Simultaneous pancreas-kidney transplantation and the impact of postoperative complications on hospitalization cost

1 Federal University of Sao Paulo, Discipline of Surgical Gastroenterology, Sao Paulo, SP, Brazil. 2 Oswaldo Ramos Foundation/Kidney Hospital, Sao Paulo, SP, Brazil. 3 Federal University of Sao Paulo, Discipline of Economics and Management in Health, Sao Paulo, SP, Brazil. Carlotto Simultaneous pancreas-kidney transplantation and the impact of postoperative complications on hospitalization cost. 2 Rev Col Bras Cir 46(1):e2096 SPKT with complications is questionable and literature is unclear on what types of complications actually impact SPKT patients’ hospitalization cost. The objective of this study is to compare hospitalization costs for SPKT with and without complications, as well as the different types of complications. We also detail hospitalization costs according to the presence of complication, type of complication, reoperation, and graft pancreatectomy.


S
imultaneous pancreas-kidney transplantation (SPKT) is the main procedure performed for pancreas transplantation 1 .It is mainly indicated for diabetic patients with terminal chronic kidney disease (CKDT) 2 .SPKT assures normal levels of glycemia and glycosylated hemoglobin (HbA1c), allows dietary freedom and exogenous insulin independence, and prevents chronic complications related to diabetes 3 .However, SPKT has a significant incidence of complications.In more than 100 simultaneous transplantations, Campos Hernández et al. 4 have described 65.5% of cases with postoperative complications.Banga et al. 5 have reported 23% of surgical complications in almost 200 SPKT cases.
Morbidity experienced in SPKT is one of the largest among abdominal visceral transplantations.
The emergence and incorporation of new technologies in patient care, associated to the management of limited and finite resources for health financing, have aroused the interest of analytical studies concerning surgical patients' care cost.Some studies have shown that the presence of postoperative complications have increased the care cost in oncological, hepatic, pancreatic, and bariatric surgeries, as well as in liver transplantation (LT) [6][7][8][9][10][11] .However, the relationship of postoperative complications in SPKT with hospitalization cost has only been studied in literature by two groups and in a limited way [12][13][14] .Therefore, the financial viability of Original Article

RESULTS
The sample consisted of 179 SPKT patients.

