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Hospitalization Costs and Resource Allocation in Cholecystectomy with Use of Intravenous Versus Oral Acetaminophen cover

Medicine

Medicine

Hospitalization Costs and Resource Allocation in Cholecystectomy with Use of Intravenous Versus Oral Acetaminophen

Ryan N. Hansen et al.

A graduate-level observational study comparing intravenous and oral acetaminophen as adjunct analgesics in cholecystectomy patients, analyzing impacts on length of stay, hospitalization costs, opioid consumption, and postoperative complication rates.

Difficulty Level
Advanced
Academic Level
Graduate
perioperative analgesiacholecystectomyhealthcare economicspain managementclinical researchcost effectiveness

01 / Research article

Research article

Citation

Hansen, R. N., Pham, A. T., Böing, E. A., Lovelace, B., Wan, G. J., Thomas, D. A., & Fontes, M. L. (2018). Hospitalization costs and resource allocation in cholecystectomy with use of intravenous versus oral acetaminophen. Current Medical Research and Opinion, 34(9), 1549–1555. https://doi.org/10.1080/03007995.2017.1412301

Chapter Summary

This is a seven-page research article rather than a book, so its structure is that of a structured abstract and the standard sections of a journal paper. It reports a retrospective analysis of hospital data on patients having gallbladder surgery (cholecystectomy), comparing those who received intravenous (IV) acetaminophen with those who received oral acetaminophen as part of pain management.

Objective

The authors set out to evaluate IV acetaminophen (APAP) versus oral APAP as adjunctive analgesics in cholecystectomy patients. They compare the two groups on hospital length of stay (LOS), hospital costs and opioid use, and on rates of nausea and vomiting, respiratory depression and bowel obstruction, outcomes tied to opioid-related harm.

Methods

The study is a retrospective analysis of the Premier Database from January 2012 to September 2015, including cholecystectomy patients who received either IV or oral APAP. Differences in LOS, hospitalization costs, mean daily morphine equivalent dose (MED) and potential opioid-related adverse events were estimated. Binary outcomes were analysed with multivariable logistic regression; continuous outcomes with instrumental variable regressions in two-stage least squares models, using the quarterly rate of IV APAP use for all hospitalizations at each hospital as the instrument. Models adjusted for patient demographics, clinical risk factors and hospital characteristics.

Results

Of 61,017 cholecystectomy patients, 31,133 (51%) received IV APAP. Patients averaged 51 years of age in the IV group and 57 in the oral group. In adjusted models, IV APAP was associated with a 0.42-day shorter length of stay, $1,045 lower hospitalization costs, a 2 mg lower average daily MED, and lower rates of respiratory depression (odds ratio 0.89) and of nausea and vomiting (odds ratio 0.86).

Conclusions

The authors conclude that adding IV APAP to perioperative pain management is associated with shorter stays, lower costs, reduced opioid use and less frequent nausea, vomiting and respiratory depression compared with oral APAP. They state that the findings should be confirmed in a prospective study comparing the two routes.

Key Concepts

Design and Analysis

  • Retrospective database analysis: patients are identified from existing hospital records rather than enrolled and followed.
  • Instrumental variable regression: an approach to continuous outcomes that uses the hospital's quarterly rate of IV APAP use as the instrument, intended to reduce confounding by differences between patients.
  • Two-stage least squares: the estimation method used with the instrument for length of stay, costs and opioid dose.
  • Multivariable logistic regression: used for yes/no outcomes such as respiratory depression.

Outcomes

  • Length of stay and hospitalization costs: the resource-use outcomes in the title.
  • Morphine equivalent dose (MED): a common scale for comparing opioid use.
  • Opioid-related adverse events: nausea and vomiting, respiratory depression and bowel obstruction.

Critical Analysis

Strengths

  • Large sample. The analysis covers 61,017 patients, with about half in each group, giving narrow intervals for most estimates.
  • Attention to confounding. The patients in the two groups differ (the abstract reports different average ages), and the authors address this with adjustment for demographics, risk factors and hospital characteristics, and with an instrumental variable approach for continuous outcomes.
  • Clinically and economically relevant outcomes. Length of stay, cost, opioid dose and opioid-related adverse events all matter to hospitals and patients.
  • Candid conclusion. The authors explicitly call for a prospective study to confirm the results.

Limitations

  • Observational design. An association in routinely collected data cannot show that IV APAP caused the shorter stays or lower costs, as the authors' call for prospective confirmation acknowledges.
  • Instrument assumptions. The instrumental variable approach depends on the hospital-level rate of IV APAP use affecting outcomes only through the drug a patient receives; readers should check how the full paper supports this.
  • Reported precision. The abstract gives a confidence interval for the nausea and vomiting odds ratio of 0.86 to 0.86, which suggests rounding and is worth checking in the full text.
  • Industry affiliation. Three of the authors are affiliated with the health economics and outcomes research department of a pharmaceutical company (Mallinckrodt Pharmaceuticals); funding and disclosures should be read in the full paper.

Where It Fits in the Course

This article is a worked example on the research articles list for practising critical appraisal. Three books on the list teach the skills: How to Read a Paper is a short, readable introduction to finding, reading and appraising clinical research and the questions to ask of each type of study; Evidence-Based Medicine: How to Practice and Teach EBM follows the steps of evidence-based medicine, including appraising studies of therapy, diagnosis, prognosis and harm; and Testing Treatments explains in plain terms why fair tests are needed and how bias and chance can mislead.

Among the other articles on the list, the study of variation in inotrope use in cardiac surgery is also an observational analysis, whereas this one compares two treatments, so it raises the question of confounding more directly. A study of perineural glucocorticoids in hip arthroplasty gives a contrast in clinical setting. Reading this paper after the appraisal books lets a student apply their checklists to a real comparison of two treatments.

How to Use This Book

The article suits students and clinicians learning to read observational comparative-effectiveness studies; basic familiarity with regression and with the idea of confounding is enough to begin.

  • Read the abstract first, then locate each element in the full paper: the population, how IV and oral APAP were defined, outcomes and follow-up.
  • Ask appraisal questions from the guide books: Were the groups comparable at baseline? What confounders could remain? Is the effect size clinically meaningful?
  • Check the instrument: how the paper justifies using the hospital's quarterly IV APAP rate, and what it assumes.
  • Compare the findings with the stated conclusion: do the results show association or cause, and does the paper acknowledge this?
  • Look up the funding and disclosure statements and consider how they bear on the interpretation.
  • Draft a one-paragraph critical summary before reading any commentary, and compare it with the appraisal frameworks in the books above.