While clinical outcomes have been reported for anti-reflux surgery (ARS), there are limited data on post-operative encounters, including readmission, and their associated costs. This study evaluates healthcare utilization during the 90-day post-operative period following ARS including fundoplication and/or paraesophageal hernia (PEH) repair.
Data were analyzed from the Truven Health MarketScan® Databases. Patients older than 16 years with an ICD-9 procedure code or Common Procedural Terminology (CPT) code for ARS and a primary diagnosis of GERD during 2012–2014 were selected. Healthcare spending and utilization on emergency department (ED) visits, performance of outpatient endoscopy, and readmission were examined. Reasons for readmission were classified based on ICD-9 code.
A total of 40,853 patients were included in the cohort with a mean age of 49 years and females comprising 76.0%. Mean length of stay was 1.4 days, and 93.0% of patients underwent a laparoscopic approach. The mean cost of the index surgical admission was $24,034. Readmission occurred in 4.2% of patients, and of those, 26.3% required a surgical intervention. Patients requiring one or more related readmissions accrued additional costs of $29,513. Some of the most common reasons for readmission were related to nutritional, metabolic, and fluid and electrolyte disorders. Presentation to the ED occurred in 14.0% of patients, and outpatient upper endoscopy was required in 1.5% of patients, but with much lower associated costs as compared to readmission ($1175).
The majority of patients undergoing ARS do not require additional care within 90 days of surgery. Patients who are readmitted accrue costs that almost double the overall cost of care compared to the initial hospitalization. Measures to attenuate potentially preventable readmissions after ARS may reduce healthcare utilization in this patient population.
Gastroesophageal Reflux Disease (GERD) affects approximately 1 in 5 people in the United States  and is one of the costliest digestive diseases in the world . In patients with medically refractory GERD or complications related to GERD, laparoscopic anti-reflux surgery (ARS) is the current “gold standard” for controlling GERD symptoms and improving patient satisfaction . ARS has been demonstrated to be cost-effective, durable, and associated with improved quality of life when compared to medical management [2, 4,5,6,7]. Moreover, patients undergoing ARS utilize fewer GERD-related healthcare resources, including visits with other healthcare providers . Despite these demonstrated benefits, it appears that ARS continues to be underutilized, with just 0.05% of patients with GERD undergoing surgical therapy [8, 9].
Until 2005, the majority of anti-reflux operations in the U.S. were still performed via an open approach, although laparoscopic approaches were being adopted with increasing frequency . In the current era, the majority of anti-reflux repairs are performed laparoscopically, and the safety and efficacy of outpatient laparoscopic ARS has led to dramatic improvements in patient satisfaction and institutional cost containment [11,12,13,14,15]. While both clinical outcomes and cost profiles for the initial patient encounter have been well documented for ARS , data on post-operative outpatient encounters and their associated costs remain limited . With the increasing adoption of outpatient ARS, it will be important to document that the “upfront” cost savings achieved with this technique are not canceled out by increased subsequent costs in the form of higher rates of readmission or other downstream complications. Given the increasing use of financial penalties by the Centers for Medicare & Medicaid Services’ (CMS) for post-operative readmissions, decreasing rates of readmission will be a primary focus for decreasing healthcare utilization costs and maintaining the financial viability of healthcare institutions [16,17,18].
The aim of this study was to assess the use of healthcare resources and their associated costs during the 90-day post-operative period following ARS including fundoplication and/or paraesophageal (PEH) repair. Rates and costs of re-hospitalization, ED visits, endoscopy, and re-operation were examined. Finally, we also examined the reasons for readmission in an effort to identify potential targets for reducing readmission rates.
Data source and study population
This was a retrospective cohort study using the Truven Health MarketScan® 2012 to 2014 Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits Databases (Truven Health, Ann Arbor, MI). Although we had access to the 2015 data, we elected not to use it because the shift from ICD-9 to ICD-10 code during 2015 would have resulted in an inconsistent patient cohort. The commercial claim databases contain 80 million enrollees from all regions in the United States while the Medicare supplemental databases include 6.5 million enrollees. These include healthcare services claims in both inpatient and outpatient settings, with associated procedures and diagnosis codes, which have been submitted for reimbursement. They also contain information on demographic information including age, sex, health plan type, and region of residence, as well as drug claims. The MarketScan databases reflect the healthcare experience of employees and dependents covered by the health benefit programs of large employers. These claims data are collected from 100 different insurance companies, Blue Cross Blue Shield plans, and third party administrators. The databases are HIPAA (Health Insurance Portability and Accountability Act) compliant and de-identified so this study is exempt from Institutional Review Board (IRB).