Demographic characteristics of recipients and donors,
as well as the implant characteristics, are described in tables 1 and 2. Comparing patients with and without postoperative complications, the samples are similar, except on recipients' hospitalization, ICU, and ward days, and sodium levels of donors.In the multivariate analysis of postoperative complications and hospitalization cost, the presence of internal hernia, acute myocardial infarction, stroke, and pancreatic graft dysfunction did not statistically interfere in SPKT patient's hospitalization cost (Table 5).In Brazil's public health system, the average hospitalization cost of a SPKT patient was US$ 20,594.16,regardless of the presence or absence of complications.  4 and Jiménez-Romero et al. 15 have described more than 60% of cases with postoperative complications.
The results of this research sample showed that the presence of reoperation, graft pancreatectomy, and postoperative complications increased the hospitalization cost of SPKT (p<0.001).However, there was no statistical difference in relation to death during hospitalization (p=0.061).Up to now, there are only three papers in world literature that associate postoperative complications with hospitalization cost after SPKT [12][13][14] .Gruessner et al. 12 and Troppmann et al. 13 have published a same series of patients and demonstrated an increase of 66.17% in the cost of transplanted patients who have undergone reoperation after SPKT.Cohn et al. 14 have reported that, in SPKT patients with some postoperative surgical complication, hospitalization cost has increased by 27%.
The results of our sample showed that, in the presence of reoperation, graft pancreatectomy, and postoperative complication, the total hospitalization cost of SPKT increased by 53.3%, 78.57%, and 58%, respectively.Death was one of the few variables that were not related to the increase of hospitalization value of SPKT.Results showed that recipients who evolved to death had an average hospitalization of 18.27 days and ICU stay of 5.4 days (21.89% and 179%, respectively, lower than recipients with any other type of complication).Therefore, we conclude that death does not increase the total hospitalization cost of SPKT patients, because it reduces the length of hospital stay and ICU days and the consumption of supplies.However, death is also related to indirect costs, that is, productivity loss of patients in the labor market and, therefore, this fact implies an inestimable financial loss for society.
This study ratified results previously presented in literature, and, above all, it added value because of its suitable methodology from the sampling and financial point of view.
In this study, when we estimated the mean income of a SPKT and the mean expenditure of patients with and without complications, SPKT represented a profit of US$ 6,782.66 in patients without postoperative complication.However, in patients who had some postoperative complication, SPKT represented a deficit of US$ 1,237.44.
Therefore, an uncomplicated transplant was needed to pay for five complicating transplants. We Initial immunosuppression for SPKT included tacrolimus, prednisone, and mycophenolate sodium in all cases.Intraoperative induction was performed with methylprednisolone and basiliximab.Thymoglobulin was used as an induction therapy in patients with a panel-reactive antibody (PRA) test greater than 30%.Preferably, the pancreas was implanted first (PBK) and into the right iliac fossa.Endocrine pancreatic drainage was performed for the iliac vessels or inferior vena cava (IVC), and exocrine pancreatic drainage was performed for the terminal ileum.Patients' clinical data were obtained through the documentary and electronic database of Kidney Hospital/Oswaldo Ramos Foundation, as well as through the written records of patients' hospitalization and the donation forms of the transplant center.Postoperative complications in the recipient were divided into four groups: surgical, infectious, clinical, and immunological.The analysis was limited to complications diagnosed during hospitalization for SPKT.The raw financial data were provided by the management and information technology team of Kidney Hospital/Oswaldo Ramos Foundation and obtained through Philips Tasy Electronic Medical Record (USA).These individual pieces of information from each patient presented the supply, service, or environment utilized by the patients, their unit cost, and the number of times or the period of use.All data were grouped, summed up, and subdivided into five categories of expenditures: supplies, medical fees, surgical center, intensive care unit (ICU), and ward.After summing up the five categories, a percentage of administrative expenses was added, comprising all indirect costs related to the patient who underwent SPKT.The value was also adjusted according to the National Broad Consumer Price Index (IPCA, in Portuguese) of the Brazilian Institute of Geography and Statistics (IBGE) and corrected monthly.Subsequently, the resulting product was converted into dollars.
also studied the relationship among different types of postoperative complications and SPKT patient's hospitalization cost.The presence of surgical (p<0.001),infectious (p<0.001),clinical (p=0.019), and immunological (p<0.001)postoperative complications increased hospitalization cost of SPKT patients.However, in the multiple comparisons of each type of complication, the presence of internal hernia, acute myocardial infarction, stroke, and pancreatic graft dysfunction did not interfere in the total hospitalization cost of SPKT.There are no other papers in literature that associate the type of postoperative complication with SPKT patient's hospitalization cost.This research is an unpublished study that demonstrates what types of postoperative complications actually increase SPKT patient's hospitalization value.Interpreting results, we believe that the correction of an internal hernia without ischemia or intestinal necrosis does not significantly increase the length of hospital stay, nor does the need for insulin at the time of hospital discharge interfere in SPKT patients' hospitalization cost.However, cardiovascular complications, such as acute myocardial infarction and stroke, are related to death during hospitalization and, consequently, to a shorter hospital stay.

Table 3 .
Summary measures of SPKT patients' hospitalization costs, according to reoperation, graft pancreatectomy, and death.

Table 4 .
Summary measures of SPKT patients' hospitalization costs, according to the most frequent postoperative complications.

Table 5 .
Results of multiple comparisons among different types of postoperative complications.
Transplantes.Transplante de Pâncreas.Complicações Pós-Operatórias.Economia Médica.Custos e Análise de Custo.Hospitalização.Its relevance is related to its sample size, manual and meticulous collection of financial data, and economic corrections caused by administrative expenditures and monthly inflation.Its weakness is associated with the period of data collection, which is restricted to the hospital stay period caused by SPKT.We think that the ideal would be a period of three months to a year, because the pancreaskidney transplant patient, after hospital discharge, presents several episodes of new hospitalizations due to complications, and these new hospitalizations also have an impact on the financial value of this SPKT patient.However, post-hospitalization data collection is not feasible in our system and the financial data from these services are not available.Cost-benefit, cost-utility, and cost-effectiveness studies are essential for fund management and to answer questions about how society's resources can be best allocated among different health programs.