Rajesh N. Keswani, MD, MS, Associate Professor of Medicine at Northwestern University Feinberg School of Medicine, in Chicago, Illinois, USA describes his article “Adverse events after surgery for nonmalignant colon polyps are common and associated with increased length of stay and costs.”
Most colon polyps are endoscopically resected with ease. Some polyps require additional expertise for removal due to their morphology, size or location—we refer to these as “complex polyps.” Our primary aim was to report the outcomes, specifically adverse events (AE) rates, length of stay, and costs, in a large cohort of patients undergoing surgical resection (SR) for nonmalignant colon polyps. The secondary aim was to compare actual surgical outcomes data with a cohort of patients undergoing primary endoscopic muscosal resection (ER) of complex polyps at our institution.
The origin of this article lies within our group’s interest in pursuing value-based care and shared decision making. There is robust data demonstrating the safety and efficacy of ER in expert hands. We know comparatively little about the morbidity and costs associated with SR of benign colon polyps with most data extrapolated from resection of malignant and inflammatory disease. Furthermore, cost-effectiveness studies that have compared endoscopy and surgery have often used imputed surgical costs, limiting generalizability. We felt “real-world” data comparing the cost-effectiveness of surgery and endoscopy for complex polyps would more effectively influence practice.
The first major finding from our study was that surgery for benign polyps is not, itself, benign. Approximately one-sixth of patients will experience an AE resulting in an increased length of stay. As expected, when an AE occurs, this markedly increases treatment costs. Furthermore, while surgical risks significantly increase with patient factors (ASA class and BMI), they do not correlate with surgical approach (open vs. laparoscopic) or location (right vs left colon). For the patients experiencing an AE, the median hospital length of stay over the year following surgery increases to 11 days. Thus, surgery for a nonmalignant polyp is life disrupting.
The second major finding is that, in a cohort of overlapping patients who undergo attempted primary ER, there is a trend towards a lower AE rate and a markedly shorter “length of stay” with most ERs not requiring admission. Primary ER costs—accounting for AEs, unexpected malignancy, and resection failures requiring surgery as well as necessary surveillance colonoscopies—were significantly lower for complex polyps compared to SR. On average at our institution, attempting primary ER would save about $13,000 in direct costs per patient. If the nearly 200 patients who were treated with primary ER over a 3-year period had, instead, gone straight to surgery the increase in costs to the hospital would have been $2,600,000. Considering charges (amount billed to the payer), primary ER represents a saving of is approximately $40,000 per patient compared to SR.
Our data should be shared with surgical colleagues and that formal or informal teams be developed to manage patients with complex polyps. In fee-for-service systems such as the United States, endoscopists should be incentivized to perform ER of benign polyps. As we move toward bundled care, payers should work toward identifying value-based solutions to managing disease. Management of large colon polyps endoscopically is one such area where care can be optimized.
Find the article abstract here.
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