Top

Published in:

01-12-2020 | Surgery | Peritoneal Surface Malignancy

What Drives High Costs of Cytoreductive Surgery and HIPEC: Patient, Provider or Tumor?

Authors: Patrick B. Schwartz, MD, Christopher C. Stahl, MD, Kara A. Vande Walle, MD, Courtney J. Pokrzywa, MD, Linda M. Cherney Stafford, MPH, Taylor Aiken, MD, James Barrett, MD, Alexandra W. Acher, MD, Glen Leverson, PhD, Sean Ronnekleiv-Kelly, MD, Sharon M. Weber, MD, Daniel E. Abbott, MD

Published in: Annals of Surgical Oncology | Issue 13/2020

Abstract

Introduction

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is utilized for peritoneal malignancies and is associated with significant resource use. To address potentially modifiable factors contributing to excessive cost, we sought to determine predictors of high cost of care for patients undergoing CRS/HIPEC.

Methods

An institutional CRS/HIPEC database was queried for adult patients from 2014 to 2018. Cost was defined as cost for the index hospitalization, and high-cost cases were defined as > 75th percentile for cost. Bivariate analyses for cost were performed, and all significant tumor, patient, and surgeon-specific variables were entered in a linear regression for cost. A separate linear regression was performed for length of stay (LOS).

Results

In total, 59 patients underwent 61 CRS/HIPEC procedures. The median direct variable cost was $20,509 (16,395–25,240). Median length of stay (LOS) was 8 (7–11.5) days and ICU stay was 1 (1–1.5) day. LOS, length of ICU stay and operative time were predictive of cost. Factors associated with increased LOS were Clavien-Dindo grade II complications and ostomy creation. Patient-related factors, including age and BMI, tumor-related factors, such as PCI and CCR, and surgeon were not predictive of cost nor LOS.

Discussion

Our results, the first to identify predictors of high cost of CRS/HIPEC-related care in the US, reveal cost was largely related to length and intensity of care. In turn, these drivers were influenced by complications and operative factors. Future work will focus on identifying an appropriate ERAS protocol following CRS/HIPEC and selection of those patients that may avoid routine ICU admission.

Bushati M, Rovers KP, Sommariva A, et al. The current practice of cytoreductive surgery and HIPEC for colorectal peritoneal metastases: results of a worldwide web-based survey of the Peritoneal Surface Oncology Group International (PSOGI). Eur J Surg Oncol J Eur Soc Surg Oncol Br Assoc Surg Oncol. 2018;44(12):1942–1948. https://doi.org/10.1016/j.ejso.2018.07.003CrossRef

Eveno C, Pocard M. Randomized controlled trials evaluating cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in prevention and therapy of peritoneal metastasis: a systematic review. Pleura Peritoneum. 2016;1(4):169–182. https://doi.org/10.1515/pp-2016-0027CrossRefPubMed

Beal EW, Ahmed A, Grotz T, et al. Trends in the indications for and short-term outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Am J Surg. 2019. https://doi.org/10.1016/j.amjsurg.2019.09.017CrossRefPubMed

Sugarbaker PH, Ronnett BM, Archer A, et al. Pseudomyxoma peritonei syndrome. Adv Surg. 1996;30:233–280.PubMed

Naffouje SA, O’Donoghue C, Salti GI. Evaluation of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a community setting: a cost-utility analysis of a hospital’s initial experience and reflections on the health care system. J Surg Oncol. 2016;113(5):544–547. https://doi.org/10.1002/jso.24162CrossRefPubMed

Squires MH, Staley CA, Knechtle W, et al. Association between hospital finances, payer mix, and complications after hyperthermic intraperitoneal chemotherapy: deficiencies in the current healthcare reimbursement system and future implications. Ann Surg Oncol. 2015;22(5):1739–1745. https://doi.org/10.1245/s10434-014-4025-7CrossRefPubMed

Hinkle NM, MacDonald J, Sharpe JP, Dickson P, Deneve J, Munene G. Cytoreduction with hyperthermic intraperitoneal chemotherapy: an appraisal of outcomes and cost at a newly established peritoneal malignancy program. Am J Surg. 2016;212(3):413–418. https://doi.org/10.1016/j.amjsurg.2016.01.022CrossRefPubMed

Roudsari B, McWilliams J, Bresnahan B, Padia SA. Introduction to Cost Analysis in IR: Challenges and Opportunities. J Vasc Interv Radiol JVIR. 2016;27(4):539–545.e1. https://doi.org/10.1016/j.jvir.2015.12.754CrossRefPubMed

Taheri PA, Butz D, Griffes LC, Morlock DR, Greenfield LJ. Physician Impact on the Total Cost of Care. Ann Surg. 2000;231(3):432–435.CrossRef

10.

Dunn A, Grosse SD, Zuvekas SH. Adjusting Health Expenditures for Inflation: A Review of Measures for Health Services Research in the United States. Health Serv Res. 2018;53(1):175–196. https://doi.org/10.1111/1475-6773.12612CrossRefPubMed

11.

Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–213. https://doi.org/10.1097/01.sla.0000133083.54934.aeCrossRefPubMedPubMedCentral

12.

Hair JF, Risher JJ, Sarstedt M, Ringle CM. When to use and how to report the results of PLS-SEM. Eur Bus Rev. 2019;31(1):2–24. https://doi.org/10.1108/ebr-11-2018-0203CrossRef

13.

