In-hospital costs of an admission for adhesive small bowel obstruction
Krielen et al. World Journal of Emergency Surgery
In-hospital costs of an admission for adhesive small bowel obstruction
Pepijn Krielen 0
Barend A. van den Beukel 0
Martijn W. J. Stommel
Harry van Goor
Richard P. G. ten Broek
0 Equal contributors Department of Surgery, Radboud University Medical Center , P.O. Box 9101, 6500, HB, Nijmegen , The Netherlands
Background: Previous research on the costs of treatment for ASBO is outdated and often based on reimbursements, rather than true healthcare provider costs of the admission and related interventions. An accurate estimate of the true costs of treatment is necessary to understand the healthcare burden and to model cost-efficacy of adhesion strategies. The aim of this study was to provide an accurate cost estimate of the in-hospital costs for treatment of adhesive small bowel obstruction (ASBO) using micro-costing methods. Methods: Consecutive patients admitted for ASBO to the Radboud University Medical Center from November 2013 to November 2015 were included. An episode of ASBO was defined as an admission for SBO with operative confirmation of adhesions or after radiological exclusion of other causes for SBO. For the purpose of generalization we used the costs of medication and interventions as provided by the Dutch Healthcare Authority and only if these were not available local hospital costs. We evaluated costs separately for operative and non-operative treatment for ASBO. Results: During the study period 39 admissions for ASBO were eligible for analysis. An operative treatment was required in 19 patients (48.7 %). Mean hospital stay for ASBO with operative treatment was 16.0 ± 11 days versus 4.0 ± 2.0 days for non-operative treatment (P = 0.003). A total of 12 patients developed complications, 2 in the non-operative group (10 %) and 10 in the operative group (52.6 %; P = 0.004). Overall costs for an admission for ASBO with operative treatment were €16 305 (SD €2 513), and for non-operative treatment € 2 277 (SD € 265) (p = <0.001). The highest expenditure with operative treatment for ASBO was made for ward stay (mean €7 856, SD €6 882), OR time (mean €2 6845, SD €1 434), ICU stay (mean €2 183, SD €4 305) and (parenteral) feeding costs (mean €1797, SD €2070). A table with correction coefficient to correct for differences in price levels for goods and services between different countries has been added. Conclusion: The in-hospital costs of an admission for ASBO are higher than previously thought. These costs can be used to guide hospital reimbursement policy and for the development of a cost-effective model for the use of adhesion barriers.
Colorectal surgery; SBO; Surgery; Adhesions
Adhesive small bowel obstruction (ASBO) is the most
common pathology of the small bowel, and frequently
results in surgical emergencies . In a national audit in
the UK small bowel obstructions accounted for 51 % of
all emergency laparotomies . In the United States
both adhesiolysis and small bowel resection appeared in
the top seven of emergency general surgeries, that count
for 80 % of morbidity and death related to emergency
surgery . The supplementary data from this report
confirmed that small bowel obstruction was the most
common diagnosis in both procedures . Part of the
huge burden small bowel obstructions cause to patients
and the healthcare system might be preventable [4, 5].
Post-operative adhesions are the cause of small bowel
obstruction in 60 % of cases . Application of an
adhesion barrier during the index operation can reduce the
risk of adhesion formation and subsequent clinical
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complications of adhesions . In a meta-analyses of
randomized controlled trials, application of a
hyaluronate carboxymethylcellulose barrier reduced the risk of
reoperations for ASBO after colorectal surgery with RR
0 · 49, 95 % CI 0 · 28–0 · 88 . Despite the evidence for
efficacy these barriers are seldom applied . A reason
why barriers are often not applied is that policy makers
question their cost-effective and consider routine
application too expensive [8, 9].
Remarkably, there is little data on the financial
implications of adhesion-related complication such as ASBO
that can guide policymakers in developing guidance for
reimbursement, management, and prevention of this
condition. The studies that modelled cost-effectiveness
of adhesion barriers have used incomplete estimates
or the negotiated reimbursement prices for treatment
of ASBO, rather than true healthcare provider costs
[7, 8, 10]. By using such incomplete estimates and
reimbursement prices the conclusions about
costeffectiveness of barriers might be falsified. Moreover,
concerns have been raised that reimbursement prices
indeed are too low, resulting in a net loss for
hospitals treating patients with ASBO .
