Cost effectiveness after a pancreaticoduodenectomy: bolstering the volume argument

AbstractBackgroundThe cost implication of variability in pancreatic surgery is not well described. It was hypothesized that for a pancreaticoduodenectomy (PD), lower volume centres demonstrate worse peri-operative outcomes at higher costs.MethodsFrom 2009–2011, 9883 patients undergoing a PD were identified from the University HealthSystems Consortium (UHC) database and stratified into quintiles by annual hospital case volume. A decision analytic model was constructed to assess cost effectiveness. Total direct cost data were based on Medicare cost/charge ratios and included readmission costs when applicable.ResultsThe lowest volume centres demonstrated a higher peri-operative mortality rate (3.5% versus 1.3%, P < 0.001) compared with the highest volume centres. When both index and readmission costs were considered, the per-patient total direct cost at the lowest volume centres was $23 005, or 10.9$2263 per case) more than at the highest volume centres. One-way sensitivity analyses adjusting for peri-operative mortality (1.3% at all centres) did not materially change the cost effectiveness analysis. Differences in cost were largely recognized in the index admission; readmission costs were similar across quintiles.ConclusionsFor PD, low volume centres have higher peri-operative mortality rates and 10.9% higher cost per patient. Performance of PD at higher volume centres can lead to both better outcomes and substantial cost savings

Stochastic input - output analysis: a simulation study

In the first part of the paper, the idea of a stochastic input - output model, as conceived by Gerking, is reviewed and criticized; and some extensions and simplifications are then made. The second part seeks to assess the small sample behavior of several regression estimators proposed by Berking. Since samples available for the construction of regional tables are typically quite small, this Monte Carlo study provides evidence as to which of the proposed estimators is most feasible for the actual empirical construction of regional input - output tables.