Article

The inpatient burden of abdominal and gynecological adhesiolysis in the US

Shire Pharmaceuticals, Wayne, PA 19087, USA.
BMC Surgery (Impact Factor: 1.4). 06/2011; 11(1):13. DOI: 10.1186/1471-2482-11-13
Source: PubMed

ABSTRACT

Adhesions are fibrous bands of scar tissue, often a result of surgery, that form between internal organs and tissues, joining them together abnormally. Postoperative adhesions frequently occur following abdominal surgery, and are associated with a large economic burden. This study examines the inpatient burden of adhesiolysis in the United States (i.e., number and rate of events, cost, length of stay [LOS]).
Hospital discharge data for patients with primary and secondary adhesiolysis were analyzed using the 2005 Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. Procedures were aggregated by body system.
We identified 351,777 adhesiolysis-related hospitalizations: 23.2% for primary and 76.8% for secondary adhesiolysis. The average LOS was 7.8 days for primary adhesiolysis. We found that 967,332 days of care were attributed to adhesiolysis-related procedures, with inpatient expenditures totaling $2.3 billion ($1.4 billion for primary adhesiolysis; $926 million for secondary adhesiolysis). Hospitalizations for adhesiolysis increased steadily by age and were higher for women. Of secondary adhesiolysis procedures, 46.3% involved the female reproductive tract, resulting in 57,005 additional days of care and $220 million in attributable costs.
Adhesiolysis remain an important surgical problem in the United States. Hospitalization for this condition leads to high direct surgical costs, which should be of interest to providers and payers.

Full-text

Available from: Vanja Sikirica
RESEARCH ARTICLE Open Access
The inpatient burden of abdominal and
gynecological adhesiolysis in the US
Vanja Sikirica
1
, Bela Bapat
2
, Sean D Candrilli
2*
, Keith L Davis
2
, Malcolm Wilson
3
and Alan Johns
4
Abstract
Background: Adhesions are fibrous bands of scar tissue, often a result of surgery, that form between internal
organs and tissues, joining them together abnormally. Postoperative adhesions frequently occur following
abdominal surgery, and are associated with a large economic burden. This study examines the inpatient burden of
adhesiolysis in the United States (i.e., number and rate of events, cost, length of stay [LOS]).
Methods: Hospital discharge data for patients with primary and secondary adhesiolysis were analyzed using the 2005
Healthcare Cost and Utilization Projects Nationwide Inpatient Sample. Procedures were aggregated by body system.
Results: We identified 351,777 adhesiolysis-related hospitalizations: 23.2% for primary and 76.8% for secon dary
adhesiolysis. The average LOS was 7.8 days for primary adhesiolysis. We found that 967,332 days of care were
attributed to adhesiolysis-related procedures, with inpatient expenditures totaling $2.3 billion ($1.4 billion for
primary adhesiolysis; $926 million for secondary adhesiolysis). Hospitalizations for adhesiolysis increased steadily by
age and were higher for women. Of secondary adhesiolysis procedures, 46.3% involved the female reproductive
tract, resulting in 57,005 additional days of care and $220 million in attributable costs.
Conclusions: Adhesiolysis remain an important surgical problem in the United States. Hospitalization for this
condition leads to high direct surgical costs, which should be of interest to providers and payers.
Keywords: Adhesions, adhesiolysis, abdominal, gynecological, burden of illness, hospitalizations
Background
Adhesions are fibrous bands of scar tissue, often result
of surgery, that form between internal organs and tis-
sues, joining them together abnormally [1]. Postopera-
tive adhesions frequently occur following abdominal
surgery and are a leading cause of intestinal obstruction.
It has been estimated that more than 90% of patients
who undergo abdominal operations w ill develop post-
operative adhesions [2].
The most severe complication of postoperative adhe-
sions is small bowel obstruction (SBO), which has a 10%
risk of mortality [3,4]. Recent r esearch has demonstrated
that readmission e pisodes averaged 2.7 per p atient for
SBO or nonspecific abdominal pain (when adhesion s
were considered likely). Inpatient readmissions accounted
for 87% of episodes; 47% of those required repeat surgery
[5]. Additionally, in the large retrospective study Surgical
and Clinical Adhesions Research, surgical procedure s
performed on the bowel or the female reproductive sys-
tem were associated with an increased chance of adhe-
sion development, termed adhesiolysis [6-8]. Ray and
colleagues found that 47% of adhesiolysis-related inpati-
ent hospitalizations were for procedures involving the
female reproductive tract [2]. Postoperative adhesiolysis-
related SBO occurred in 2.8% of patients undergoing
hysterectomy for benign cond itions and in 5% of thos e
undergoing radical hysterectomy [4,9].