Our study population consisted of patients undergoing ARS including primary fundoplication and/or PEH repair, at least 16 years of age, with an ICD-9 procedure code or Common Procedural Terminology (CPT) code for ARS (both laparoscopic and open) and a primary diagnosis of GERD on the same day, during 2012–2014 (Appendix Table 4). Only patients with continuous enrollment of 6 months prior to the date of index surgery and 90 days after surgery were included in this analysis, to allow for a 6-month lookback period and 90-day follow-up period (except in case of death) to identify co-morbidities and antecedent anti-reflux procedures. Patients with: diagnoses of esophageal cancer, achalasia, or diaphragmatic hernia with gangrene; a procedure of diaphragmatic hernia repair with thoracic approach; a capitated insurance plan; or patients who underwent emergency surgery were excluded (Appendix Table 5).
ARS healthcare utilization and costs were evaluated for the 90-day post-index periods and were assessed in various care settings: outpatient, inpatient, and ED. The related healthcare utilization included: (1) related readmission (including related surgical readmission); (2) related ED visit; and (3) outpatient endoscopy—defined using ICD-9and CPT codes (Appendix Table 6). The number of times of the healthcare utilization and the associated costs were analyzed. The total cost was the combined costs of index surgery, related readmissions, ED visits, and outpatient endoscopies.
Baseline demographic and clinical characteristics of patients who were readmitted within the 90-day follow-up period were compared with those who were not. These characteristics included age, sex, Charlson Comorbidity Index (Charlson Score), region, benefit plan type, event type (outpatient, or outpatient to inpatient vs. inpatient), length of stay (LOS), and surgical type (open, or laparoscopic to open vs. laparoscopic). Charlson Score values were calculated based on presence of associated ICD-9 codes for the index procedure.
The database captures primary diagnosis for readmission by ICD-9 codes. These codes were categorized using the Clinical Classifications Software (CCS) into discrete, clinically relevant categories pertaining to ARS, which were selected by the investigators. Among the different diagnoses (CCS categories), the CCS category (CCS = 238) of “complications of surgical procedures or medical care” was not included in the analysis as it did not provide insight into the actual reason for admission and the CCS category (CCS = 143) of “abdominal hernia” was further broken down into the category of “ventral/incisional hernia” using the ICD-9 code (Appendix Table 7).
Patient characteristics, healthcare utilization, and costs were analyzed descriptively. Continuous measures were summarized as means and standard deviations, and categorical measures were summarized as counts and percentages. Baseline demographic and clinical characteristics were compared between readmitted and not readmitted patients using the Pearson’s Chi square test for categorical variables and Student’s t test for continuous variables. Both bivariable and multivariable logistic regressions were performed to identify factors associated with readmission among these patients. Factors identified to be statistically significant on bivariable analysis, defined at P < 0.05, were included in the final logistic regression model comparing readmission versus no readmission and included the following covariates: age, sex, Charlson Score, benefit plan type, event type, LOS (categorical variable), and surgical type. Analysis was performed using STATA SE 15.0 software.
A total of 40,853 patients were included in the final analysis. The mean age of the cohort was 49 years, and 76.0% were female. Nearly three-fourths (74.0%) did not have major co-morbidities as calculated by a Charlson Score of 0. Insurance plan type was most commonly Preferred Provider Organization—PPO (65.4%), followed by Health Maintenance Organization—HMO (10.2%), and point-of-service—POS (7.4%). The patient characteristics are further summarized in Table 1.
