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Original Investigation |

Effect of Laparoscopic Surgery on Health Care Utilization and Costs in Patients Who Undergo Colectomy FREE

Benjamin P. Crawshaw, MD1; Hung-Lun Chien, MPH2; Knut M. Augestad, MD, PhD1,3; Conor P. Delaney, MD, PhD1
[+] Author Affiliations
1Department of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
2Data and Analytic Resources, Covidien, Mansfield, Massachusetts
3Department of Gastrointestinal Surgery, University Hospital of North Norway, Tromsø, Norway
JAMA Surg. 2015;150(5):410-415. doi:10.1001/jamasurg.2014.3171.
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Published online

Importance  Laparoscopic colectomy is safe and effective in the treatment of many colorectal diseases. However, the effect of increasing use of laparoscopy on overall health care utilization and costs, especially in the long term, has not been thoroughly investigated.

Objective  To evaluate the effect of laparoscopic vs open colectomy on short- and long-term health care utilization and costs.

Design, Setting, and Participants  Retrospective multivariate regression analysis of national health insurance claims data was used to evaluate health care utilization and costs up to 1 year following elective colectomy. Data were obtained from the Truven Health Analytics MarketScan Commercial Claims and Encounters database. Patients aged 18 to 64 years who underwent elective laparoscopic or open colectomy from January 1, 2010, through December 31, 2010, were included. Patients with complex diagnoses that require increased non–surgery-related health care utilization, including malignant neoplasm, inflammatory bowel disease, human immunodeficiency virus, transplantation, and pregnancy, were excluded. Of 25 481 patients who underwent colectomy, 4160 were included in the study.

Main Outcomes and Measures  Healthcare utilization, including office, hospital outpatient, and emergency department visits and inpatient services 90 and 365 days after the index procedure; total health care costs; and estimated days off from work owing to health care utilization.

Results  Of 25 481 patients who underwent colectomy, 4160 were included in the study (laparoscopic, 45.6%; open, 54.4%). The mean (SD) net and total payments were lower for laparoscopy ($23 064 [$14 558] and $24 196 [$14 507] vs $29 753 [$21 421] and $31 606 [$23 586]). In the first 90 days after surgery, an open approach was significantly associated with a 1.26-fold increase in health care costs (estimated, $1715; 95% CI, $338-$2853), increased use of heath care services, and more estimated days off from work (2.78 days; 95% CI, 1.93-3.59). Similar trends were found in the full postoperative year, with an estimated 1.18-fold increase (95% CI, 1.04-1.35) in health care expenditures and an increase of 1.15 times (95% CI, 1.08-1.23) the number of health care utilization days compared with laparoscopy.

Conclusions and Relevance  Laparoscopic colectomy results in a significant reduction in health care costs and utilization in the short- and long-term postoperative periods.

Figures in this Article

Laparoscopy continues to become the preferred approach for an increasing number of colorectal operations. While laparoscopic approaches represented less than 2% of all colorectal surgical procedures in 2003, by 2009, its use rose to nearly 30% of all cases.1 Multiple studies26 have demonstrated the clinical benefits of laparoscopy, including decreased complications, mortality, and rates of readmission as well as shorter postoperative lengths of stay and decreased need for skilled nursing care.

As laparoscopic approaches replace the traditional open approach for many operations, the economic effects of the new technology have been examined. New technology often carries with it an increase in costs, both in the form of initial expenses as the technology is purchased and per case as new tools and techniques are required.7 Early financial analysis of laparoscopic colectomy has demonstrated this scenario to be true, with mean total costs of approximately $400 more for laparoscopic than open cases.2 This increase in up-front costs, however, is offset by decreases in length of stay, complications, readmissions, and mortality, each of which can carry significant financial consequences.8 In addition, a recent systemic review9 showed that, as experience with laparoscopy has increased, there has been a trend toward overall improved cost-effectiveness compared with open surgery. While these short-term outcomes are significant, there has been little research into the long-term effects of laparoscopy on health care resource utilization beyond the immediate postoperative period. A recent study10 demonstrated that laparoscopy, including laparoscopic and endovascular approaches for coronary revascularization, uterine fibroid resection, prostatectomy, and peripheral revascularization, was associated with significantly decreased workplace absenteeism in the year after surgery.

To our knowledge, analysis of the long-term health care utilization effects of laparoscopy has not been conducted for colectomy. In this study, we aimed to examine the short- (90 days after surgery) and long-term (365 days after surgery) utilization and costs of health care resources after laparoscopic compared with open colectomy.