A number of studies have shown that the economic bur-
den of adhesiolysis is significant [2,5,10]. It was estimated
that adhesiolysis procedures resulted in 303,836 hospitali-
zations, 846,415 days of inpatient care, and nearly $1.3 bil-
lion in health care expenditures in the United States (US)
in 1994 [2]. This cost has decreased when compared with
similar data from 1988,[10] due in part to laparoscopic
surgery. Despite the decrease in costs associated with
laparoscopic surgery, increased use of such techniques did
not lead to a decreased rate of overall hospitalizations [2].
* Correspondence: scandrilli@rti.org
2
RTI Health Solutions, 200 Park Offices, Research Triangle Park, NC 27709 USA
Full list of author information is available at the end of the article
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Page 1
Utilizing more recent data, we estimated the current
burden of inpatient treatment of adhesiolysis in the US.
Thi s stu dy examined the number and rate of adhesioly-
sis-related hospitalizations, days of care attributable to
adhesiolysis, and length of stay (LOS) for adhesiolysis-
related hospitalizations, with primary and secondary
procedures considered separately. Additionally, we
assessed total inpatient costs attributable to adhesiolysis.
Methods
Data Source
Data were taken from the 2005 Healthcare Cost and
Utilization Projects (HCUP) Nationwide Inpatient Sam-
ple (NIS)[11]. The NIS is the largest all-payer inpatient
care database in the US and contains data from approxi-
mately 8 million hospital stays in 2005. The database
also contains clinical and resource use information,
including patient demographics, International Classifica-
tion of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM) diagnosis and procedure codes, diagnosis-
related group (DRG) codes, LOS, charges, discharge st a-
tus, payer source, and hospital-specific characteristics.
Using the survey design elements provided with the
NIS, data can be weighted to produce nationally repre-
sentative estimates [12]. All financial information in the
NIS database is presented as charges rather than costs.
To convert hospital charges to costs, facility-specific
cost-to-charge ratios were used. Finally, the medical
care component of the Consumer Price Index was
applied to inflate all financial data to 2007 US dollars
[13].
RTI I nternationals Institutional Review Board deter-
mined that this study met all criteria for exemption.
Study Sample
From the NIS, all hospitalizations containi ng a DRG
code of peritoneal adhesiolysis with or without compli-
cations (i.e., DRG 150, 151) were defined as primary
adhesiolysis-related hospitalizations. Hospitalizations
containing a primary or nonprimary ICD-9-CM proce-
dure code for adhesiolysis, but without DRG 150 or 151,
were defined as seco ndary adhesiolysis-r elated hospitali-
zations (Table 1). Hospitalizations related to secondary
adhesiolysis were stratified by body system, using the
following DRG coding:
(1) Digestive system (i.e., DRG 148, 149, 154, or
468),
(2) Hepatobiliary system (i.e., DRG 197, 493, or 494),
(3) Female reproductive system (i.e., DRG 358, 359,
361, or 365),
(4) Pregnancy with evidence of Cesarean section (i.e.,
DRG 370, 371, or 378).
Study Measures
Study measures included the number of inpatient hospi-
talizations involving adhesiolysis, adhesiolysis-related
hospitalization rates, days of care, and costs attributable
to adhesiolysis.
Hospitalization rates per 100,000 persons were assessed
using the US Census Bureaus 2005 total US civilian popu-
lation projection. The total days of care attributable to
adhesiolysis were estimated using methods presented by
Ray and colleagues that then were adapted for the HCUP
NIS [2]. When DRG 150 or 151 (i.e., primary adhesiolysis)
was the primary reason for admission, the attributed LOS
was s imply the mean LOS for this group. For records
without a DRG of 150 or 15 1, excess days attribu ted to
adhesiolysis were calculated as the difference between the
mean LOS for those same procedures with adhesiolysis
and those procedures without adhesiolysis within each
DRG. The total number of adhesiolysis-related days then
was estimated as the product of the attributed LOS for the
group and the number of adhesiolysis-related hospitaliza-
tions within the group.
This study utilized the methodology from Ray and col-
leagues to estimate the per-day cost attributable to
adhesiolysis [2]. Cost per day was estimated by dividing
the total cost of adhesiolysis- related hospitalizations
divided by the total number of adhesiolysis-related inpa-
tient days. The total inpatient expenditures attributable
to adhesiolysis were estimated by multiplying the esti-
mated cost per day attributable to adhesiolysis by the
number of days attributed to adhesiolysis.
Aver age expenditures for surgeons services were esti-
mated using the Resource-Based Relative Value Scale
(RBRVS). The RBRVS value was estimated for Current
Procedural Terminology codes related to adhesiolysis
(Table 2) and then multiplied by a fixed conversion fac-
tor to determine the average surgeon expenditures for
each specific procedure. These figures then were inflated
to 2007 dollars using the medical care component of the
Consumer Price Index.