In a recent study, the hospital costs of patients
undergoing an emergency laparotomy in general were
estimated at €15 500 per patient, which is on average
€7 000 more than its reimbursement . The
estimate was based on operating room time, ICU and
hospital stay, and did not take diagnostic or
medication costs into account. Thus, it may still
underestimate the actual healthcare provider costs. The costs
of emergency laparotomies were also not specified for
ASBO in this study . More accurate and up to
date data is necessary to provide a better guide to
reimbursement policies, adhesion prevention, and unveil
opportunities for cost reduction.
In the present study we modelled the costs of an
admission for ASBO based on accurate data that in
addition to the operating room times, ICU and ward stay
comprised full detailed information on all relevant
interventions made during the admission, including
medication, parenteral feeding, imaging studies, and laboratory
All consecutive patients admitted with ASBO to the
Radboudumc between November 2013 and November
2015 were eligible for inclusion. A waiver for ethical
approval was obtained by local institutional review
board after review of the protocol. To identify cases,
the hospitals’ discharge registry was searched for
patients with a reimbursement code for small bowel
obstruction. The Radboudumc is a university teaching
hospital in Nijmegen, the Netherlands, with complete
electronic patient files. Electronic patient files of the
identified records were reviewed for an admission for
ASBO during the study period. ASBO was defined as
an episode with operative confirmation of adhesions,
or in the non-operative group as an episode of
postoperative SBO in which other potential causes of
bowel obstruction were excluded by appropriate means.
Patients who were treated non-operatively received tube
decompression and no oral feeding. Operative treatment
of ASBO consisted of an explorative laparotomy with
cleaving of adhesions and if necessary partial resection of
small bowel. None of the patients had laparoscopic
cleaving of adhesions. Complications were defined according to
the criteria of the International Classification of Diseases,
Tenth Revision, the National Nosocomial Infections
Surveillance System, the Center for Disease Control and
Prevention, or according to the decision of the senior
medical staff of the department. Complications were
categorized according to the Clavien-Dindo classification .
All complications categorized as Clavien- Dindo grade II
or higher were reported.
The total costs of the admission were divided in nine
categories: operation (materials and occupancy of
operating room), medication, radiology, laboratory,
microbiology, ward stay, ICU days, feeding, and blood
products administered during admission. All data
needed for an accurate estimate of admission costs were
derived from the electronic patients file. A standardized
price list from the Dutch Healthcare Authority was used
for the calculation of costs for occupancy of operating
room, medication, radiology, laboratory, microbiology,
ward stay, ICU stay, feeding and blood products .
No standardized price list was available for materials
used during the operation. Therefore we used local
prices for operation materials instead.
The price for occupancy of the operating room was
based on the total anaesthesia time, and a standardized
price of €16,70 per minute. Medication costs comprised
the costs of all medications prescribed during the
admission. The costs of medication were updated per April
2016 . Costs for radiology, laboratory, microbiology
were all calculated in accordance to the table provided
by the Dutch healthcare authority . The prices for
ICU, ward stay, feeding and blood products were based
on the 2015 version of the manual for costs research
. The costs of a day on the ICU were determined at
€2015 per day. The costs of ward stay were determined
at €435 per day. The prices for ward stay and ICU
comprise honorarium for medical specialists, the costs for a
resident managing the ward, nursing personnel,
consumable goods, housing and overhead. The ICU price also
counted for expenditures on respiratory support .
Oral feeding was also counted for in the price of ward
stay. Additional expenditures for other types of feeding,
such as parenteral feeding, were calculated separately
and presented under the feeding category.
The average costs of operation materials were €155 if
no bowel resection was performed and €436 if bowel
resection was performed. The difference in price of
materials was mainly attributable to the use of stapling
A table of correction coefficients was added to allow
for quick comparison of costs between different
countries . These correction coefficients are published by
the European Union’s statistics department (EUROSTAT)
and can be used to quickly adjust prices for the differences
in price levels of goods and services between countries.
