analysis. J Coffey e analysis. P Grace e analysis. S Kinsella e design, analysis, writing. S Walsh e design, analysis, writing.
Summary of relationship between age and total cost 10000
8000 t ot al cost in Euro
527
6000
Conflict of interest The authors report no conflicts of interest.
4000
2000
Acknowledgement 0 0
10
20
30
40 50 age in years
60
70
80
90
Fig. 4. Scatter plot showing variation in total cost in euro according to age of patients in years.
We wish to acknowledge the important contribution made by Ms. Siobhan Collins and Mr. John O’Brien of Mount Carmel Hospital by providing details on hospital bed-day costs at their institution. We also wish to acknowledge the contribution of the UHL surgical, radiology, pharmacy and laboratory departments.
ORIGINAL RESEARCH 528
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References 1. Williams GR. Presidential address: a history of appendicitis. With anecdotes illustrating its importance. Ann Surg 1983 May;197(5):495e506. 2. Heikkinen TJ, Haukipuro K, Hulkko A. Cost-effective appendectomy. Open or laparoscopic? A prospective randomized study. Surg Endosc 1998 Oct;12(10): 1204e8. 3. Sporn E, Petroski GF, Mancini GJ, Astudillo JA, Miedema BW, Thaler K. Laparoscopic appendectomyeis it worth the cost? Trend analysis in the US from 2000 to 2005. J Am Coll Surg 2009 Feb;208(2):179e85. e2. 4. Kald A, Kullman E, Anderberg B, Wiren M, Carlsson P, Ringqvist I, et al. Costminimisation analysis of laparoscopic and open appendicectomy. Eur J Surg 1999 Jun;165(6):579e82. 5. Lintula H, Kokki H, Vanamo K, Valtonen H, Mattila M, Eskelinen M. The costs and effects of laparoscopic appendectomy in children. Arch Pediatr Adolesc Med 2004 Jan;158(1):34e7. 6. Frazee RC, Roberts JW, Symmonds RE, Snyder SK, Hendricks JC, Smith RW, et al. A prospective randomized trial comparing open versus laparoscopic appendectomy. Ann Surg 1994 Jun;219(6):725e8. discussion 8e31. 7. Ignacio RC, Burke R, Spencer D, Bissell C, Dorsainvil C, Lucha PA. Laparoscopic versus open appendectomy: what is the real difference? Results of a prospective randomized double-blinded trial. Surg Endosc 2004 Feb;18(2):334e7. 8. Kaplan M, Salman B, Yilmaz TU, Oguz M. A quality of life comparison of laparoscopic and open approaches in acute appendicitis: a randomised prospective study. Acta Chir Belg 2009 MayeJun;109(3):356e63. 9. Little DC, Custer MD, May BH, Blalock SE, Cooney DR. Laparoscopic appendectomy: an unnecessary and expensive procedure in children? J Pediatr Surg 2002 Mar;37(3):310e7. 10. Macarulla E, Vallet J, Abad JM, Hussein H, Fernandez E, Nieto B. Laparoscopic versus open appendectomy: a prospective randomized trial. Surg Laparosc Endosc 1997 Aug;7(4):335e9.
11. Minne L, Varner D, Burnell A, Ratzer E, Clark J, Haun W. Laparoscopic vs open appendectomy. Prospective randomized study of outcomes. Arch Surg 1997 Jul;132(7):708e11. discussion 12. 12. Mutter D, Vix M, Bui A, Evrard S, Tassetti V, Breton JF, et al. Laparoscopy not recommended for routine appendectomy in men: results of a prospective randomized study. Surgery 1996 Jul;120(1):71e4. 13. Williams MD, Collins JN, Wright TF, Fenoglio ME. Laparoscopic versus open appendectomy. South Med J 1996 Jul;89(7):668e74. 14. Myers AL, Williams RF, Giles K, Waters TM, Eubanks 3rd JW, Hixson SD, et al. Hospital cost analysis of a prospective, randomized trial of early vs interval appendectomy for perforated appendicitis in children. J Am Coll Surg 2012 Apr;214(4):427e34. 15. Masoomi H, Mills S, Dolich MO, Ketana N, Carmichael JC, Nguyen NT, et al. Does laparoscopic appendectomy impart an advantage over open appendectomy in elderly patients? World J Surg 2012 Jul;36(7):1534e9. 16. Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2010;(10):CD001546. 17. Macario A. What does one minute of operating room time cost? J Clin Anesth 2010 Jun;22(4):233e6. 18. http://oregonstate.edu/cla/polisci/sites/default/files/faculty-research/sahr/ inflation-conversion/pdf/cv2011.pdf [17.04.13]. 19. http://www.x-rates.com/average/? from¼USD&to¼EUR&amount¼1&year¼2011 [17.04.13]. 20. Waddle JP, Evers AS, Piccirillo JF. Postanesthesia care unit length of stay: quantifying and assessing dependent factors. Anesth Analg 1998 Sep;87(3): 628e33. 21. Casemix.ie. 2012. Available from: http://www.casemix.ie/. 22. Cash CL, Frazee RC, Abernathy SW, Childs EW, Davis ML, Hendricks JC, et al. A prospective treatment protocol for outpatient laparoscopic appendectomy for acute appendicitis. J Am Coll Surg 2012 Jul;215(1):101e 5. discussion 5e6.