Total inpatient costs attributable to adhesiolysis con-
sisted of inpatient costs and costs for the surgeons ser-
vices. Estimates were made separately for primary and
secondary adhesiolysis. These also were examined by
body system and then aggregated to estimate a total
cost. Additionally, inpatient expenditures were summar-
ized to compare Cesarean section deliveries with and
without adhesiolysis.
Statistical Analyses
Descriptive analyses were con ducted to display the
mean, standard deviation, median, and range of continu-
ousvariables,aswellasthefrequencydistributionof
categorical variables. All data management and analyses
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were conducted with SAS and SUDAAN statistical soft-
ware packages [14,15].
Results and Discussion
Table 3 illustrates that there were 351,777 adhesiolysis-
related hospitalizations in the US in 2005, representing
119 adhesiolysis hospitalizations per 100,000 persons.
There were 898 adhesiolysis hospitalizations per 100,000
hospitalizations and 3,549 per 100,000 surgical hospitali-
zations of any kind (3.5%). Primary adhesiolysis (i.e.,
DRG 150 or 151) was fo und i n 23.2% of these hospitali-
zations, while the remaining 76.8% were classified as
secondary adhesiolysis (i.e., evidence of t he procedure
but with a DRG other than 150 or 151).
Table 4 presents background characteristic s for the
study sample. For primary adhesiolysis, the number of
hospitalizations increased steadily by age; for secondary
adhesiolysis, the number increased for most age cate-
gories. The lowest rate was in patients who wer e young er
than 25 years (5.2 per 100,000 per sons for primary adhe-
siolysis; 13.8 per 100,000 persons for secondary adhesio-
lysis), and th e highest rate was in patients who were
older than 65 years (88.4 per 100,000 persons for primary
adhesiolysis; 176.7 per 100,000 persons for secondary
adhesiolysis). Women had a higher hospitalization rate
than men (34.9 vs. 19.7 per 100,000 persons for primary
adhesiolysis; 153.1 vs. 13.4 per 100,000 persons for
secondary adhesiolysis). Among primary adhesiolysis
Table 1 Description of Procedure (ICD-9-CM) Codes Used to Identify Adhesiolysis-Related Surgical Procedures
ICD-9-CM Procedure Code Brief Description
Nongynecologic
54.5 Lysis of peritoneal adhesions
54.51 Laparoscopic lysis of peritoneal adhesions
54.59 Other lysis of peritoneal adhesions
56.81 Lysis of intraluminal adhesions of ureter
57.12 Lysis of intraluminal adhesions with incision into bladder
57.41 Transurethral lysis of intraluminal adhesions
58.5 Release of urethral structure
59.01 Ureterolysis with freeing or repositioning of ureter for retroperitoneal fibrosis
59.02 Other lysis of perirenal or periureteral adhesions
59.03 Laparoscopic lysis of perirenal or periureteral adhesions
59.11 Other lysis of perivesical adhesions
59.12 Laparoscopic lysis of perivesical adhesions
68.21 Division of endometrial synechiae
Gynecologic
65.8 Lysis of adhesions of ovary and fallopian tube
65.81 Laparoscopic lysis of adhesions of ovary and fallopian tube
65.89 Other lysis of adhesions of ovary and fallopian tube
70.13 Lysis of intraluminal adhesions of vagina
71.01 Lysis of vulvar adhesions
ICD-9-CM = International Classification of Diseases, 9th Revision, Clini cal Modification.
Table 2 Description of Procedure (CPT) Codes Used to Identify Adhesiolysis-Related Surgical Procedures to Estimate
Expenditures for Surgeons Services
a
CPT Code Brief Description
44005 Enterolysis (freeing of intestinal adhesion)
50715 Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis
50722 Ureterolysis for ovarian vein syndrome
50725 Ureterolysis for retrocaval ureter, with reanastomosis of upper urinary tract or vena cava
58660 Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate)
58559 Hysteroscopy with lysis of intrauterine adhesions (any method)
56441 Lysis of labial adhesions
58740 Lysis of adhesions (salpingolysis, ovariolysis)
CPT = Current Procedural Terminology.
a
CPT codes 56304 and 58985 were replaced by code 58660, and CPT code 57451 was retired.
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hospitalizations, almost half (48%) of the patients were
admitted via the emergency department, whereas only
20.5% of the secondary adhesiolysis hospitalizations were
via the emergency department. Primary adhesiolysis-
related hospitalizations were evenly distributed between
private insurance and governmental coverage, i.e., Medi-
caid and Medicare (44% and 48%, respectively), whereas
more than half (56%) of the patients with secondary
adhesiolysis hospitalizations had private insurance and
37.4% had government-sponsored health care coverage.
A total of 967,332 inpatient days of care were attribu-
ted to primary and secondary adhesiolysis (Table 5).