Data Source

Data for this study were obtained from the Truven Health Analytics MarketScan Commercial Claims and Encounters Database. This commercial database contains the enrollment and health care (medical and drug) claims of millions of employees and their dependents who are covered annually under a variety of health care plans offered by medium- and large-sized firms. Specifically, this commercial database includes inpatient, outpatient, and emergency department encounters, as well as outpatient prescription drug claims, linked by a unique patient identifier. The commercial database contains deidentified claims data for enrollees from more than 300 self-insured employers (employers who provide health insurance to their employees), 25 health care plans, and 350 unique insurance carriers in the United States since 1995. The data conformed to the Health Insurance Portability and Accountability Act of 1996 confidentiality requirements, so neither informed consent nor institutional review board approval were required by University Hospitals Case Medical Center for this study.

Study Population

All adults aged 18 to 64 years with a primary procedure code (using the International Classification of Diseases, Clinical Modification, Ninth Edition and Current Procedural Terminology surgical codes) for elective laparoscopic and open colectomy procedures with a related diagnosis from January 1, 2010, through December 31, 2010, were selected (eTable 1 in the Supplement). We selected the first colectomy inpatient service in 2010 as the index hospitalization. Patients with less than 2 years of continuous health insurance enrollment, with 1 year before and 1 year after the index surgery date, were excluded. Payment outliers were set as the first percentile on each end of the data spectrum and were excluded from analysis (<$1000 or >$180 000). To measure the association between health care utilization and laparoscopic and open surgery, we also excluded patients with complicated conditions that may confound the results, including primary malignant neoplasm, secondary malignant neoplasm, inflammatory bowel disease, end-stage renal disease, pregnancy, transplantation, and human immunodeficiency virus, during the 2-year study period (eTable 2 in the Supplement). Procedures that were converted from laparoscopy to open surgery were included in the open study group.

Main Outcome Measures

Our study included 3 main outcomes: (1) health care utilization, including office, hospital outpatient, and emergency department visits and inpatient services 90 and 365 days after the index procedure; (2) health care expenditures; and (3) estimated days off from work owing to health care utilization. The health care expenditures included claim payments to facilities as well as to physicians. For days off from work owing to health care utilization, 1 half day was estimated if a patient had a claim for an office visit or laboratory test. One full day was estimated for a claim for an outpatient, emergency department, urgent care, or ambulatory surgical visit. For inpatient service claims, the length of stay was converted directly to days of utilization.

Statistical Analysis

We used a difference-in-difference approach to adjust patients’ prior health care utilization. Outcomes were modeled using a generalized linear model. Correlation between individuals was adjusted using the generalized estimating equation. Office visits, outpatient visits, and days of health care utilization were modeled using negative binominal distribution. Expenditures were estimated with γ distribution. Emergency department and inpatient service were modeled only in the postoperative period using logit link and binomial distribution. Independent variables in the regression model included age, sex, region, procedure type, Charlson Comorbidity Index score, index hospital expenditure, index hospital length of stay, conversion from laparoscopy to open surgery, and comorbidities.

A total of 25 481 patients were identified as having received colectomy procedures from January 1, 2010, through December 31, 2010. After applying the population selection process (Figure), 4160 patients were included in our study. Of these, 1895 (45.6%) received laparoscopy and 2265 (54.4%) received an open procedure. Table 1 shows the demographic and clinical characteristics of patients who underwent laparoscopic and open surgery. The mean ages were 50.6 and 50.8 years, and 52.2% and 52.0% were male in the laparoscopy and open surgery groups, respectively. The major diagnoses were diverticulitis, colitis, and disorders of the intestine. Table 1 also demonstrates the length of stay, total net payment, and total payment for the index hospital encounter between open surgery and laparoscopy. The mean (SD) length of stay for open and laparoscopic procedures was 7.36 (4.85) days and 4.48 (2.95) days, respectively. The mean (SD) net and total payments were $23 064 ($14 558) and $24 196 ($14 507) for laparoscopy and $29 753 ($21 421) and $31 601 ($23 586) for open surgery.

Place holder to copy figure label and caption
Figure.
Patient Selection Process

aUsing 2009-2011 Truven Health Analytics MarketScan Commercial Claims and Encounters database. Patients were selected using International Classification of Diseases, Clinical Modification, Ninth Edition procedure and diagnosis codes.

bDefined using Prometheus and Agency for Healthcare Research and Quality Clinical Classification Software definitions.

cDiagnoses included stoma, inflammatory bowel disease, intestinal obstruction, acute vascular insufficiency of the intestine, and intra-abdominal injury.

dLess than 1% and greater than 99% distribution in payment data.