Thus, these coefficient provide a rough estimate of the
prices for treatment of ASBO in other countries than the
Netherlands. For convenience the coefficients as published
by EUROSTAT were adjusted setting the Dutch price
levels as the reference standard.
Data and statistical analysis
Baseline data consisted of patients age, sex, Charlson
comorbidty index, ASA classification and the number of
previous abdominal operations. Comparison was made
between patients undergoing operative treatment and
non- operative treatment using a Chi-square, Fisher’s
exact test, independent t-test or Mann-Whitney U test
where appropriate. Continuous variables are presented
as means with standard deviation, or medians with
interquartile range (25–75) if non-normal distribution.
Dichotomous or categorical variables are presented as
absolute numbers and percentages. P < 0.05 was
considered significant. All analyses were performed using SPSS
version 23°0 (Armonk, NY: IBM Corp).
From the hospital registry we identified 185 cases with a
code of SBO. We excluded 49 patients because they
were not admitted but only seen on the outpatient clinic.
A total of 97 admitted patients were excluded, 29
patients were diagnosed with Hirschprung’s disease, 16
patients had a tumor, 23 had other specified cause for
bowel obstruction, and in 21 patients an adhesive
aetiology was unsure. Thirty-nine patients had a total of 46
admissions for ASBO during the study period. We
excluded 7 admissions because patients were transferred to
other hospitals for further treatment of ABSO. A total of
39 admissions of ASBO during the study period were
included in the analysis (Fig. 1). Operative treatment of
ASBO was required in 19 admissions (48.7 %), 20
patients were managed non- operatively (51.3 %).
Indications for operative treatment was failure of
nonoperative management in 14 patients (73.7 %), suspected
strangulation in 4 patients (21,0 %), and 1 patient had a
diagnostic laparotomy (5,2 %).
Patient characteristics are shown in Table 1. There
were no significant differences between groups in terms
of age, sex, number of previous operations, comorbidity
index, or ASA classification. Of 19 operated patients, 9
were operated within the first 24 h. Median time from
admission till operation was 2 days (IQR 1–4 days). One
patient was operated after 16 days. This patient had
developed an adhesive small bowel obstruction after a
previous appendectomy, during late pregnancy. She was
treated with parenteral feeding and had explorative
laparotomy delayed to be combined with caesarean
section at 32 weeks of gestational age. Her bowel
obstruction quickly resolved after laparotomy, and mother and
child were discharged in good condition 4 days after
Operative treatment of ASBO led to a mean hospital
stay of 16.0 days (SD 11.0 days) while non- operative
treatment of ASBO led to a mean hospital stay of
4.0 days (SD 2.0 days p = 0.003). A total of 12 patients
developed complications, two in the non- operative
group (10.0 %) and 10 in the operatively treated group
(52.6 %; P = 0.004). Complications in the non- operative
group were pneumonia (n = 1), and de novo atrial
fibrillation (n = 1). One patient in the operative group
developed a staphylococcal sepsis, for which prolonged ICU
admission was indicated. Other complications in the
operative group comprised pneumonia (n = 2), wound
infection (n = 2), intra-abdominal abscess formation (n = 1),
de novo atrial fibrillation (n = 1), urinary tract
infection (n = 1), bacteremia (n = 1), and delirium (n = 1).
Two operative patients had a second-look laparotomy.
In the first patient almost the entire small bowel was
entrapped in the adhesions and appeared ischemic at
the initial explorative laparotomy. Because there was
doubt about the reversibility of this bowel ischemia a
second look laparotomy was performed the next day,
at which the bowel had normal appearance and
peristalsis. The second patient underwent a second look
laparotomy to inspect the anastomosis made following
bowel resection at initial laparotomy. The indication
for this second look was made after the patients
became septic on the ICU and an anastomotic leakage
was expected based on clinical evaluation. At second
look on day 3 a sufficient anastomosis without signs
of leakage was found. Origin of sepsis remained
unsure, but a pulmonary origin was suspected after
negative second look. The patient fully recovered with
intravenous antibiotic treatment.