There were 81,532 hospitalizations and an average LOS
of 7.8 days per stay, totaling 632,688 inpatient days of
care for primary adhesiolysis. An estimated 334,644 days
of care were attributed to secondary adhesiolysis. For
hospitalizations in which adhesiolysis was a secondary
procedure, we compared the LOS between adhesiol ysis
and nonadhesiolysis procedures to estimate the LOS
attributable to adhesiolysis by each DRG. The majority
of DRGs showed an increa se in LOS for adhesiolysis
hospitalizations versus nonadhesiolysis hospitalizations.
On average, hospitalizations related to secondary adhe-
siolysis resulted in an additional 1.24 hospitalized da ys
compared with nonadhesiolysis-related hospitalizations.
The difference in mean LOS was greatest for extensive
operation room procedures unrelated to p rincipal diag-
nosis (i.e., DRG 468), with 4.9 days attributable to adhe-
siolysis. For stomach, esophageal, and duodenal
procedures with complications of comorbid conditions
(i.e., DRG 154), 4.6 days were attributable to adhesioly-
sis. Almost half (46.3%) of all secondary adhesiolysis
procedures (125,069) were female reproductive tract
related, resulting in 57,005 days of care. Thus, 0.46 day
of additional stay were attributable to adhesiolysis. The
longest LOS for female reproductive system procedures
was for DRG 358 (uter ine and adnexa procedures for
nonmalignancy), which resulted in an additional day of
inpatient stay (0.90 day).
Table 6 shows that tot al inpatient expenditures for
adhesiolysis-related hospitalizations were $2.25 billion:
of this amount, primary adhes iolysis-related hospitaliz a-
tions accounted for $1.35 billion and secondary adhesio-
lysis-related hospitalizations accounted for $902 million.
Of the total secondary adhesiolysis expenditures, $622
million (69%) were related to procedures for the diges-
tive system and $220 million (24.3%) were related to
procedures for the female reproductive system. Adhesio-
lysis related to the hepatobiliary system and pancreas
and Cesarean sections accounted for $41 million and
$18 million, respectively.
The rate of adhesiolysis-related h ospitalizations in the
US has remained fairly constant from 1998 to 2005:
from 115.5 in 1988 [10] to 117.3 in 1994 [2] and ulti-
mately 118.6 per 100,000 persons in 2005. In these same
time periods, the average LOS for primary adhesio lysis-
related hospitalizations has steadily decreased from 11.2
days to 9.7 days and 7.8 days, respectively. The costs for
such hospitalizations, when inflated to reflect 2007 dol-
lars, indicated an increase of $112 million between 1988
and 2005, despite the 3. 4-day (or 30%) de crease i n
LOSthis represented a 5% increase in medical care
costs. This increase suggested that costs of treating
adhesiolysis have increased substantially.
Primary adhesiolysis contributed 23% of all adhesioly-
sis procedures (81,532) but represented more t han half
of the total cost burden ($1.3 billion). Secondary adhe-
siolysis was substantially higher in volume, representing
77% of procedures (270,245) but less half of the total
cost burden ($902 million). The greatest number of pro-
cedures was to the female reproductive trac t (125,069)
while pr ocedures to the digestive tract yielded the high-
est overall costs ($622 million).
Potentially mitigating this growth in the cost of adhe-
siolysis may be the continuing trend in the US toward
minimally invasive and laparoscopic approaches, which
may lessen the occurrence of postoperative adhesions
[2]. Although laparoscopy reduces surgical trauma, the
Table 3 Rate of Adhesiolysis-Related Hospitalizations
Characteristic Estimated
Hospitalizations
Rate of Hospitalizations per
100,000 in the US
Population
a
Rate of Hospitalizations per
100,000 Hospitalized
Persons
b
Rate of Hospitalizations per 100,000
Hospitalized Persons for Surgical
Intervention
c
Total number 351,777 118.64 898.22 3,549.04
Adhesiolysis,
primary
procedure
81,532 27.50 208.18 822.57
Adhesiolysis,
secondary
procedure
270,245 91.14 690.04 2,726.47
US = United States.
a
Based upon the US Census Bureaus 2005 population estimate.
b
Among all hospitalizations.
c
Among all hospitalized surgical patients.