Index procedure details
A laparoscopic approach was utilized in 93.0% (37,999) of the procedures, 2.0% (831) were initially laparoscopic but converted to open, and 5.0% (2023) were performed with an initial open approach. The setting in which the surgical procedure were performed demonstrated that 53.4% (21,818) were classified as inpatient, 43.0% (17,545) were outpatient, and 3.7% (1490) were outpatient converted to inpatient. Mean LOS for the index hospitalization for all patients was 1.41 days (SD 2.37 days) where LOS for procedures performed as an inpatient was 2.43 days, outpatients converted to inpatient was 1.88 days, and outpatients was 0.10 days. Index surgical cost data were available for 40,732 patients with mean cost per patient of $24,034.15 (SD $22,512.79). The cost of inpatient, outpatient, and outpatient converted to inpatient status was $28,539.87, $18,415.03, $23,875.63, respectively. The cost of the index operation, stratified by approach was $23,567.81, $26,193.11, and $32,129.33, respectively for laparoscopic, laparoscopic converted to open, and open surgeries.
Associated post discharge 90-day healthcare utilization and costs
Outpatient endoscopy was required in only 1.5% (630), 0.12% (48) of which required more than one endoscopy. Endoscopy utilization resulted in a mean additional cost of $3,436.91 (SD $7,323.39) per patient. No difference in endoscopy utilization was identified between index procedures being performed as inpatient or outpatient.
Presentation to the ED at least once within 90 days of surgery for evaluation related to the ARS occurred in 14.2% (5802), resulting in a mean additional cost of $926.53 (SD $2,578.49) per person. Those with ED visits were more likely to have co-morbidities compared to patients who did not utilize the ED as defined as a Charlson Score of two or more (OR 1.92, 95% CI 1.73–2.13, P < 0.001), and were more likely to have a prolonged index hospitalization (1.92 vs. 1.32 days, P < 0.001) as compared to patients not presenting to the ED. A higher rate of ED utilization by patients with procedures performed as inpatients versus outpatients (15.2% vs. 13.0%, P < 0.001) was also observed.
The majority of patients (95.82%) did not require a related readmission, 4.2% (1709) of patients were readmitted one or more times, and 1.1% (450) of patients required a surgical intervention during the admission. The most common surgical re-intervention (75% of the re-operations) was for a recurrent hiatal hernia followed by re-operation for gastric or esophageal injuries (8% of the re-operations). Patients with outpatient index procedures were more likely to be readmitted with rates of 4.7% compared with 3.8% for inpatient procedures and 3.2% for outpatient to inpatient procedures (P < 0.001). Patients requiring one or more related readmissions accrued a mean additional cost of $29,512.97 (SD $57,031.20) in general, or $31,082.14 (SD $54,707.36) if they required an intervention (Table 2). No difference in readmission cost was identified between inpatient or outpatient index encounter type.
The overall mean cost of anti-reflux surgery and the associated 90-day healthcare utilization totaled $25,443.68 (SD $26,539.01) per patient. When stratified by index procedure patient class costs were $29,972.10 for inpatient, $19,829.13 for outpatient, and $24,909.95 for outpatient-inpatient (P < 0.001).
Multivariable analysis and reasons for readmission
The multivariable logistic regression model identified having Charlson Score ≥ 2 (OR 1.49, 95% CI 1.24–1.79), procedure performed as an outpatient (OR 1.48, 95% CI 1.29–1.69), and an index hospitalization of > 2 days (OR 2.00, 95% CI 1.70–2.36) as independent factors increasing risk for readmission. Patient age, sex, and insurance benefit plan type were not found to be significant on multivariable analysis (Table 3).
The primary diagnosis for readmission in 31.0% of the cases was reported as “complications of surgical procedures or medical care”. Of the more specific diagnoses, the most common categories listed as reason for readmission included esophageal disorders (8.5%); other nutritional, endocrine, and metabolic disorders (5.9%); and fluid and electrolyte disorders (5.1%); abdominal pain (4.3%); and ventral-incisional hernia (1.7%). These results are depicted in Fig. 1.
In this study, we found that the most important determinant of cost in the peri-operative period after ARS was readmission. Irrespective of whether or not an additional surgical procedure was performed, the cost of readmission was greater than that of the index hospitalization itself, more than doubling the overall cost of care. Although we found significant rates of ED utilization, this was not a significant factor in increasing the overall cost per patient. While patients undergoing outpatient ARS were more likely to be readmitted than those undergoing inpatient surgery, it is important to note that this increased readmission rate attenuated, but did not wholly erase, the initial cost savings realized with same-day surgery.