Contents lists available at SciVerse ScienceDirect
International Journal of Surgery journal homepage: www.theijs.com
Original research
A descriptive cost analysis study of cases of right iliac fossa pain D.A. Healy a, A. Aziz a, M. Wong a, M. Clarke Moloney a, J.C. Coffey a, P.A. Grace a, S. Kinsella b, S.R. Walsh a, * a b
Department of Surgery, University Hospital Limerick, Limerick, Ireland Department of Economics, University of Limerick, Ireland
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 December 2012 Received in revised form 18 April 2013 Accepted 1 May 2013 Available online 13 May 2013
Patients with suspected appendicitis comprise a large proportion of general surgical workload. The resulting healthcare burden is significant when one considers that investigations, observation and surgical procedures are often needed. As no previous study has examined the cost of managing patients with suspected appendicitis, we performed a cost analysis study of management of cases of right iliac fossa (RIF) pain in University Hospital Limerick. Patients who were admitted with right iliac fossa pain from 1st April 2011 to 4th May 2011 were identified prospectively. After discharge, patients’ medical records were reviewed. Costing data collected comprised details on length of stay, number and type of radiological investigations, number and type of blood investigations, medications administered and operations performed. Costs for radiological investigations were obtained from casemix data. Blood investigation costs were obtained from relevant laboratories. Medication costs were obtained from the pharmacy department. Operation costs were based on the cost of equipment combined with cost relating to operating theatre time and recovery unit time. Due to unavailability of data on Irish public hospital bed-day cost, a private hospital provided cost details on this aspect. 94 patients (M ¼ 33, F ¼ 61) were admitted with RIF pain during this time period. 62 underwent surgery. There were 53 appendicectomies performed with 42 (79%) positive for appendicitis on histological analysis. Blood test, radiology, pharmacy, operative and bed-day costs were V1857, V6252, V3517, V184,191 and V152,706 respectively. The total estimated cost was V348,525 (V3708 average per patient). There is a high cost associated with managing suspected appendicitis in Ireland. Strategies to reduce cost include reducing unnecessary admissions and unnecessary operations. Reducing LOS may be another potentially valuable cost saving method. It is imperative that resources are channelled into the provision of accurate costing structures. Ó 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Appendicitis Cost analysis Non-specific abdominal pain Laparoscopic appendicectomy Open appendicectomy Appendectomy
1. Introduction Appendicitis is one of the most common surgical emergencies.1 Patients with right iliac fossa (RIF) pain and suspected appendicitis are one of the most common groups of general surgical admissions. These patients frequently require admission although initial diagnoses are often uncertain. The health system burden attributable to these patients is significant, when one considers that investigations and a period of observation are frequently needed, with a surgical procedure following in certain cases. While several previous studies,2e15 including a Cochrane review,16 have
* Corresponding author. Tel.: þ353 61 234920; fax: þ353 61 233778. E-mail addresses: [email protected], [email protected] (S.R. Walsh).
examined the cost of managing patients with appendicitis, there has been no previous study on the cost of managing patients who are admitted with suspected appendicitis. Determining the cost of managing these patients is important in order to guide future resource allocation and research directions. Knowing the cost becomes important also when we consider that many patients with suspected appendicitis subsequently are found to have benign and self-limiting disease that would not have necessitated admission if a clear diagnosis had been known. Theoretical ways to reduce cost include achieving early diagnosis with subsequent prompt discharge for those without serious disease and urgent surgical intervention for those with serious disease. With the budgetary problems of managing suspected appendicitis in mind, we performed a prospective cost analysis study of management of cases of RIF pain in the setting of a tertiary referral teaching hospital in Ireland.