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Table 4 Demographics and Other Patient- and Facility-Specific Characteristics of Interest Among Adhesiolysis-Related Hospitalizations (i.e., DRG 150 or 151)
in the US in 2005
Primary Procedure (N = 81,532) Secondary Procedure (N = 270,245)
Characteristic Estimated
Hospitalizations
Hospitalizations
per 100,000
Population
Rate of
Hospitalization
(All
Hospitalizations)
Rate of
Hospitalization
(Surgical
Hospitalizations)
Estimated
Hospitalizations
Hospitalizations
per 100,000
Persons
Rate of
Hospitalization per
100,000
Hospitalizations
Rate of Hospitalization per
100,000 Hospitalizations With
Surgical Procedure
Age (years)
< 25 5,297 5.15 56.19 456.49 14,212 13.82 150.75 1,224.79
25-34 5,402 13.46 133.39 419.16 46,483 115.79 1,147.76 3,606.77
35-44 11,106 25.32 308.40 888.83 71,062 162.00 1,973.28 5,687.19
45-54 15,691 36.93 372.13 1,142.65 52,732 124.11 1,250.61 3,840.06
55-64 14,324 47.19 322.36 970.96 27,644 91.07 622.13 1,873.86
65-74 13,615 73.00 276.54 877.54 25,980 139.30 527.70 1,674.52
75 16,034 88.40 189.72 893.19 32,047 176.69 379.20 1,785.20
Missing 64 125.96 352.54 86 169.25 473.72
Gender
Female 52,579 34.93 228.80 874.57 230,422 153.07 1002.71 3,832.69
Male 28,696 19.66 178.76 746.39 39,614 13.36 246.77 1,030.37
Missing 256 195.29 463.40 208 158.68 376.51
Race/ethnicity
Caucasian 47,344 19.90 241.10 889.04 134,079 56.36 682.79 2,517.78
African-
American
6,325 16.69 186.29 920.21 31,153 82.19 917.53 4,532.39
Other
a
7,398 35.71 133.96 591.38 37,206 179.59 673.71 2,974.15
Missing 20,466 192.91 772.80 67,808 639.14 2,560.44
Admission source
ER 38,748 232.79 1,553.63 55,369 332.64 2,220.06
Another
facility
2,274 119.81 524.63 4,666 245.83 1,076.48
Other
b
40,509 196.45 579.99 210,210 1,019.41 3,009.70
Discharge status
Routine 63,979 220.83 865.62 225,752 779.22 3,054.37
Transfer to
short-term
hospital
579 68.15 882.96 1,324 155.85 2,019.06
Skilled
nursing
facility
7,252 152.54 567.78 16,752 352.36 1,311.57
Died in
hospital
1,439 175.74 989.64 4,662 569.34 3,206.17
Other
c
8,282 219.70 802.10 21,755 577.11 2,106.94
Primary source of
payment
Medicare 32,085 220.41 913.00 63,421 435.68 1,804.68
Medicaid 7,445 97.42 560.04 37,547 491.32 2,824.44
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Table 4 Demographics and Other Patient- and Facility-Specific Characteristics of Interest Among Adhesiolys is-Related Hospitalizations (i.e., DRG 150 or 151)
in the US in 2005 (Continued)
Private
Insurance
36,057 263.49 848.19 150,852 1,102.37 3,548.56
Other
d
5,853 181.10 731.63 18,280 565.60 2,285.01
Missing 91 186.24 528.76 145 296.76 842.53
Hospital region
Northeast 16,376 29.95 211.20 857.55 55,070 100.71 710.24 2,883.80
Midwest 18,994 28.81 210.56 838.51 57,623 87.39 638.80 2,543.83
South 31,772 29.54 212.63 849.84 108,511 100.89 726.20 2,902.44
West 14,389 21.06 193.21 720.01 49,041 71.76 658.51 2,453.96
Hospital location/
teaching status
Urban 70,728 208.10 787.13 237,845 699.81 2,646.96
Rural 10,804 208.70 1,166.35 32,399 625.86 3,497.65
Hospital bed size
e
Small 10,532 218.05 1,001.92 32,559 674.10 3,097.36
Medium 20,062 206.81 861.57 63,964 659.39 2,746.96
Large 50,938 206.78 779.80 173,721 705.23 2,659.47
Hospital teaching
status
Teaching 32,737 200.09 698.61 108,747 664.68 2,320.66
Nonteaching 48,795 213.99 933.72 161,498 708.23 3,090.37
Hospital control
Government
or private,
collapsed
47,163 207.20 775.62 155,489 683.12 2,557.11
Government,
nonfederal,
public
5,150 197.77 978.84 16,048 616.29 3,050.19
Private,
nonprofit,
voluntary
16,957 208.70 832.92 58,180 716.06 2,857.76
Private,
investor
owned
8,419 205.72 867.45 30,627 748.36 3,155.64
Private,
collapsed
3,843 243.13 1,286.57 9,901 626.39 3,314.69
DRG = diagnosis-related group; HCUP = Healthcare Cost and Utilization Project; NHDS = National Hospital Discharge Survey; US = United States.
a
Other category includes Hispanic, Asian/Pacific Islander, Native American, and other HCUP category (no further information provided in the data dictionary).
b
Other category includes court and law enforcement, and routine, including other HCUP category (no further information provided in the data dictionary).
c
Other category includes home health, against medical advice, and alive but destination unknown.
d
Other category includes self-pay, no charge, and other HCUP category (no further information provided in the data dictionary).
e
Hospital bed size is based upon facility-specific geographic location and teaching status. These allocations are from the NHDS classification grid.