Graphic Jump Location
Table Graphic Jump LocationTable 1.  Patient Characteristics for Laparoscopic and Open Colectomy Proceduresa

For unadjusted health care utilization in the first 90 days after surgery (Table 2), patients who underwent open surgery used significantly more heath care services than those in the laparoscopy group except for emergency department visits. Most notably, the mean preoperative health care expenditures were similar between the laparoscopy and open surgery groups ($7040 vs $7441), but a significant difference of $3695 was seen in expenditures in the first 90 days after surgery ($4176 vs $8272). After adjustment (Table 3), open surgery was significantly associated with a 1.32-fold (95% CI, 1.20-1.45) increase in days off from work for health care utilization (mean, 2.78 days; 95% CI, 1.93-3.59) compared with laparoscopy. In addition, patients who underwent open surgery also had significantly higher health care expenditures in the postsurgery period than those who underwent laparoscopy. The estimated difference was 1.26 times (95% CI, 1.04-1.53), or $1715 (95% CI, $338-$2853) by estimation with γ distribution.

Table Graphic Jump LocationTable 2.  Unadjusted Utilization 90 Days Before and After Surgery
Table Graphic Jump LocationTable 3.  Adjusted Utilization After 90 and 365 Days

Similar results were found in health care utilization when examining the entire year before and after surgery (Table 4). Mean 1-year preoperative and postoperative health care expenditures were higher between patients who underwent laparoscopic and open surgery; however, while the preoperative difference was $4238, the postoperative difference was $9879, with a $5640 difference-in-difference based on the operative approach. In addition, patients who underwent open surgery had higher numbers of emergency department, inpatient, and outpatient visits, longer lengths of stay (when readmitted), and a greater number of days off from work than those in the laparoscopy group. After adjustment (Table 3), the differences in health care utilization persisted. Patients who underwent open surgery showed an increase of 1.15 times (95% CI, 1.08-1.23) the number of health care utilization days compared with those who underwent laparoscopy. In addition, open procedures were also associated with higher health care and drug expenditures than laparoscopy in the postsurgery period. Health care expenditures increased 1.18 times (95% CI, 1.04-1.35) and drug expenditures 1.13 times (95% CI, 1.01-1.27).

Table Graphic Jump LocationTable 4.  Utilization 365 Days Before and After Surgery

This study shows that the use of laparoscopy in a select group of colectomies results in significantly decreased health care costs and resource utilization compared with open approaches in both the short- and long-term postoperative periods. We found a significant difference in the index hospitalization costs between laparoscopic and open cases ($24 196 vs $31 601), which is in agreement with the trend seen in a recent systemic review.9 In addition, in both the initial 3 months and the first year after surgery, patients who underwent laparoscopic procedures were significantly more likely to require fewer days of health care utilization and spend less on their overall health care and drug expenses. These results likely reflect the well-documented benefits of laparoscopy, which include faster recovery, less pain, and fewer complications.11

The economic effect of laparoscopic colectomy on health care is strong—the reduction in initial hospital costs, combined with decreased postoperative utilization, represents a significant decrease in overall health care spending related to the operation. In addition, with significantly fewer days required for health care utilization in the laparoscopic group, patients are less likely to miss days of work, further strengthening the economic effect and improving quality of life.

In an attempt to isolate the benefit of a laparoscopic approach, we have selected a specific subset of patients who underwent colectomy by excluding patients with diseases that could confound our outcome variables. First, we excluded patients with emergency and complicated diseases, such as inflammatory bowel disease, that inherently require higher health care utilization before and after surgery owing to their chronic and often multidisciplinary nature. Similarly, cancer cases were excluded because the need for extensive preoperative and postoperative imaging and other testing, as well as the potential for preoperative radiation and postoperative chemotherapy, would lead to a disease-specific increase in health care utilization requirements. This approach gave us a population of elective, benign colectomies that we believed would be the least confounded to identify a difference in health care utilization based solely on an open vs minimally invasive approach. While there is potential for selection bias in our results, we believe that the effects on health care utilization demonstrated here are likely most representative of the effects of laparoscopic vs open approaches on the colectomy population.

Procedures that were converted from a laparoscopic to open approach were included in the open study group to show the importance of completing a case laparoscopically. The analysis was repeated with conversions included in the laparoscopy group on an intention-to-treat basis with no change in results.

