title: Endoscopic stenting versus surgical colostomy for the management of malignant colonic obstruction: comparison of hospital costs and clinical outcomes.
abstract: BACKGROUND
  Although stent placement is increasingly performed, colostomy still is considered the gold standard for emergent relief of malignant colonic obstruction (MCO). This study aimed to compare hospital costs and clinical outcomes between patients undergoing colostomy and those undergoing stenting for the management of MCO.
  
  
  METHODS
  A retrospective claims analysis of the Medicare Provider Analysis and Review (MedPAR) data set was conducted to identify inpatient hospitalizations for colostomy or stent placement for the treatment of colon cancer (2007-2008). The outcomes evaluated using MedPAR compared the total length of hospital stay (LOS) and the costs associated with both techniques. Because MedPAR is a claims data set that does not provide outcomes at a patient level, a single-institution retrospective case-control study was conducted in which each stent placement patient was matched with two colostomy patients during the same period. Outcome measures (institutional data) were used to compare rates of treatment success, postprocedure LOS, and reinterventions between the two cohorts.
  
  
  RESULTS
  The MedPAR data evaluated 778 stent placements and 5,868 colostomy hospitalizations. There were no differences in gender, age distribution, or comorbidity between the two groups. Compared with colostomy, the median LOS (8 vs. 12 days; p<0.0001) and the median cost ($15,071 vs. $24,695; p<0.001) per claim were significantly less for stent placement. Stent placement was more commonly performed at urban versus rural hospitals (84% vs. 16%; p<0.0001), teaching versus nonteaching hospitals (56% vs. 44%; p=0.0058) and larger versus smaller institutions (mean bed capacity, 331 vs. 227; p<0.0001). The institution data included 12 patients who underwent stent placement and 24 who underwent colostomy. Although both methods were technically successful, the median postprocedure LOS (2.17 vs. 10.58 days; p=0.0004) and the rate of readmissions for complications (0% vs. 25%; p=0.01) were significantly lower for stent placement.
  
  
  CONCLUSIONS
  Although the technical and clinical outcomes for colostomy and stent placement appear comparable, stent placement is less costly and associated with shorter LOS and fewer complications. Dissemination of stent placement beyond large teaching hospitals located in urban areas as a treatment for MCO is important given its implications for patient care and resource use.
authors.affiliation: Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, JT 664, 1530-3rd Avenue S, Birmingham, AL 35294-0012, USA. svaradarajulu@yahoo.com
authors.forename: Shyam
authors.initials: S
authors.lastname: Varadarajulu
authors.forename: Ann
authors.initials: A
authors.lastname: Roy
authors.forename: Tercio
authors.initials: T
authors.lastname: Lopes
authors.forename: Ernesto R
authors.initials: ER
authors.lastname: Drelichman
authors.forename: Micheline
authors.initials: M
authors.lastname: Kim
mesh_terms: D000368:Aged; D016022:Case-Control Studies; D016009:Chi-Square Distribution; D003110:Colonic Neoplasms / Q000191:economics / Q000601:surgery*; D003125:Colostomy / Q000191:economics / Q000379:methods*; D005260:Female; D017721:Hospital Costs; D006801:Humans; D007415:Intestinal Obstruction / Q000191:economics / Q000601:surgery*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D019233:Retreatment; D012189:Retrospective Studies; D015607:Stents / Q000191:economics; D016896:Treatment Outcome