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Table 5 Inpatient Care Attributable to Abdominal Adhesiolysis by Surgical Procedure in the US in 2005
Reason for Hospitalization Mean Length of Stay (Days)
(Diagnosis-Related Group) Adhesiolysis Nonadhesiolysis AttributedLOS
(Days)
Number of
Adhesiolysis-Related
Hospitalizations
Attributed
Days of
Care
Rate of Days
Due to
Adhesiolysis
Adhesiolysis only (DRG 150, 151) 7.76 7.76 81,532 632,688 7.76
Adhesiolysis as a Secondary Procedure
Digestive System
DRG 148: Major small and large
bowel procedures with CC
13.87 10.57 3.30 64,588 213,140 3.30
DRG 149: Major small and large
bowel procedures without CC
6.30 5.20 1.10 9,313 10,244 1.10
DRG 154: Stomach, esophageal,
and duodenal procedures with
CC
16.41 11.84 4.57 7,183 32,826 4.57
DRG 468: Extensive OR
procedures unrelated to principal
diagnosis
16.12 11.25 4.87 3,491 17,001 4.87
Digestive System Total —— 84,575 273,212 3.23
Hepatobiliary System
DRG 197: Total cholecystectomy
without CDE with CC
8.66 8.10 0.56 4,698 2,631 0.56
DRG 493: Laparoscopic
cholecystectomy without CDE
with CC
5.99 5.21 0.78 9,568 7,463 0.78
DRG 494: Laparoscopic
cholecystectomy without CDE
without CC
2.70 2.46 0.24 6,811 1,635 0.24
Hepatobiliary System Total —— 21,077 11,729 0.56
Female Reproductive System
DRG 358: Uterine and adnexa
procedures for nonmalignancy
with CC
3.90 3.00 0.90 38,263 34,437 0.90
DRG 359: Uterine and adnexa
procedures for nonmalignancy
without CC
2.46 2.14 0.32 81,543 26,094 0.32
DRG 361: Laparoscopy and
incisional tubal interruption
2.80 2.58 0.22 484 106 0.22
DRG 365: Other female
reproductive system OR
procedures
4.81 5.57 -0.76 4,779 -3,632 -0.76
Female Reproductive System
Total
—— 125,069 57,005 0.46
Pregnancy, C-Section
DRG 370: Cesarean section with
CC
4.30 4.45 -0.15 9,901 -1,485 -0.15
DRG 371: Cesarean section
without CC
3.12 3.37 -0.25 26,011 -6,503 -0.25
DRG 378: Ectopic pregnancy 2.16 1.97 0.19 3,612 686 0.19
Pregnancy, C-section Total —— 39,524 -7,302 -0.18
Total, Adhesiolysis as a secondary
procedure
—— 270,245 334,644 1.24
Total, all adhesiolysis-related
procedures
—— 351,777 967,332 2.75
CC = complications and comorbidities; DRG = diagnosis-related group; LOS = length of stay; US = United States.
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procedure has not been show to reduce the incidence of
adhesion-related readmissions [16].
This study is subject to potential limitations consistent
with retrospective database studies. Con ditions and
events of interest were identified by diagnosis codes.
Previous research has sugg ested that the condition may
be underreported [17]. This may mean that the actual
cost of adhesiolysis-related disease is greater than the
estimate provided by our study. The database used for
this s tudy was not specifically designed to assess inpa ti-
ent burden. Like all administrative billing databases, the
data contained in the HCUP NIS are dependent upon
the quality of coding, which may be influenced by reim-
bursement incentives. However, we do not feel it likely
that such incentives greatly affected our results since the
majority of overall a dhesiolysis costs were a part of sec-
ondary adhesiolysis procedures and not the more co stly
primary adhesiolysis. Moreover, even if such incentives
exist and are reflected in the data used for this study,
these data are indicative of real world practice. Addi-
tionally, with such a large sample, the ef fect of any cod-
ing errors or anomalies would likely be minimized.
Furthermore, due to the nature of the database, detailed
clinical characteristics could not be ascertained; therefore,
the results could not be adjusted for disease severity or
other clinical parameters. However, it is unlikely that these
factors would have had a large impact on the results, as
this study focused on those patients receiving inpatient
care. Additionally, since the database contains US data
only, the results may not be generalizable to other popula-
tions outside of the US. Lastly, because the focus of this
study was on direct cost measures, the results do not
account for productivity loss for the patient or caregiver
and potential future societal contributions that may be lost
due to death resulting from or related to adhesiolysis.
