Should Patients Travel to High Volume Centers to Undergo Proctectomy with Ileal Pouch Anal Anastomosis?

Vol. 219, No. 3S, September 2014

Should Patients Travel to High Volume Centers to Undergo Proctectomy with Ileal Pouch Anal Anastomosis? Joshua W Kuethe, MD, Gregory C Wilson, MD, Koffi Wima, MS, Daniel E Abbott, MD, Shimul A Shah, MD, FACS, Ian M Paquette, MD, FACS University of Cincinnati College of Medicine, Cincinnati, OH INTRODUCTION: Proctectomy with ileal pouch anal anastomosis (IPAA) is a complex surgical procedure. The extent to which patients travel to have this procedure is unknown. METHODS: The University Health Consortium Clinical Database (UHC) was queried for patients >18 years of age undergoing elective proctectomy with IPAA between 2009-2012. Hospital volumes were stratified into quartiles (high, medium, low, and lowest-volume) based on the number of cases performed per year. A summary measure of socioeconomic status (SES) using US Census American Community Survey 5-year estimates from 2011 for each US ZIP code was constructed. Patient travel characteristics were calculated using patient and hospital zip codes and Maptitude Geographic Information System software. RESULTS: A total of 4,952 patients underwent proctectomy with IPAA at 149 centers. Patients were predominantly white (81%) and male (56%) with a median age of 43 years (IQR 30 e 54). HV centers were associated with lower total direct cost ($9,948 vs $13,168, p<0.001) and lower 30-day readmission rate (18.6% vs 28.2%, p<0.001) compared to the lowest volume centers. Median travel distance was 93.1 miles for HV centers vs 18.4 miles for the lowest volume centers (p<0.001). Patients of high SES travelled significantly greater distances (58.4 miles vs 18.7 miles, p< 0.001) compared to the lowest SES quintile. CONCLUSIONS: Patients who underwent proctectomy with IPAA at HV centers traveled greater distances, but incurred less cost and significantly lower readmission rates compared to patients at LV centers. Patients from high SES class travelled substantially greater distances for surgery compared to low SES patients. A Statewide Teleradiology System Reduces Radiation Exposure and Charges in Trauma Patients Alexis M Moren, MD, MPH, Brian S Diggs, PhD, Benjamin D Houser, BS, Lynn Eastes, RN, Dawn Brand, MS, Martin A Schreiber, MD, FACS, Laszlo N Kiraly, MD, FACS Oregon Health and Science University, Portland, OR INTRODUCTION: Trauma transfer patients routinely get repeat studies due to inability to view referring hospital imaging. In 2009 the virtual private network (VPN) telemedicine system was adopted throughout Oregon allowing for virtual transfer of imaging. We hypothesized that the VPN would result in decreased repeat imaging, charges, and transfer time between the Emergency Department (ED) and the Intensive Care Unit (ICU). METHODS: A retrospective review from 2007-2012 of 400 adult trauma transfer patients (200 prior to VPN, 200 post VPN) was

Surgical Forum Abstracts

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conducted. SPSS was used to randomly match patients. Medians were compared between the two groups using descriptive statistics. Univariate analysis using X2 or Mann-Whitney-U tests was used on categorical or continuous data respectively. RESULTS: Injury severity score (ISS) was statistically different between pre and post VPN groups (16, 14) p¼0.05. After implementation, there was a significant decrease in the number of patients with a repeat CT of the abdomen (13.2% vs 2.8%; p<0.01) and CT of the cervical spine (34.4% vs 18.2%; p<0.01). Charges saved post VPN were $80,738, applied to the 2012 trauma transfer populace (n¼826) savings totaled $333,452. The average dose of radiation spared per person was 1.8mSv, and the length of stay in the ED for patients with ISS<15 transferring to the ICU decreased from a mean of 91.4mins to 68.3mins (p¼0.04) pre and post VPN. CONCLUSIONS: Implementation of a statewide teleradiology network is associated with fewer repeat CT scans, cost savings, decreased radiation exposure, less time spent in the ED, and a theoretical cancer risk reduction. Antibiotics vs Appendectomy as Initial Treatment for Uncomplicated Acute Appendicitis: A Cost-Effectiveness Analysis Vincent E Chong, MD, MS, Wayne S Lee, MD, Gregory P Victorino, MD, FACS, Terrence H Liu, MD, MPH University of California, SanFrancisco-East Bay, Oakland, CA INTRODUCTION: Randomized controlled trials suggest antibiotics treatment is a safe, feasible alternative to appendectomy as the initial management for patients with uncomplicated acute appendicitis (AA). Initial non-operative treatment eliminates appendectomy-related complications and reduces sick leave; however, this approach subjects patients to potential failure and recurrences. Cost-effectiveness comparison of operative and non-operative strategies for patients with AA has not been previously reported. This cost-utility analysis compares antibiotics vs laparoscopic appendectomy (LA) as initial treatment for uncomplicated AA. METHODS: Our analysis is based on a hypothetical cohort of 25 year-old women with computed tomography-proven uncomplicated AA. LA was compared to antibiotics in a Markov decision model. Costs, utilities, and outcome probabilities were derived from published data. Costs were measured in U.S. 2010 dollars and outcomes were measured in quality-adjusted life years (QALYs), both calculated at a 3% annual discounted rate. The analysis was constructed from a societal perspective. Calculations included medical costs and opportunity loss. Sensitivity analysis was performed for important variables. RESULTS: The total cost with operative treatment was $10,560.89 vs $16,185.12 for non-operative treatment (Table 1), resulting in a cost-savings of $5,624.23/patient. QALYs were comparable (27.85 vs 27.91, respectively). Antibiotics treatment was associated with an excess cost of $200.57/QALY when compared to surgery ($579.81 vs $379.24). Univariate analysis revealed