1743-9191/$ e see front matter Ó 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijsu.2013.05.001
ORIGINAL RESEARCH D.A. Healy et al. / International Journal of Surgery 11 (2013) 524e528 Table 1 Summary of total costs displayed in five components.
525
The primary objective was to determine the cost of managing consecutive patients who were admitted to University Hospital Limerick (UHL) with RIF pain over a 5 week period from April 2011 to May 2011. Our secondary aim was to examine relationships between cost and gender, age, operation type (non-operated, diagnostic laparoscopy, laparoscopic appendicectomy or open appendicectomy) and appendicitis severity (based on histology reports of normal, inflamed or perforated specimens).
patient needed surgery, the on-call team of that day performed the surgery and managed the patient post-operatively. After discharge, patients’ medical notes were reviewed. Computerised laboratory and radiology databases were also interrogated and data were entered into an electronic spreadsheet. Data were obtained on number and type of blood and radiological investigations, amount of medications used, length of hospital stay (LOS) and whether or not surgery was performed. If surgery was performed, the type and length of procedure was documented. The costs of these components of care were obtained where possible from relevant departments. Histology results were obtained and used to determine definitive diagnoses. The haematology, biochemistry and serology laboratories provided figures for the cost of blood tests. The cost figures for the haematology and biochemistry tests were solely the reagent costs and did not account for staffing, building and other running costs (an accurate costing structure which accounts for all fixed and variable costs in these departments was not available). The figure for the cost of a C-reactive protein (CRP) assay included both fixed and variable costs. The casemix department provided information on the cost of radiological investigations which are specific to University Hospital Limerick radiology department. They are calculated on an annual basis by trained Irish healthcare service casemix staff and include all costs relating to radiological investigations divided by the number of investigations per year (capital costs and depreciation are not included). For ultrasound (USS) and computed tomography (CT) examinations, we additionally incorporated reporting fees based on figures obtained from an Irish health insurance company (VHI). Using this method, costs were as follows: plain radiographs e V64; USS examinations e V177; CT examinations e V303. The pharmacy department provided details on the cost of medications. Individual drug costs were not available due to a confidentiality agreement between the hospital pharmacy and suppliers. However, the pharmacy provided a cumulative figure for the overall cost to the hospital for the drugs used. This figure did not include costs related to staffing and pharmacy departmental running costs. For simplicity, medication costs were divided into three categories (analgesic medications, anaesthetic medications and general medications), thereby allowing a degree of individualisation of costs. Operation costs were derived by adding the costs of the equipment, operating theatre time cost and post anaesthesia care unit (PACU) cost. We used 2010 operating theatre time cost of $30 per minute17 as a measure of operative time cost. This per minute rate was converted to a corresponding 2011 value via Consumer Price Index (CPI) conversion18 and subsequently to Euro based on an average 2011 conversion rate of V0.7190 per US dollar.19 This resulted in an operating theatre per minute cost of V22.29. We assumed that patients spend 30 min in the PACU, corresponding to V58.56. This is based on published PACU costing data20 with CPI and Euro conversions. Regarding length of stay costs, the casemix department provided a nationwide average figure of V1356 per hospital bed-day for Ireland, which reflects the total overall average cost of medical care per day in Ireland and so is not relevant to this study. As a substitute, we searched for costing details from the private sector. Mount Carmel Hospital (a private hospital in Dublin) quoted a semi-private bed day cost of V533.94 and a private bed-day cost of V678.43, which reflects solely length of stay. For the current study, we used the semi-private figure as the bed-day cost, accepting that this is prone to some inaccuracy. Statistical analyses were performed with Minitab version 16. Descriptive statistics and boxplots were used to summarise costs. Students t test and one way analysis of variance (ANOVA) (with Tukey multiple comparison testing) were used to examine differences in mean costs. For all tests, significance was set at 0.05.
3. Methods
4. Results
All patients who were admitted under the on-call surgical team with RIF pain from 1st April to 4th May 2011 were eligible for inclusion. There were no exclusion criteria. RIF pain was defined as abdominal pain with RIF tenderness on assessment by the admitting surgical team member. Eligible patients were identified prospectively by liaising with the on-call surgical team on a daily basis. All decisions regarding management were made by the on-call team. If it was decided that a
94 patients (M ¼ 33, F ¼ 61) were admitted with RIF pain during this time period. 71 patients were under 30 years of age. 62 patients underwent surgery of whom 14 patients underwent open appendicectomy, 39 underwent laparoscopic appendicectomy (with 3 open conversions) and nine underwent diagnostic laparoscopy.
