Incidence and estimated annual cost of emergency laparotomy in England: is there a major funding shortfall?*

Abstract

Significant recent interest has focussed on improving outcomes after emergency laparotomy. This retrospective database analysis estimated the annual incidence and associated inpatient costs of emergency laparotomy in England. Demographic, process and outcome data were collected for all patients undergoing emergency laparotomy in Brighton for two calendar years (2009-2010). Cost analysis assumed £16 per minute theatre time, and £282 per day ward bed and £1382 per day critical care bed costs. National incidence was confirmed from Hospital Episode Statistics and Office of National Statistics mid-year population data. In total, 768 patients underwent 850 emergency laparotomies. The incidence of emergency laparotomy was estimated as ∼1:1100 population. Thirty-six percent (276 patients) were admitted for a median (IQR [range]) of 5 (3-11 [1-76]) days of critical care. Postoperative median (IQR [range]) length of stay was 13 (8-24 [1-176]) days. Our estimated annual inpatient cost of emergency laparotomy for Brighton was ∼£5 million, equivalent to ∼£13 000 per patient, and for England, an annual estimated cost of ∼£650 million. However, 'Payment by Results' reimbursement amounted to a mean (SD) hospital income of just £6905 (2639) per patient, a net financial loss of ∼£6100 per patient, equivalent to a reimbursement shortfall nationally of ∼£300 million. We also found that patients > 70 years (46%) had significantly higher 30-day postoperative mortality (18% vs 6%, p < 0.0001), significantly prolonged median (IQR [range]) length of stay (15 (10-26 [1-123]) days vs 12 (7-22 [1-176]) days, p < 0.001) and incurred higher costs (median (IQR [range]) £9667 (6620-15 732 [1920-103 624]) vs £7467 (4975-14 251 [1178-118 060]), p < 0.001). Emergency laparotomy is a common procedure associated with considerable cost, particularly among elderly patients. A National Emergency Laparotomy Database will help provide an evidence base on which to improve clinical outcome and cost efficiency.

Emergency surgery: the big three – abdominal aortic aneurysm, laparotomy and hip fracture

“…Cook and Day reported an in-hospital postoperative mortality among elderly emergency laparotomy patients aged~80 years of 44% in 1998 [34] and 42% in 2007 [35], similar to other recent studies in the UK (21% 30-day aged over 70 years [36]) and USA (32% for emergency colorectal surgery in octogenarians [37]). In a prospective audit of almost 1900 patients undergoing emergency laparotomy, the UK Emergency Laparotomy Network reported a direct relationship between age and 30-day mortality; for patients in their 50s, mortality was 10%, increasing by~5% per decade, such that patients in their 80 s had a 30-day mortality of 24.4% and in their 90 s, 32% [5].…”

Cost‐effectiveness of a quality improvement bundle for emergency laparotomy

“…This is similar to the average expenses reported by Shapter and colleagues9 of £13 000 (€16 676·40) and by Murray and co‐workers34 of median £9282 (range 6222–14 400) (€11 906·95 (7981·58–18 472·32)). Although there are variations in NHS reimbursement rates (payment by results tariffs) of approximately £4000–7000 (€5131·20–8979·60) per emergency case35, these results confirm that significant NHS funding deficits exist for each patient (funding shortfall of £4550–6450 (€5836·74–8274·06)).…”

“…Implementation costs, costs due to increased ICU admissions, and the presence of consultant surgeons and consultant anaesthetists may increase the hospital expenditure costs for survivors and lead to increased hospital costs. This problem is further aggravated by the current UK National Health Service (NHS) reimbursement scheme, which not only incurs a significant shortfall for emergency laparotomy9 10 but also, owing to a lack of long‐term outcomes and cost‐effectiveness studies, often ignores potential long‐term cost savings for society.…”

Survival After Emergency General Surgery: What can We Learn from Enhanced Recovery Programmes?

“…In the UK, it has been estimated that an emergency laparotomy is carried out each year for every 1100 patients [7]. This would approximate to 55,000 operations carried out per year, and based on 14.6 % mortality, potentially 8000 deaths.…”