Abstract
Background
Although centralization of complex surgical procedures such as pancreaticoduodenectomies is associated with a reduction in morbidity and mortality rates, it is unclear whether such surgeries are adequately represented in the German disease-related group (DRG) system.
Patients and methods
Out of all patients who underwent pancreatic resections (n = 450) at our institution between January 2008 and November 2011, 76 patients who underwent a pylorus-preserving pancreatic head resection due to pancreatic head adenocarcinoma were selected for analysis. The revenues generated by these surgical procedures were compared with those of 144 patients who had undergone elective laparoscopic cholecystectomies for symptomatic gallstone disease between January 2009 and September 2010 in our hospital.
Results
In patients undergoing pylorus-preserving pancreaticoduodenectomy, revenues per case were 1,585.55 Euros, with an average length of hospital stay (ALOS) of 19.9 days (range 7–55 days) and an average postoperative hospital stay of 16 days; however, if the ALOS was exceeded, expenditures increasingly exceeded returns. Analysis of the cohort of patients with pylorus-preserving pancreaticoduodenectomies demonstrated average revenues per day of 79.27 Euros. In contrast, for laparoscopic cholecystectomy, which was treated with high surgical standardization and stringent case management, the ALOS was only 2.8 days, producing average revenues of 288.80 Euros per day and total revenues of 817.53 Euros per case.
Conclusion
At university hospitals, cost-effective realization of major pancreatic surgery is difficult, while highly standardized surgeries such as laparoscopic cholecystectomies can be performed at a favorable balance. This may be due to, firstly, an underrepresentation of university hospitals in the German DRG calculation basis and, secondly, to a relatively long preoperative hospital stay as a result of extensive diagnostic measures. We consider this kind of preoperative assessment paramount for an academic pancreatic center and thus argue for an increased reimbursement for these procedures.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Birkmeyer JD, Finlayson SR, Tosteson AN, Sharp SM, Warshaw AL, Fisher ES (1999) Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy. Surgery 125(3):250–256
Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE (2002) Hospital volume and surgical mortality in the United States. N Engl J Med 346(15):1128–1137. doi:10.1056/NEJMsa012337-346/15/1128
Birkmeyer JD, Warshaw AL, Finlayson SR, Grove MR, Tosteson AN (1999) Relationship between hospital volume and late survival after pancreaticoduodenectomy. Surgery 126(2):178–183
van Heek NT, Kuhlmann KF, Scholten RJ, de Castro SM, Busch OR, van Gulik TM, Obertop H, Gouma DJ (2005) Hospital volume and mortality after pancreatic resection: a systematic review and an evaluation of intervention in the Netherlands. Ann Surg 242(6):781–788, discussion 788–790
Topal B, Van de Sande S, Fieuws S, Penninckx F (2007) Effect of centralization of pancreaticoduodenectomy on nationwide hospital mortality and length of stay. Br J Surg 94(11):1377–1381. doi:10.1002/bjs.5861
Finks JF, Osborne NH, Birkmeyer JD (2011) Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 364(22):2128–2137. doi:10.1056/NEJMsa1010705
Gooiker GA, van der Geest LG, Wouters MW, Vonk M, Karsten TM, Tollenaar RA, Bonsing BA (2011) Quality improvement of pancreatic surgery by centralization in the western part of the Netherlands. Ann Surg Oncol 18(7):1821–1829. doi:10.1245/s10434-010-1511-4
Eppsteiner RW, Csikesz NG, McPhee JT, Tseng JF, Shah SA (2009) Surgeon volume impacts hospital mortality for pancreatic resection. Ann Surg 249(4):635–640. doi:10.1097/SLA.0b013e31819ed958
Samra JS, Bachmann RA, Choi J, Gill A, Neale M, Puttaswamy V, Bell C, Norton I, Cho S, Blome S, Maher R, Gananadha S, Hugh TJ (2011) One hundred and seventy-eight consecutive pancreatoduodenectomies without mortality: role of the multidisciplinary approach. Hepatobiliary Pancreat Dis Int 10(4):415–421
Cameron JL, Riall TS, Coleman J, Belcher KA (2006) One thousand consecutive pancreaticoduodenectomies. Ann Surg 244(1):10–15, doi:10.1097/01.sla.0000217673.04165.ea
Hartwig W, Hackert T, Hinz U, Gluth A, Bergmann F, Strobel O, Buchler MW, Werner J (2011) Pancreatic cancer surgery in the new millennium: better prediction of outcome. Ann Surg 254(2):311–319. doi:10.1097/SLA.0b013e31821fd334
Balzano G, Zerbi A, Capretti G, Rocchetti S, Capitanio V, Di Carlo V (2008) Effect of hospital volume on outcome of pancreaticoduodenectomy in Italy. Br J Surg 95(3):357–362. doi:10.1002/bjs.5982
Berberat PO, Ingold H, Gulbinas A, Kleeff J, Muller MW, Gutt C, Weigand M, Friess H, Buchler MW (2007) Fast track–different implications in pancreatic surgery. J Gastrointest Surg 11(7):880–887. doi:10.1007/s11605-007-0167-2