Our study design has several limitations. It is not possible to evaluate clinical outcomes from this data set. The relative underrepresentation of the western region is an inherent limitation of the database. Our data are based on insurance claims and therefore may not truly reflect clinical data or outcomes. Similarly, we were unable to account for variations between insurance carriers, which may have affected our results. It is not possible to ensure that all subsequent health care utilization after surgery was related to, or the result of, the surgery itself and not an unrelated issue. In addition, the retrospective nature of this study does not take into account differences in patients who underwent laparoscopic vs open procedures. Minimally invasive procedures are clearly inappropriate for some patients, often because of other comorbidities. We have attempted to correct for this selection bias in our multivariate analysis using comorbidities and the Charlson Comorbidity Index; however, the fact that patients who undergo open procedures are often sicker than those who undergo the same operation laparoscopically may artificially increase the observed postoperative health care utilization.12 Finally, our estimation of days of health care utilization may not accurately reflect the true requirements for patients because we cannot account for variables that may vary the time required for included claims.

Laparoscopic colectomy results in a significant reduction in health care costs and utilization in the short- and long-term postoperative periods. There is significant potential for health care cost savings and improved patient quality of life in the form of fewer days required for health care visits as laparoscopy continues to expand within the field of colorectal surgery.

Accepted for Publication: August 25, 2015.

Corresponding Author: Benjamin P. Crawshaw, MD, Department of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Ave, Cleveland, OH 44106 (benjamin.crawshaw@uhhospitals.org).

Published Online: March 25, 2015. doi:10.1001/jamasurg.2014.3171.

Author Contributions: Mr Chien had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Crawshaw, Chien, Delaney.

Acquisition, analysis, or interpretation of data: Crawshaw, Chien, Augestad.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Chien.

Obtaining funding: Delaney.

Administrative, technical, or material support: Chien, Delaney.

Study supervision: Augestad, Delaney.

Conflict of Interest Disclosures: Mr Chien reports being an employee of Covidien. No other disclosures were reported.

Funding/Support:Covidien provided funding for data downloaded for this study as well as unrestricted statistical support. Funding for the collection, management, analysis, and interpretation of the data for this study was provided by Covidien.

Role of the Funder/Sponsor: Covidien had no role in the preparation, review, or approval of the manuscript and in the decision to submit the manuscript for publication.

Additional Contributions: Lobat Hashemi, MS, Michael Morseon, MBA, and Santosh Agarwal, BPharm, MS, Covidien, provided support in data collection and analysis.

Peterson  CY, Palazzi  K, Parsons  JK, Chang  DC, Ramamoorthy  SL.  The prevalence of laparoscopy and patient safety outcomes: an analysis of colorectal resections. Surg Endosc. 2014;28(2):608-616.
PubMed   |  Link to Article
Delaney  CP, Kiran  RP, Senagore  AJ, Brady  K, Fazio  VW.  Case-matched comparison of clinical and financial outcome after laparoscopic or open colorectal surgery. Ann Surg. 2003;238(1):67-72.
PubMed
Delaney  CP, Chang  E, Senagore  AJ, Broder  M.  Clinical outcomes and resource utilization associated with laparoscopic and open colectomy using a large national database. Ann Surg. 2008;247(5):819-824.
PubMed   |  Link to Article
Kang  CY, Chaudhry  OO, Halabi  WJ,  et al.  Outcomes of laparoscopic colorectal surgery: data from the Nationwide Inpatient Sample 2009. Am J Surg. 2012;204(6):952-957.
PubMed   |  Link to Article
Kiran  RP, Delaney  CP, Senagore  AJ, Steel  M, Garafalo  T, Fazio  VW.  Outcomes and prediction of hospital readmission after intestinal surgery. J Am Coll Surg. 2004;198(6):877-883.
PubMed   |  Link to Article
Senagore  AJ, Stulberg  JJ, Byrnes  J, Delaney  CP.  A national comparison of laparoscopic vs. open colectomy using the National Surgical Quality Improvement Project data. Dis Colon Rectum. 2009;52(2):183-186.
PubMed   |  Link to Article
Barbash  GI, Glied  SA.  New technology and health care costs: the case of robot-assisted surgery. N Engl J Med. 2010;363(8):701-704.
PubMed   |  Link to Article
Dimick  JB, Chen  SL, Taheri  PA, Henderson  WG, Khuri  SF, Campbell  DAJ  Jr.  Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199(4):531-537.
PubMed   |  Link to Article
Aly  OE, Quayyum  Z.  Has laparoscopic colorectal surgery become more cost-effective over time? Int J Colorectal Dis. 2012;27(7):855-860.
PubMed   |  Link to Article
Epstein  AJ, Groeneveld  PW, Harhay  MO, Yang  F, Polsky  D.  Impact of minimally invasive surgery on medical spending and employee absenteeism. JAMA Surg. 2013;148(7):641-647.
PubMed   |  Link to Article
Schwenk  W, Haase  O, Neudecker  J, Müller  JM.  Short term benefits for laparoscopic colorectal resection. Cochrane Database Syst Rev. 2005;(3):CD003145.
PubMed
Dimick  JB, Ryan  AM.  Taking a broader perspective on the benefits of minimally invasive surgery. JAMA Surg. 2013;148(7):648.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Patient Selection Process

