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Original Investigation | Pacific Coast Surgical Association

Outcomes of Pancreaticoduodenectomy:  Where Should We Focus Our Efforts on Improving Outcomes?

Erin G. Brown, MD1; Anthony Yang, MD1; Robert J. Canter, MD1; Richard J. Bold, MD1
[+] Author Affiliations
1Division of Surgical Oncology, University of California Davis Comprehensive Cancer Center, Sacramento
JAMA Surg. 2014;149(7):694-699. doi:10.1001/jamasurg.2014.151.
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Importance  Changes in health care reimbursement policy have led to an era in which hospitals are motivated to improve quality of care while simultaneously reducing costs. Research demonstrating the most efficient means to target costs may have a positive effect on patient quality of life and the overburdened health care system.

Objective  To evaluate the effect of hospital length of stay (LOS) and the occurrence of postoperative complications on total charges in patients undergoing elective pancreaticoduodenectomy.

Design, Setting, and Patients  We performed a retrospective review of 89 cases identified in an institutional database of patients who underwent elective pancreaticoduodenectomy at an academic tertiary care center from December 1, 2007, through May 31, 2012.

Main Outcomes and Measures  Occurrence of postoperative and inpatient complications, LOS, incidence of readmission within 60 days of discharge, and hospital charges from initial postoperative hospitalization. Linear regression analysis was performed comparing LOS with hospital charges.

Results  Thirty-four of 89 patients (38%) developed postoperative complications. Mean and median LOSs were 12 and 8 days, respectively. The LOS was significantly related to postoperative complications. Of the 34 patients who developed complications, the mean LOS was 19 days compared with 7 days for those patients not developing complications (P < .001). Only 2 of 55 patients (4%) without complications were readmitted to the hospital, whereas 13 of 34 patients (38%) with complications required readmission. Perioperative hospital charges were significantly related to LOS (R2 = 0.840, R = 0.917). For those patients without complications, linear regression demonstrated a daily hospital charge of $11 612 (R2 = 0.923, R = 0.961). However, for those patients with complications, the optimal relationship between LOS and hospital charges was exponential (R2 = 0.832).

Conclusions and Relevance  Prolonged LOS is associated with increased total charges, but given the exponential increase in charges, the complication itself has an effect on increased charges above and beyond that of a prolonged hospitalization. The drive to reduce LOS after pancreaticoduodenectomy has minimal effect on overall charges to the patient. Efforts should be directed instead at reducing complications because this has a much more significant effect on financial outcomes.

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Figure 1.
Proportion of Patients Remaining Inpatients in Relation to Hospital Length of Stay for Those With No Complications Compared With the 3 Most Common Complications

The curves reveal similar time to discharge for patients without complications and with infection and delayed gastric emptying, whereas the curve for patients with pancreatic leak reveals longer time to discharge.

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Figure 2.
Regression of Length of Stay (LOS) vs Charges in All Patients

Linear regression analysis was performed to determine the relationship between hospital charges and LOS for all 89 patients. Hospital charges for all patients were significantly related to LOS (R2 = 0.840, R = 0.917).

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Figure 3.
Regression of Length of Stay (LOS) vs Charges in Patients With and Without Complications

A, Linear regression analysis was performed to determine the relationship between hospital charges and LOS in patients without complications and demonstrated a linear relationship with a rate of $11 612 per day (R2 = 0.923, R = 0.961). B, Linear regression analysis was performed to determine the relationship between hospital charges and LOS in patients with complications and demonstrated an exponential relationship (R2 = 0.832).

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