di Sebastiano P, Festa L, De Bonis A, Ciuffreda A, Valvano MR, Andriulli A, di Mola FF (2011) A modified fast-track program for pancreatic surgery: a prospective single-center experience. Langenbecks Arch Surg 396(3):345–351. doi:10.1007/s00423-010-0707-1
French JJ, Mansfield SD, Jaques K, Jaques BC, Manas DM, Charnley RM (2009) Fast-track management of patients undergoing proximal pancreatic resection. Ann R Coll Surg Engl 91(3):201–204. doi:10.1308/003588409X391893
Nienhuijs SW, Rutten HJ, Luiten EJ, van Driel OJ, Reemst PH, Lemmens VE, de Hingh IH (2010) Reduction of in-hospital mortality following regionalisation of pancreatic surgery in the south-east of the Netherlands. EUR J Surg Oncol 36(7):652–656. doi:10.1016/j.ejso.2010.05.008
Lemmens VE, Bosscha K, van der Schelling G, Brenninkmeijer S, Coebergh JW, de Hingh IH (2011) Improving outcome for patients with pancreatic cancer through centralization. Br J Surg 98(10):1455–1462. doi:10.1002/bjs.7581
de Wilde RF, Besselink MG, van der Tweel I, de Hingh IH, van Eijck CH, Dejong CH, Porte RJ, Gouma DJ, Busch OR, Molenaar IQ (2012) Impact of nationwide centralization of pancreaticoduodenectomy on hospital mortality. Br J Surg 99(3):404–410. doi:10.1002/bjs.8664
Ljungman D, Lundholm K, Hyltander A (2011) Cost-utility estimation of surgical treatment of pancreatic carcinoma aimed at cure. World J Surg 35(3):662–670. doi:10.1007/s00268-010-0883-8
Hjelmgren J, Ceberg J, Persson U, Alvegard TA (2003) The cost of treating pancreatic cancer—a cohort study based on patients records from four hospitals in Sweden. Acta Oncol 42(3):218–226
Du W, Touchette D, Vaitkevicius VK, Peters WP, Shields AF (2000) Cost analysis of pancreatic carcinoma treatment. Cancer 89(9):1917–1924
Elixhauser A, Halpern MT (1999) Economic evaluations of gastric and pancreatic cancer. Hepatogastroenterology 46(26):1206–1213
Muller-Nordhorn J, Bruggenjurgen B, Bohmig M, Selim D, Reich A, Noesselt L, Roll S, Wiedenmann B, Willich SN (2005) Direct and indirect costs in a prospective cohort of patients with pancreatic cancer. Aliment Pharmacol Ther 22(5):405–415. doi:10.1111/j.1365-2036.2005.02570.x
Tingstedt B, Andersson E, Flink A, Bolin K, Lindgren B, Andersson R (2011) Pancreatic cancer, healthcare cost, and loss of productivity: a register-based approach. World J Surg 35(10):2298–2305. doi:10.1007/s00268-011-1208-2
InEK Das deutsche DRG-System (2007). http://www.g-drg.de/cms/
Gurusamy KS, Junnarkar S, Farouk M, Davidson BR. (2008) Day-case versus overnight stay in laparoscopic cholecystectomy. Cochrane Database Syst Rev (1):CD006798. doi:10.1002/14651858.CD006798.pub2
Abbott DE, Merkow RP, Cantor SB, Fleming JB, Varadhachary GR, Crane C, Bentrem DJ, Bilimoria KY (2012) Cost-effectiveness of treatment strategies for pancreatic head adenocarcinoma and potential opportunities for improvement. Ann Surg Oncol 19(12):3659–3667. doi:10.1245/s10434-012-2610-1
Ho CK, Kleeff J, Friess H, Buchler MW (2005) Complications of pancreatic surgery. HPB (Oxford) 7(2):99–108. doi:10.1080/13651820510028936
Enestvedt CK, Diggs BS, Cassera MA, Hammill C, Hansen PD, Wolf RF (2012) Complications nearly double the cost of care after pancreaticoduodenectomy. Am J Surg 204(3):332–338. doi:10.1016/j.amjsurg.2011.10.019
Vonlanthen R, Slankamenac K, Breitenstein S, Puhan MA, Muller MK, Hahnloser D, Hauri D, Graf R, Clavien PA (2011) The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients. Ann Surg 254(6):907–913. doi:10.1097/SLA.0b013e31821d4a43
Tittelbach-Helmrich D, Abegg L, Wellner U, Makowiec F, Hopt UT, Keck T (2011) Insurance costs in pancreatic surgery: does the pecuniary aspect indicate formation of centers? Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen 82(2):154–159. doi:10.1007/s00104-010-1953-z
Kennedy TJ, Cassera MA, Wolf R, Swanstrom LL, Hansen PD (2010) Surgeon volume versus morbidity and cost in patients undergoing pancreaticoduodenectomy in an academic community medical center. J Gastrointest Surg 14(12):1990–1996. doi:10.1007/s11605-010-1280-1
Acknowledgments
We are grateful to Mrs. Mitterer-Lang for excellent assistance in data retrieval and accounting. This work is a part of TS’s dissertation.
Conflicts of interest
None.
Author information
Authors and Affiliations
Corresponding author
Additional information
Tina Stellwag and Christoph W. Michalski equally contributed to this study.
Rights and permissions
About this article
Cite this article
Stellwag, T., Michalski, C.W., Kong, B. et al. Comparative analysis of the revenues of pylorus-preserving pancreatic head resections and laparoscopic cholecystectomies as prototypic surgical procedures in the German health-care system. Langenbecks Arch Surg 398, 825–831 (2013). https://doi.org/10.1007/s00423-013-1091-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00423-013-1091-4