Cost component
Total cost
Blood tests Radiology Medications Operative costs Hospital stay Total cost Average cost
V1857 V6252 V3517 V184,191 V152,707 V348,525 V3708
Summary of total costs displayed according to operation type 10000
Total cost
8000
6000
4000
2000
0 DL(n= 9)
LA(n= 39) non-operated(n= 32) Operation type
OA(n= 14)
DL–diagnostic laparoscopy; LA – laparoscopic appendicectomy; OA – open appendicectomy.
Fig. 1. Boxplot of costs (in euro) displayed according to operation type, including patients who had no operation.
2. Aim
Table 2 Summary cost data (in euro) when patients are divided into groups based on operation type e open/laparoscopic appendicectomy, diagnostic laparoscopy and non e operated. 95% confidence intervals were calculated using one-way ANOVA testing. p < 0.001 ANOVA.
ANOVA e analysis of variance; CI e confidence intervals; DL e diagnostic laparoscopy; LA e laparoscopic appendicectomy; none e no operation; OA e open appendicectomy; SD e standard deviation.
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Summary of total costs displayed according to gender
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Fig. 2. Boxplot displaying costs in euro according to whether patients had no operation, diagnostic laparoscopy only, removal of a histologically normal appendix, removal of an appendix with simple appendicitis or removal of a perforated appendix.
There were 53 appendicectomies performed with 42 (79%) positive for appendicitis on histological analysis (36 uncomplicated appendicitis, 6 perforated appendicitis). The total number of hospital bed days used was 286 days (186 days in the operated group and 100 in the non-operated group). Table 1 outlines the contribution of each of the five cost components to the total cost (blood test costs e V1857; radiological costs e V6252; medication costs e V3517; surgical costs e V184,191; hospital bed costs e V152,707; total cost e V348,525). Fig. 1 and Table 2 summarise costs using operation type as the distinguishing feature (open appendicectomy, laparoscopic appendicectomy, diagnostic laparoscopy and no operation). The Tukey method for multiple comparison testing showed that patients who had no operation incurred significantly lower costs and that there was no significant cost difference between patients who had operations. Fig. 2 and Table 3 summarise costs by categorising patients based on histology results (normal appendix, acute appendicitis, perforated appendicitis) and also includes those who underwent diagnostic laparoscopy without appendicectomy and those who had no operation. The Tukey method for multiple comparison testing showed that significantly lower costs were seen in the non-operated group. Costs incurred by patients who had uncomplicated appendicitis, diagnostic laparoscopy or removal of a normal appendix were not significantly different although cases of perforated appendicitis incurred significantly more cost than cases of uncomplicated appendicitis. When costs were examined according to patients’ gender, no differences were seen (p ¼ 0.53)
male(n= 33) gender
Fig. 3. Boxplot of costs in euro displayed according to gender of patients.
(Fig. 3 and Table 4). Age was positively correlated with cost (Pearson’s r ¼ 0.225; p ¼ 0.03) (Fig. 4). 5. Discussion The present study found that the estimated total hospital cost for managing 94 consecutive patients with RIF pain was V348,524 with an average cost per patient of V3708. Operative cost was the single biggest contributor to cost at 52.8% of the total cost. This is the first study that attempted to determine the hospital costs associated with managing all cases of RIF pain, irrespective of the final diagnosis. The calculated cost of management of cases of suspected appendicitis in our institution is comparable to the appendicectomy cost in most of the studies mentioned in the introduction. We feel that is important to emphasise that cost conclusions should be formed based on contemporary studies performed in one’s own country or in countries with similar healthcare systems. This particularly true for common conditions such as appendicitis (as has been highlighted before16) as healthcare system differences may limit generalisability. Though we think that the internal validity of the current study is high, it is possible that our low reliance on imaging and blood testing could limit extrapolation of our results to centres that use more pre-operative investigations (this low reliance on investigations may also be reflected in our relatively high negative appendicectomy rate, though reasons for this are beyond the scope of this study). For this cost analysis, we focused on five key components of patient care e number and cost of blood tests, number and costs of radiological tests, amount of medications used, operative costs and length of hospital stay. We did not intend this to be an exhaustive
Table 3 Summary cost data (in euro) when patients are divided into groups e non-operated, diagnostic laparoscopy only, normal appendix removed, simple appendicitis, perforated appendicitis. 95% confidence intervals were calculated using one-way ANOVA testing. p < 0.001 ANOVA.
ANOVA e analysis of variance; CIs e confidence intervals; DL e diagnostic laparoscopy; SD e standard deviation.