Since 2012, there has been an increased focus on prevention of surgical readmissions, primarily driven by CMS’s implementation of the Hospital Readmission Reduction Program, under which payments are reduced to hospitals whose readmission rates exceed a pre-determined standard . Although no benchmarks have been established specifically for ARS, the present study demonstrated an overall readmission rate of 4.2%, which is consistent with previous studies demonstrating 30-day readmission rates of 4.9% and 6.3% for fundoplication and PEH repair, respectively . Using our model, high Charlson Score, performance of the procedure as an outpatient, and a prolonged index hospitalization, were identified as independent risk factors for increased rate of readmission. LOS > 2 days is likely a surrogate for complex patients or a complicated post-operative course and is therefore not surprising. An unexpected finding in our analysis was that open surgical approach was not a risk factor for readmission. Other investigators have shown older age, black race, higher ASA classification, open approach, and pre-discharge complications to be predictors of increased readmission following foregut surgery  and comparable findings have been seen after other types of similar procedures. In a study by Petrick et al., of the 5.5% of patients who were readmitted after laparoscopic bariatric surgery, almost half of the readmissions were classified as “preventable.” These readmissions were largely due to nausea, vomiting and dehydration . This highlights the potential for quality improvement measures, such as clinic-based infusion of intravenous fluids to prevent dehydration, which might better optimize patient care and decrease readmission rates. Surprisingly, same-day surgery, a long-growing trend borne of the imperative for cost containment, is currently performed for a wide variety of laparoscopic procedures, from cholecystectomy to colectomy. Outpatient ARS is now performed quite frequently, as demonstrated by its utilization in 43% of patients in this study. Same-day discharge after surgery of the diaphragmatic hiatus has been reported in 67% of cases, with this achieved in 81.6% of cases in which it was intended . A systematic review published in 2011 demonstrated 30-day hospital readmission rates ranging from 0 to 12.2% for ambulatory laparoscopic fundoplication (extrapolated mean 3.5%) , which is similar to the 4.7% readmission rate in our cohort. Contrary to our findings, other groups have shown no difference in post-operative morbidity, ED visits, or readmissions with outpatient ARS in selected patients when compared to traditional inpatient management [14, 15]. This seeming contradiction may be explained by the fact that those prospective studies investigated ambulatory ARS in highly selected populations, excluding patients with co-morbidities requiring surveillance such as diabetes, coronary artery disease, chronic pulmonary disease, and patients with more complex hiatal hernias or complicated past surgical history. Similarly, Lee and colleagues demonstrated that, in appropriately selected patients, laparoscopic sleeve gastrectomy can be performed safely in the outpatient setting with very low complication and readmission rates, suggesting that this trend is likely to continue .
We found a higher readmission rate in patients undergoing outpatient procedures as compared with those performed on an inpatient basis (4.69% vs. 3.84%, P < 0.001), and this finding persisted in the adjusted model (OR 1.48, 95% CI 1.29–1.69). Nevertheless, although readmission certainly increased the cost of care in those individual cases in which it occurred, the increased readmission rate seen in our study did not negate the overall cost savings achieved with outpatient ARS for the patient population in aggregate: i.e., the overall cost saving achieved clearly favors performing these procedures in the outpatient setting ($19,829.13 vs. $29,972.10, P < 0.001). Similar financial conclusions were reached by Gronnier, who—reporting on outpatient ARS procedures in France—demonstrated cost savings of 3921 Euros for outpatient ARS (2248 Euros cost per day-case vs. 6569 Euros per inpatient case), despite a significantly higher readmission rate for the outpatient cohort . Findings similar to this have been demonstrated across surgical specialties. Cancienne et al. reported significant cost reduction for total shoulder arthroplasty performed in an ambulatory setting, with no increase in complications or readmissions . In addition, enhanced recovery programs designed to decrease LOS and inpatient resource utilization have been shown to be cost-effective for colorectal  and bariatric procedures  without increased complication or readmission rates. Given that dehydration, nausea, and vomiting were identified in this study, as well as others [13, 25], to be common causes of readmission, the use of ERAS protocols and/or aggressive outpatient management of these conditions could reasonably be expected to reduce readmission rates, further augmenting the positive impact on healthcare utilization costs seen in our study.
