Financial implications of laparoscopic abdominoperineal excision of the rectum and factors influencing its uptake in the United States – an analysis of 22,792 patients.

Jamie Murphy, BChir, PhD, FRCS¹, Tonia M Young-Fadok, MS, MD². ¹St. Mark’s Hospital, ²Mayo Clinic

INTRODUCTION: Laparoscopic abdominoperineal resection (APR) of the rectum is a technically demanding procedure, which is thought to be associated with faster patient recovery and improved cosmesis. Evidence assessing the cost associated with laparoscopic APR, however, is limited. Similarly, factors influencing the uptake of this procedure remain poorly understood. The purpose of this population-based study was to determine the cost associated with laparoscopic APR and assess which variables influence the availability of this technique throughout the United States.

METHODS: The Nationwide Inpatient Sample database was used to sample admissions for laparoscopic or open APR during the period 2008 – 2012. Patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification coding. Univariate analyses were performed.

RESULTS: A total of 22,792 (mean age: 61.9+/-1.5; male: 13,028; female: 9,764) admissions were identified. The use of laparoscopy increased from 21% in 2008 to 33% in 2012 (p<0.0054). A laparoscopic approach was demonstrated to decrease mean length of stay by 2.8+/-0.23 days (p<0.0001), mean hospital costs by 3,648+/-894 dollars (p=0.0008), mean aggregate costs by 5,579+/-4,203 dollars (p=0.0144) and the need for discharge to nursing / rehabilitation facilities postoperatively (p=0.0004). Utilisation of home health services did not differ between patients undergoing open or laparoscopic surgery. Gender did not appear to influence surgical approach; however, an increased use of laparoscopy was noted for younger patients (p=0.0244). While patients from low-income families were more likely to undergo open surgery (p=0.0116), insurance status did not predict surgical approach. Patients undergoing procedures at major metropolitan centres (p=0.0249) and private not-for profit institutions (p=0.0031) were more likely to undergo a laparoscopic approach. Hospital size was not associated with surgical approach. Geographic variations were noted in the availability of laparoscopic APR, with the lowest rates in the Northeast and highest rates in the south (p=0.0208).

CONCLUSION: Throughout the United States as a whole laparoscopic APR was associated with significant decreases in length of stay and hospital / aggregate charges when compared with an open approach. Despite these benefits patients from older age groups, low-income families and rural areas were less likely to be offered laparoscopic resection. In future centralisation of APR to high volume centres with a specialist interest in laparoscopy may confer significant benefits for patients and decrease costs for health maintenance and preferred provider organisations.