aUsing 2009-2011 Truven Health Analytics MarketScan Commercial Claims and Encounters database. Patients were selected using International Classification of Diseases, Clinical Modification, Ninth Edition procedure and diagnosis codes.

bDefined using Prometheus and Agency for Healthcare Research and Quality Clinical Classification Software definitions.

cDiagnoses included stoma, inflammatory bowel disease, intestinal obstruction, acute vascular insufficiency of the intestine, and intra-abdominal injury.

dLess than 1% and greater than 99% distribution in payment data.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1.  Patient Characteristics for Laparoscopic and Open Colectomy Proceduresa
Table Graphic Jump LocationTable 2.  Unadjusted Utilization 90 Days Before and After Surgery
Table Graphic Jump LocationTable 3.  Adjusted Utilization After 90 and 365 Days
Table Graphic Jump LocationTable 4.  Utilization 365 Days Before and After Surgery

References

Peterson  CY, Palazzi  K, Parsons  JK, Chang  DC, Ramamoorthy  SL.  The prevalence of laparoscopy and patient safety outcomes: an analysis of colorectal resections. Surg Endosc. 2014;28(2):608-616.
PubMed   |  Link to Article
Delaney  CP, Kiran  RP, Senagore  AJ, Brady  K, Fazio  VW.  Case-matched comparison of clinical and financial outcome after laparoscopic or open colorectal surgery. Ann Surg. 2003;238(1):67-72.
PubMed
Delaney  CP, Chang  E, Senagore  AJ, Broder  M.  Clinical outcomes and resource utilization associated with laparoscopic and open colectomy using a large national database. Ann Surg. 2008;247(5):819-824.
PubMed   |  Link to Article
Kang  CY, Chaudhry  OO, Halabi  WJ,  et al.  Outcomes of laparoscopic colorectal surgery: data from the Nationwide Inpatient Sample 2009. Am J Surg. 2012;204(6):952-957.
PubMed   |  Link to Article
Kiran  RP, Delaney  CP, Senagore  AJ, Steel  M, Garafalo  T, Fazio  VW.  Outcomes and prediction of hospital readmission after intestinal surgery. J Am Coll Surg. 2004;198(6):877-883.
PubMed   |  Link to Article
Senagore  AJ, Stulberg  JJ, Byrnes  J, Delaney  CP.  A national comparison of laparoscopic vs. open colectomy using the National Surgical Quality Improvement Project data. Dis Colon Rectum. 2009;52(2):183-186.
PubMed   |  Link to Article
Barbash  GI, Glied  SA.  New technology and health care costs: the case of robot-assisted surgery. N Engl J Med. 2010;363(8):701-704.
PubMed   |  Link to Article
Dimick  JB, Chen  SL, Taheri  PA, Henderson  WG, Khuri  SF, Campbell  DAJ  Jr.  Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199(4):531-537.
PubMed   |  Link to Article
Aly  OE, Quayyum  Z.  Has laparoscopic colorectal surgery become more cost-effective over time? Int J Colorectal Dis. 2012;27(7):855-860.
PubMed   |  Link to Article
Epstein  AJ, Groeneveld  PW, Harhay  MO, Yang  F, Polsky  D.  Impact of minimally invasive surgery on medical spending and employee absenteeism. JAMA Surg. 2013;148(7):641-647.
PubMed   |  Link to Article
Schwenk  W, Haase  O, Neudecker  J, Müller  JM.  Short term benefits for laparoscopic colorectal resection. Cochrane Database Syst Rev. 2005;(3):CD003145.
PubMed
Dimick  JB, Ryan  AM.  Taking a broader perspective on the benefits of minimally invasive surgery. JAMA Surg. 2013;148(7):648.
PubMed   |  Link to Article

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