This study has important limitations. The Truven Health database fails to distinguish important details on pre-operative patient variables such as BMI, surgical history, or indication for surgery. Moreover, 50.6% of the readmissions in this dataset carried simply the generic diagnosis code for “complications of surgery” without further specification, thus limiting our ability to discern a precise cause for these readmissions and confounding efforts to determine relationships among risk factors for readmission. Finally, we would have liked to look at readmissions and need for further surgical interventions at time periods outside of 90 days, however, we were unable to do so with the years of data available to us. However, since current fiscal penalties are based only on 90 day readmissions, we feel that our analysis provides very interesting data to consider.
Because healthcare delivery systems will continue to function under immense pressure to contain costs while at the same time increasing the value of every health care dollar spent, it will remain essential that we scrutinize those elements of care which may be unnecessarily expensive and/or contribute to negative patient outcomes. In accordance with the findings reported here, it can be expected that anti-reflux surgery will be performed in the outpatient setting with increasing frequency in properly-selected patients. Notwithstanding a somewhat higher 90-day readmission rate when ARS is performed on an outpatient basis, an approach favoring outpatient ARS is likely to realize a significant reduction in the cost of care for this patient population as a whole. The most fruitful area for reaping further cost containment advantage is likely to consist of improved management of the modifiable risk factors for readmission.
El-Serag HB, Sweet S, Winchester CC, Dent J (2014) Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut 63:871–880
Gawron AJ, French DD, Pandolfino JE, Howden CW (2014) Economic evaluations of gastroesophageal reflux disease medical management. Pharmacoeconomics 32:745–758
Niebisch S, Peters JH (2012) Update on fundoplication for the treatment of GERD. Curr Gastroenterol Rep 14:189–196
Funk LM, Zhang JY, Drosdeck JM, Melvin WS, Walker JP, Perry KA (2015) Long-term cost-effectiveness of medical, endoscopic and surgical management of gastroesophageal reflux disease. Surgery 157:126–136
Robinson B, Dunst CM, Cassera MA, Reavis KM, Sharata A, Swanstrom LL (2015) 20 years later: laparoscopic fundoplication durability. Surg Endosc 29:2520–2524
Goeree R, Hopkins R, Marshall JK, Armstrong D, Ungar WJ, Goldsmith C, Allen C, Anvari M (2011) Cost-utility of laparoscopic Nissen fundoplication versus proton pump inhibitors for chronic and controlled gastroesophageal reflux disease: a 3-year prospective randomized controlled trial and economic evaluation. Value Health 14:263–273
Grant AM, Boachie C, Cotton SC, Faria R, Bojke L, Epstein DM, Ramsay CR, Corbacho B, Sculpher M, Krukowski ZH, Heading RC, Campbell MK, REFLUX Trial Group (2013) Clinical and economic evaluation of laparoscopic surgery compared with medical management for gastro-oesophageal reflux disease: 5-year follow-up of multicentre randomised trial (the REFLUX trial). Health Technol Assess 17:1–167
Niebisch S, Fleming FJ, Galey KM, Wilshire CL, Jones CE, Litle VR, Watson TJ, Peters JH (2012) Perioperative risk of laparoscopic fundoplication: safer than previously reported-analysis of the American College of Surgeons National Surgical Quality Improvement Program 2005 to 2009. J Am Coll Surg 215:61–68 discussion 68-69
Khan F, Maradey-Romero C, Ganocy S, Frazier R, Fass R (2016) Utilisation of surgical fundoplication for patients with gastro-oesophageal reflux disease in the USA has declined rapidly between 2009 and 2013. Aliment Pharmacol Ther 43:1124–1131