Because we examined only the direct health care costs
associated with inpatient adhesio lysis, we have not exam-
ined any adhesiolysis-related surgeries performed at other
sites of care, such as ambulatory surgical centers. Further,
our study does not c apture di rect costs relating to but
occurring before or after surgery, including pain medica-
tions, cost of work-up visits, and procedures related to
diagnosis. Similarly, patient work-ups and di agnostic
laparoscopic procedures that may have occurred at
Table 6 Inpatient Expenditures Attributable to Abdominal Adhesiolysis in the US in 2005
Expenditure Attributed to Adhesiolysis Total in Millions (2007 $)
By type of procedure
Adhesiolysis as primary procedure
Total days of care 632,688 $1,277
Surgical procedures 81,532 $68
Subtotal $1,345
Adhesiolysis as secondary procedure
Total days of care 334,644 $675
Surgical procedures 270,245 $227
Subtotal $902
Cost stratification of secondary adhesiolysis, by body system
Digestive system
Total days of care 273,212 $551
Surgical procedures 84,575 $71
Subtotal $622
Hepatobiliary system and pancreas
Total days of care 11,729 $24
Surgical procedures 21,077 $18
Subtotal $41
Female reproductive system
Total days of care 57,005 $115
Surgical procedures 125,069 $105
Subtotal $220
Pregnancy, C-sections
Total days of care -7,302 -$15
Surgical procedures 39,524 $33
Subtotal $18
Total expenditures $2,247
US = United States.
Sikirica et al. BMC Surgery 2011, 11:13
http://www.biomedcentral.com/1471-2482/11/13
Page 8 of 9
Page 8
separate visits and prior to the adhesiolysis surgery were
not captured if specific DRG codes were not listed for
those hospitalizations [6,7,9]. Hence, this studys estimates
of costs are likely to be conservative.
Conclusions
Adhesions r emain an important surgical problem, and
hospitalization for adhesiolysis leads to a high direct
cost burden in the US. Despite a trend of decreasing
LOS for adhesiolysis-related hospitalizations from 2001
to 2005, adhesiolysis-related costs continue to rise even
while the overall rate of adh esiolysis procedures remains
constant. Consistent with previous research, the distri-
bution of inpatient care a nd costs across the diagnostic
categories remained steady from 2001 to 2005 , with
only a slight increase in primary adhesiolysis procedures
over time. From 2001 to 2005, hospitalizations for adhe-
siolysis related to the digestive system and to the female
reproductive tract had the largest number of inpatient
days and accounted for the majority of costs r elated to
secondary adhesiolysis procedures.
Adhesiolysis remains a substantial economic burden to
the US health care system, which should be of interest
to providers and commercial and government payers.
Further research incorporating detailed clinical data and
indirect costs would aid in a greater understanding of
the overall burden of adhesiolysis.
Funding
This study and the preparation of this manuscript were
funded by Ethicon, Inc. The authors acknowledge that
Ethicon, Inc. is the maker of GYNECARE INTERCEED,
a product that is marketed to prevent pelvic adhesions.
Acknowledgements
Portions of the study data presented in this paper were previously
presented as a podium presentation at the VIII
th
PAX Meeting; Clermont-
Ferrand, France; September 18-20, 2008, as well as a poster presentation at
the 57
th
Annual Clinical Meeting of the American College of Obstetricians
and Gynecologists; Chicago, Illinois; May 2-6, 2009.
The authors wish to thank Ms. Gail Zona of RTI Health Solutions and Ms.
Heidi Waters of Ethicon, Inc., for assistance with preparing this manuscript.
Author details
1
Shire Pharmaceuticals, Wayne, PA 19087 USA.
2
RTI Health Solutions, 200
Park Offices, Research Triangle Park, NC 27709 USA.
3
The Christie NHS
Foundation Trust, Manchester, M20 4BX, UK.
4
Texas Health Care, Fort Worth,
TX 76109 USA.
Authors contributions
VS was responsible for developing the study design, interpreting the analysis
results, and drafting the manuscript text; he is the primary author of this
manuscript. BB, SDC, and KLD were responsible for the acquisition,
management, inter pretation, and analysis of all study data. BB, SDC, and KLD
also assisted with developing the study design, interpreting the analysis
results, and drafting the manuscript. AJ and MW contributed clinical
expertise and guidance and assisted in interpreting the analysis results and
drafting the manuscript text.
All authors confirm that they have read the journals position on issues
involved in ethical publication and affirm that this research report is
consistent with those guidelines. Finally, all authors have read and approved
the final manuscript.
Competing interests
VS was an employee of Ethicon, Inc. at the time that this manuscript was
prepared; he is currently an employee of Shire Pharmaceuticals. BB, SDC, and
KLD are employees of RTI Health Solutions, the research organization
contracted by Ethicon to conduct this study. AJ is an employee of Texas
Healthcare; MW is an employee of Christie NHS Foundation Trust.
Received: 5 January 2011 Accepted: 9 June 2011 Publi shed: 9 June 2011
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Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2482/11/13/prepub
doi:10.1186/1471-2482-11-13
Cite this article as: Sikirica et al.: The inpatient burden of abdominal and
gynecological adhesiolysis in the US. BMC Surgery 2011 11:13.