Mean hospital stay for ASBO with operative treatment
was 16.0 ± 11 days versus 4.0 ± 2.0 days for non-operative
strategies, ward and ICU stay was the largest
component of costs (Fig. 2). The costs for operative
treatment was €14 315 (SD €3 352) in uncomplicated
cases and €18 095 (SD €3 776) in complicated cases,
the difference was not significant. Four of the patients
in the operative treatment group underwent bowel
resection during laparotomy (21.5 %). Mean costs were
significantly different between operative treatment
with or without bowel resection, €25 395 versus €13 058
respectively. The additional operative costs for second
look laparotomy in two patients were € 601 and €1 319
An overview of correction coefficients is presented in
Table 3. The correction coefficients give a global
impression of differences in price levels between countries, and
were standardized to the Dutch price levels. For example
the correction coefficient for the United Kingdom is
1.29. This means that prices for goods and services in
the United Kingdom are generally 1.29 times higher than
the costs for the same goods and services in the
Netherlands. The price for a non- operative treatment
Fig. 1 Flow chart of patients included in the study
treatment (P = 0.003), resulting in a mean overall
costs of €16 305 (SD €2 513) and 2 277 (SD €265)
respectively. Mean costs were significantly different
between both groups (P < 0.005). Costs of the different
components are shown in Table 2. For both treatment
Table 1 Baseline patient characteristics
Values are presented as mean ± standard deviation or N (percentage)
a median + inter quartile range
Table 2 Comparison of costs for operative vs. non-operative treatment for ASO
Operation – anesthesia time
Operation – materials
for ASBO in the United Kingdom are roughly estimated
at 1.29*€ 2 227 = €2 872.
Adhesive small bowel is associated with high morbidity
and costs. The average costs for a non- operative episode
were over €2 000 and for a surgical episode over €16 000.
The majority of costs were related to ward and ICU stay.
The costs for operative treatment of ASBO determined
in this study were comparable to the €15 500 Shapter et
al. reported in their estimation of the costs for an
unspecified emergency laparotomy . In their study, the
costs for an emergency laparotomy were estimated from
only the ICU stay, hospital stay, and duration of the
operation. In our study these three parameters made up for
only 77 % of total hospital costs in operative cases,
indicating that Shapter’s estimate is too low. Local
differences in price levels between the United Kingdom and
the Netherlands might account for the discrepancy,
implicating that true costs in the United Kingdom are
higher. Indeed the correction coefficient for the United
Kingdom was 1.29, indicating that goods and services
are generally more expensive in the United Kingdom as
compared to the Netherlands. The most important
additional expenditure in operative patients is the costs for
parenteral feeding. Parenteral feeding made up for 11 %
of total healthcare costs in our group. The costs for
operative treatment of ASBO are much higher than
reimbursements for emergency laparotomies found by
Shapter et al., implicating that hospitals in the United
Kingdom bear a financial loss for treating patients with
Fig. 2 Pie charts of treatment costs for ASBO
Table 3 Correction coefficients for differences in prizes of
goods and surfaces
Source: Eurostat (http://ec.europa.eu/eurostat/web/civil-servants-remuneration/
correction-coefficients) The correlation coefficients give a general estimate for
the differences in price level in different countries
Correction coefficients can be used to calculate a
quick estimate of the costs in a different country.
However, a more precise estimate would require to
recalculate the prices from the different components as listed in
Table 2. An important limitation to the correction
coefficients is that they are not specific for healthcare
services . Attempts to create more specific coefficients
for healthcare have been complicated by the fact that for
most condition not only the price levels of goods and
services vary between countries, but also the treatment
protocols itself . However, we believe that it is
reasonable to suggest that differences in ASBO treatment
decreasing over recent years by the use of international
guidelines. Adherence to the international Bologna
guidelines for treatment of ASBO in this study was high
. As a rule, a non- operative treatment was initially
instigated, unless there were signs of strangulation or
ischemia. Most operative patients underwent surgery
within 3 days as suggested by these guidelines.