Lee ZJ, Teo CCM. ASO Author Reflections: Cost Effectiveness of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC). Ann Surg Oncol. 2018;25(Suppl 3):757–758. https://doi.org/10.1245/s10434-018-6967-7CrossRefPubMed

14.

Tentes AA, Pallas N, Korakianitis O, et al. The cost of cytoreductive surgery and perioperative intraperitoneal chemotherapy in the treatment of peritoneal malignancy in one Greek institute. J BUON Off J Balk Union Oncol. 2012;17(4):776–780.

15.

Chua TC, Martin S, Saxena A, et al. Evaluation of the cost-effectiveness of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (peritonectomy) at the St George Hospital peritoneal surface malignancy program. Ann Surg. 2010;251(2):323–329. https://doi.org/10.1097/sla.0b013e3181c9b53cCrossRefPubMed

16.

Stiles ZE, Hinkle NM, Munene G, Dickson PV, Davidoff AM, Deneve JL. The Impact of Ostomy Creation after Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy in a Newly Established Peritoneal Malignancy Program. Am Surg. 2018;84(6):776–782.CrossRef

17.

Pakraftar S, Ramalingam L, Shuai Y, et al. Institutional Experience with Ostomies Created During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemoperfusion. Ann Surg Oncol. 2017;24(13):3811–3817. https://doi.org/10.1245/s10434-017-6114-xCrossRefPubMed

18.

Kelly KJ, Cajas L, Baumgartner JM, Lowy AM. Factors Associated with 60-Day Readmission Following Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol. 2018;25(1):91–97. https://doi.org/10.1245/s10434-017-6108-8CrossRefPubMed

19.

Lee TC, Wima K, Sussman JJ, et al. Readmissions After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: a US HIPEC Collaborative Study. J Gastrointest Surg Off J Soc Surg Aliment Tract. 2019. https://doi.org/10.1007/s11605-019-04463-yCrossRef

20.

Whealon MD, Gahagan JV, Sujatha-Bhaskar S, et al. Is Fecal Diversion Needed in Pelvic Anastomoses During Hyperthermic Intraperitoneal Chemotherapy (HIPEC)? Ann Surg Oncol. 2017;24(8):2122–2128. https://doi.org/10.1245/s10434-017-5853-zCrossRefPubMed

21.

Lu PW, Fields AC, Shabat G, et al. Cytoreductive Surgery and HIPEC in an Enhanced Recovery After Surgery Program: A Feasibility Study. J Surg Res. 2019. https://doi.org/10.1016/j.jss.2019.10.042CrossRefPubMed

22.

Webb C, Day R, Velazco CS, et al. Implementation of an Enhanced Recovery After Surgery (ERAS) Program is Associated with Improved Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol. 2020;27(1):303–312. https://doi.org/10.1245/s10434-019-07900-zCrossRefPubMed

23.

Siddharthan R, Dewey E, Billingsley K, Gilbert E, Tsikitis VL. Feasibility and benefits of an enhanced recovery after surgery protocol for patients undergoing cytoreductive surgery and heated intraperitoneal chemotharpy: a single institution experience. Am J Surg. 2019. https://doi.org/10.1016/j.amjsurg.2019.06.019CrossRefPubMed

24.

Mogal HD, Levine EA, Fino NF, et al. Routine Admission to Intensive Care Unit After Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy: Not Always a Requirement. Ann Surg Oncol. 2016;23(5):1486–1495. https://doi.org/10.1245/s10434-015-4963-8CrossRefPubMed

Title: What Drives High Costs of Cytoreductive Surgery and HIPEC: Patient, Provider or Tumor?
Authors: Patrick B. Schwartz, MD
Christopher C. Stahl, MD
Kara A. Vande Walle, MD
Courtney J. Pokrzywa, MD
Linda M. Cherney Stafford, MPH
Taylor Aiken, MD
James Barrett, MD
Alexandra W. Acher, MD
Glen Leverson, PhD
Sean Ronnekleiv-Kelly, MD
Sharon M. Weber, MD
Daniel E. Abbott, MD
Publication date: 01-12-2020
Publisher: Springer International Publishing
Keyword: Surgery
Published in: Annals of Surgical Oncology / Issue 13/2020
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-020-08583-7

ACC 2024 Congress

Springer Medicine

What Drives High Costs of Cytoreductive Surgery and HIPEC: Patient, Provider or Tumor?

Abstract

Introduction

Methods

Results

Discussion

ACC 2024 Congress

Springer Medicine

Abstract

Introduction

Methods

Results

Discussion

Please log in to get access to this content

Other articles of this Issue 13/2020

ASO Author Reflections: Fluorescent-Image Guidance in Surgical Oncology

Implications of Postoperative Complications for Survival After Cytoreductive Surgery and HIPEC: A Multi-Institutional Analysis of the US HIPEC Collaborative

Indocyanine Green Compression Technique for Anatomical S8 Dorsal Subsegmentectomy for Hepatocellular Carcinoma

Sentinel Lymph Node Biopsy for T1b Melanoma: Balancing Prognostic Value and Cost

Peritoneal Cell-Free Tumor DNA as Biomarker for Peritoneal Surface Malignancies

ASO Author Reflections: Real-World Incidence of Peritoneal Carcinomatosis After Colon Cancer Resection and Why It Matters