Schlottmann F, Strassle PD, Patti MG (2017) Comparative analysis of perioperative outcomes and costs between laparoscopic and open antireflux surgery. J Am Coll Surg 224:327–333
Gronnier C, Desbeaux A, Piessen G, Boutillier J, Ruolt N, Triboulet JP, Mariette C (2014) Day-case versus inpatient laparoscopic fundoplication: outcomes, quality of life and cost-analysis. Surg Endosc 28:2159–2166
Desbeaux A, Gronnier C, Piessen G, Vanderbeken M, Ruolt N, Triboulet JP, Mariette C (2017) Same-day discharge in benign esophageal surgery: a prospective cohort study. Dis Esophagus 30:1–7
Mariette C, Pessaux P (2011) Ambulatory laparoscopic fundoplication for gastroesophageal reflux disease: a systematic review. Surg Endosc 25:2859–2864
Molina JC, Misariu AM, Nicolau I, Spicer J, Mulder D, Ferri LE, Mueller CL (2018) Same day discharge for benign laparoscopic hiatal surgery: a feasibility analysis. Surg Endosc 32:937–944
Mariette C, Boutillier J, Arnaud N, Piessen G, Ruolt N, Triboulet JP (2011) Outcome of day-case laparoscopic fundoplication for gastro-esophageal reflux disease. J Visc Surg 148:50–53
Bliss LA, Maguire LH, Chau Z, Yang CJ, Nagle DA, Chan AT, Tseng JF (2015) Readmission after resections of the colon and rectum: predictors of a costly and common outcome. Dis Colon Rectum 58:1164–1173
Dimick JB, Ghaferi AA (2015) Hospital readmission as a quality measure in surgery. JAMA 313:512–513
Chen J, Mackenzie J, Zhai Y, O’Loughlin J, Kholer R, Morrow E, Glasgow R, Volckmann E, Ibele A (2017) Preventing returns to the emergency department following bariatric surgery. Obes Surg 27:1986–1992
Readmissions Reduction Program (HRRP). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html Sep 27, 2018. Accessed 20 Nov 2018
Poupore AK, Stem M, Molena D, Lidor AO (2016) Incidence, reasons, and risk factors for readmission after surgery for benign distal esophageal disease. Surgery 160:599–606
Petrick A, Brindle SA, Vogels E, Dove J, Parker D, Gabrielsen J (2018) The readmission contradiction: toward clarifying common misconceptions about bariatric readmissions and quality improvement. Surg Obes Relat Dis 14:1026–1032
Cancienne JM, Brockmeier SF, Gulotta LV, Dines DM, Werner BC (2017) Ambulatory total shoulder arthroplasty: a comprehensive analysis of current trends, complications, readmissions, and costs. J Bone Joint Surg Am 99:629–637
Lee L, Mata J, Ghitulescu GA, Boutros M, Charlebois P, Stein B, Liberman AS, Fried GM, Morin N, Carli F, Latimer E, Feldman LS (2015) Cost-effectiveness of enhanced recovery versus conventional perioperative management for colorectal surgery. Ann Surg 262:1026–1033
Jonsson A, Lin E, Patel L, Patel AD, Stetler JL, Prayor-Patterson H, Singh A, Srinivasan JK, Sweeney JF, Davis SS Jr (2018) Barriers to enhanced recovery after surgery after laparoscopic sleeve gastrectomy. J Am Coll Surg 226:605–613
Molena D, Mungo B, Stem M, Feinberg RL, Lidor AO (2014) Outcomes of operations for benign foregut disease in elderly patients: a National Surgical Quality Improvement Program database analysis. Surgery 156:352–360
Effort on this study and manuscript was made possible by a VA Career Development Award to Dr. Funk (CDA 015-060).
Anne Lidor, MD, MPH, Kyle L. Kleppe MD, Yiwei Xu MHS, Xing Wang PhD, Jeff A. Havlena PhD, Jake Greenberg MD, EdM: nothing to disclose, Luke M. Funk MD MPH: Effort on this study and manuscript was made possible by a VA Career Development Award to Dr. Funk (CDA 015-060). The views represented in this article represent those of the authors and not those of the DVA or the US Government. Dr. Funk declares no conflicts of interest related to this funding source.
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Kleppe, K.L., Xu, Y., Funk, L.M. et al. Healthcare spending and utilization following antireflux surgery: examining costs and reasons for readmission. Surg Endosc 34, 240–248 (2020). https://doi.org/10.1007/s00464-019-06758-2
- Paraesophageal hernia
- Hiatal hernia
- Anti-reflux surgery
- Healthcare utilization