Massachusetts Chapter of the American College of Surgeons

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Association Between Facility Volume and Survival Following Proctectomy for Rectal Cancer
Vanessa M. Welten MD MPH1,2, Kerollos Wanis MD3, Adam C. Fields MD MPH1, Pamela W. Lu MD MPH1, Robert A. Malizia1, James Yoo MD1, Joel E. Goldberg MD MPH1, Jennifer L. Irani MD1, Ronald Bleday MD1, Nelya Melnitchouk MD MSc1,2
1Division of General and GI Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA 2Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA 3Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA

Background: Value-based health-care reform requires assessment of outcomes and costs of medical interventions. In cleft care, pre-surgical infant orthopedics (PSIO) is still being evaluated for clinical benefits and risks; however, cost of these procedures has been largely ignored. This study employs robust accounting methods to quantify the cost of providing two types of PSIO: Latham and nasoalveolar molding (NAM). Methods:This is a prospective study of patients with non-syndromic cleft lip and/or palate (CL/P) who underwent PSIO from 2017-2019 at two academic centers. Costs were measured using time-driven activity-based costing (TDABC). Personnel costs, facility costs (operating room, clinic, and inpatient ward), and equipment costs were included. Travel expenses were incorporated as an estimate of direct costs borne by the family, but indirect costs (e.g., time off from work) were not considered.
Results: Twenty-three patients were treated with Latham and 14 with NAM. For Latham, average total cost was /patient ( for personnel, for equipment, for facility, and for travel over 6.5 visits). Unilateral and bilateral costs were and , respectively. For NAM, average cost totaled ( for personnel, for equipment, for facility, and for travel over 13 visits); for unilateral and for bilateral treatment.
Conclusion: The major difference in cost is attributable to operative placement of the Latham device. Travel cost for NAM is often higher due to frequent clinical encounters required. Future investigation should focus on whether outcomes achieved by PSIO justify the - expenditure for these adjunctive procedures.<0.001). Median survival was 91.9 months (95%CI 90.1 – 93.5) for low volume facilities, 103.2 months (95%CI 101.3 – 105.5) for intermediate volume facilities, and 114.2 months (95%CI 111.9 – 116.7) for high volume facilities, with differences between tertiles statistically significant (p<0.001). 5-year survival rates for the three tertiles were 62.5% (95%CI 62.0-63.0) for low volume, 65.4% (95%CI 64.9-65.8) for intermediate volume, and 68.5% (95%CI 68.1-69.0) for high volume (p<0.001).
Conclusion: This study identifies a strong association between facility volume and survival following proctectomy for rectal cancer. Further work is needed to evaluate drivers of this association.


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