The cost estimates in our study are useful to guide
reimbursement policies and model cost-effectiveness of
adhesion barriers, Because the study had high adherence
to the international guidelines and the morbidity found
was comparable to that reported in literature [6, 18, 19,
11]. However, the study had low power to assess the
impact of factors such as complications on costs, because
of the relative low sample size and retrospective nature
of the study.
The relative small sample size is explained by the
methodology used in this study. We included only
recently admitted patients from our own institution with
high ascertainment of adhesive etiology to enable the
micro-costing method. Micro-costing is the gold
standard for accurately defining healthcare provider costs, but
seldom applied because of the large quantity of data that
needs to be collected from each patient . In our
institution all patient data, including medication, radiology
orders etc. are entered into the electronic patient file,
which enabled this highly accurate method of cost
estimation. For the same reasons the number of patients
undergoing operative treatment was relative high in our
cohort. In previous literature, non- operative treatment
is successful in more than 70 % of patients with ASBO
[20, 21]. We only included patients with high
ascertainment of adhesive aetiology and in many of the
non- operative cases the presence of adhesions could
not be proved. We included only patients with high
ascertainment of ASBO in this study because costs
rather than treatment result was the primary
endpoint. Without additional imaging or a history of
previous episodes of ASBO, adhesions count for only
60 % of all cases of post-operative bowel obstruction
. The other 40 % might have somewhat different
clinical course and costs.
We also excluded a larger number of paediatric
patients with Hirschsprung’s disease. Our Institution is
also a referall central for paediatric surgery. Because
Hirschsprung’s disease has no separate reimbursement
code in the Dutch reimbursement system, it often
received the same code as used for bowel obstruction .
Our results show that the largest part of the
expenditures in treatment of ASBO are related to the duration
of hospital stay. Several studies have reported a reduced
length of stay and lower incidence of postoperative ileus
when adhesiolysis is performed through laparoscopy
instead of laparotomy [23–25]. However, no randomized
trials have been performed. In general, it will be more
difficult to perform laparoscopic surgery on patients
with multiple operations in history and when the bowel
is very distended, increasing the risk of bowel injuries
. In the study of Wullstein et al. incidence of bowel
injuries was higher during laparoscopic surgery for
ASBO compared to open, despite a possible favourable
selection in laparoscopic cases . Thus, the results
that laparoscopic surgery for ASBO reduces hospital
stay and subsequent costs should be interpreted with
The results of our study have important implications
for policies regarding reimbursements. Reimbursement
for operative cases of ASBO is generally too low .
The costs that we found for operatively treated episodes
of ASBO were also much higher than the estimate
Wilson applied in a cost-effectiveness model for
adhesion barriers . With the higher costs we found for
operative cases of ASBO, it becomes more likely that
adhesion barriers are cost effective in high risk
procedures such as colorectal surgery. Adhesion barriers are
proven to be effective in reducing the risk of reoperation
for ASBO in randomized controlled trials [4, 5, 27, 28].
Moreover, a complete evaluation of cost-effectiveness of
adhesion barriers should also count for other
complications of adhesions, such as complications associated with
adhesiolysis during repeat abdominal surgery, infertility
treatments and chronic abdominal pain [8, 10].
The costs of an admission for ASBO are higher than
what is reported in the previous literature. Our results
can be used to guide reimbursement policy and the
development of a cost-effectiveness model for the use of
Availability of data and materials
The datasets during and/or analysed during the current study available from
the corresponding author on reasonable request.
PK– Study design, collection of data, statistical analysis, drafted manuscript,
final approval of manuscript. BB – Study, design, collection of data, statistical
analysis, drafted manuscript, final approval of manuscript. MS – Study design,
interpretation of data, critically reviewed manuscript, final approval of
manuscript. HG - Study design, interpretation of data, critically reviewed
manuscript, final approval of manuscript. CS - Study design, supervision of
statistical analysis, interpretation of data, critically reviewed manuscript, final
approval of manuscript. RB – Study design, creation of data collection tool,
supervision of statistical analysis, interpretation of data, critically reviewed
manuscript, final approval of manuscript.
The authors declare that they have no competing interests.
Consent for publication
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