ORIGINAL RESEARCH D.A. Healy et al. / International Journal of Surgery 11 (2013) 524e528 Table 4 Summary cost data (in euro) incurred by male and female patients. Gender
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2160 1985
277 34
SD e standard deviation; SE e standard error.
and intricately detailed micro-cost analysis but rather a robust snapshot focusing on the key aspects of care that could be altered in order to minimise future costs. It is not surprising that patients who needed surgery and those who had more severe disease incurred more cost. It is also unsurprising that there was no cost difference relating to gender but that older patients tended to incur more costs. There are several limitations that should be highlighted. We found much difficulty in accurately determining individual costs in this study. A figure encompassing fixed and variable costs for haematology and biochemistry tests was not available in our hospital. Rather, these costs were based on equipment and reagent costs. In contrast, the cost for CRP measurement included both fixed and variable costs. Radiology costs were obtained from the hospital casemix21 unit. These figures are obtained annually in our institution by a trained casemix team by calculating the total cost relating to imaging modalities and dividing this by the number of investigations performed in the year. These costs are highly accurate for the annual running costs of the radiology department. However, they do not account for capital costs or depreciation.21 In relation to pharmacy costs, we calculated cost based solely on the fee that the hospital pays to purchase groups of drugs. This “point of sale” method was chosen due to its simplicity as we felt that microcosting medication related expense was not feasible given the relatively low overall cost yet high level of detail. Furthermore, there is no system in place in our institution to allow accurate costing of operations. The way operation equipment cost was calculated in this study is prone to error as it was based on the assumption that similar equipment is always used in similar operations. Our operative theatre time and PACU costs are based on North American figures due to unavailability of alternatives. We used length of stay cost figures from a private hospital (as no public hospital figures were available). This costing estimate proved to be the most difficult costing figure to obtain. Though it is understandable that the Irish public healthcare system does not have reliable figures, this should be a target for the future. Further limitations are that the sample size is small and that the study lacks
temporal cost information e possibly costs are incurred unevenly with increased costs in the initial part of hospital stay. In order for hospitals to increase productivity, individualised and accurate costs should be available for all departments. However, there are enormous difficulties involved in obtaining and maintaining such data. Casemix21 is an internationally accepted system that monitors the activity and costs in hospitals with a focus on different Diagnosis Related Groups (DRGs). This system is operational in 38 Irish hospitals. It focuses on 12 aspects of cost (allied healthcare, coronary care units, emergency departments, intensive care units, imaging, pay, nursing, pathology, pharmacy, theatre, blood related costs, prosthesis related costs) and four aspects of activity (inpatients, day cases, outpatients and emergency department usage) in order to draw evidence based conclusions on the provision of healthcare. Our study focused on certain aspects of the casemix system that could be targeted to reduce cost, but did not focus on several other categories. As budgeting is central to future healthcare provision, it follows that accurate costing data is essential for both definite and suspected diagnoses. In this manner, components of cost can be targeted to reduce overall cost. Casemix teams have a crucial role to play. Based on our suspected appendicitis data, we can suggest several cost reduction strategies. Unnecessary admissions and unnecessary operations should be avoided when possible (early cross sectional imaging before admission is an option). Furthermore, efforts can be made reduce LOS. The approach to reducing LOS should include streamlining theatre access for patients with likely or confirmed appendicitis and expediting discharge (such an approach has lead to successful outpatient management of uncomplicated appendicitis22). 6. Conclusion There is a high cost associated with managing suspected appendicitis in Ireland. Maintaining accurate costing data is of considerable importance for future service provision. We feel that it is important to develop strategies to streamline the management of patients with both suspected and confirmed diagnoses and to keep cost reduction as a central healthcare theme. Ethical approval None. Funding None. Author contribution D Healy e design, data collection, analysis, writing. A Aziz e design, data collection. M Wong e data collection, analysis. M Clarke Moloney e design, data collection, analysis. J Coffey e analysis. P Grace e analysis. S Kinsella e design, analysis, writing. S Walsh e design, analysis, writing.
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Conflict of interest The authors report no conflicts of interest.
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Fig. 4. Scatter plot showing variation in total cost in euro according to age of patients in years.
We wish to acknowledge the important contribution made by Ms. Siobhan Collins and Mr. John O’Brien of Mount Carmel Hospital by providing details on hospital bed-day costs at their institution. We also wish to acknowledge the contribution of the UHL surgical, radiology, pharmacy and laboratory departments.
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