Sikirica et al. BMC Surgery 2011, 11:13
http://www.biomedcentral.com/1471-2482/11/13
Page 9 of 9
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    • "It is estimated that up to 34% of post-operative patients are readmitted for reasons related to adhesions within the next decade (Lower et al., 2000; Parker et al., 2001). The end result is an enormous financial burden attributable to post-operative adhesions—an estimated annual total of $2.3 billion for the cost of hospitalizations for adhesiolysis in the USA (Sikirica et al., 2011).Figure 1 summarizes the common clinical sequelae of post-operative adhesions. "
    [Show abstract] [Hide abstract] ABSTRACT: BACKGROUND Adhesion development is the most common sequelae of intra-abdominal and pelvic surgery and represents a significant, yet poorly understood, cause of morbidity among post-operative patients. It remains unclear, for example, exactly why adhesions form more frequently in certain tissues and/or patients, or at specific locations within them, as opposed to others. This review contributes to the growing knowledge pool by elucidating factors that potentially predispose to the development of adhesions. Given the strong correlation between a hypofibrinolytic state and adhesion formation, this review article will examine not only those factors that have been shown to directly predispose to adhesion development, but also those that are likely do so indirectly by means of altering the coagulation/fibrinolytic profile.
    No preview · Article · May 2015 · Human Reproduction Update
  • Source
    • "Postoperative adhesions are also associated with a large economic burden. In the United States during 1994, adhesion was responsible for about 300,000 hospitalizations and the estimated annual costs for adhesiolysis was 1.3 billion U.S. dollars [6]. In 2005, the number of adhesiolysis-related hospitalizations was approximately $350,000 and the costs for adhesiolysis increased another 1.0 billion U.S. dollars [7] In the field of liver surgery, repeated hepatectomy has been widely performed as one of the most curative treatments for primary and secondary liver cancers. Therefore, hepato-pancreatico-biliary surgeons are not free from concerns about postoperative adhesions8910111213. "
    [Show abstract] [Hide abstract] ABSTRACT: Postoperative adhesion is a critical clinical issue after almost all abdominal or pelvic surgeries including liver surgery. Postoperative adhesion causes several complications, such as small bowel obstruction and chronic abdominal pain. Furthermore, it makes reoperation much more difficult, leading to increased mortality and morbidity rate. Postoperative adhesion is particularly problematic for repeated hepatectomy, since hepatic malignant neoplasm recurs frequently and repeated hepatectomy is widely used as one of the most curative treatments. Several treatments to reduce postoperative adhesion have been developed, which include laparoscopic surgery, administration of pharmacological agents and use of prophylactic barrier materials. However, none of them are optimal. We have proposed a novel treatment using a cell sheet of fetal liver mesothelial cells (FL-MCs) to prevent postoperative adhesion in a novel mouse model. Besides adhesion, repeated hepatectomy has another serious problem; although the liver has a remarkable ability to regenerate, the recovery of liver mass and function of the remnant liver after multiple repeated hepatectomy is limited. The FL-MC cell sheet enhances proliferation of hepatocytes after hepatectomy by providing growth factors for hepatocytes. Thus the FL-MC sheet could simultaneously solve the two problems associated with repeated hepatectomy. © 2015 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
    Preview · Article · Apr 2015 · Journal of Hepato-Biliary-Pancreatic Sciences
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    • "Management of bowel obstructions typically involves a period of non-operative management, which often varies based upon the timing of their presentation and admission. This is important, as small bowel obstructions (SBO) represent a common reason for emergency room visits, hospitalizations, and patient morbidity and mortality, comprising nearly 15% of all emergency room visits for abdominal pain and roughly 300 000 hospital admissions yearly in the United States [1, 2]. Recently, there have been multiple studies analysing the “weekend effect”: that is, do patient management and outcomes differ, based on the time of admission? "
    [Show abstract] [Hide abstract] ABSTRACT: Aims: To determine whether day and time of admission influences the practice patterns of the admitting general surgeon and subsequent outcomes for patients diagnosed with small bowel obstruction. Methods: A retrospective database review was carried out, covering patients admitted with the presumed diagnosis of partial small bowel obstruction from 2004–2011. Results: A total of 404 patients met the inclusion criteria. One hundred and thirty-nine were admitted during the day, 93 at night and 172 on the weekend. Overall 30.2% of the patients were managed operatively with no significant difference between the groups (P = 0.89); however, of patients taken to the operating room, patients admitted during the day received operative intervention over 24 hours earlier than those admitted at a weekend, 0.79 days vs 1.90 days, respectively (P = 0.05). Overall mortality was low at 1.7%, with no difference noted between the groups (P = 0.35). Likewise there was no difference in morbidity rates between the three groups (P = 0.90). Conclusions: Despite a faster time to operative intervention in those patients admitted during the day, our study revealed that time of admission does not appear to correlate to patient outcome or mortality.
    Full-text · Article · Jul 2014
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