Utility of clinical pathway and prospective case management to achieve cost and hospital stay reduction for aortic aneurysm surgery at a tertiary care hospital
Identifieur interne : 002687 ( Istex/Corpus ); précédent : 002686; suivant : 002688Utility of clinical pathway and prospective case management to achieve cost and hospital stay reduction for aortic aneurysm surgery at a tertiary care hospital
Auteurs : Satish C. Muluk ; Lisa Painter ; Saba Sile ; Robert Y. Rhee ; Michel S. Makaroun ; David L. Steed ; Marshall W. WebsterSource :
- Journal of Vascular Surgery [ 0741-5214 ] ; 1997.
English descriptors
- KwdEn :
- Actual costs, Aneurysm, Aneurysm patients, Aneurysm surgery, Aortic, Aortic surgery, Care mechanisms, Case management, Case manager, Case manager concept, Clinical characteristics, Clinical features, Clinical outcomes, Clinical paths, Clinical pathway, Clinical pathways, Consecutive series, Critical care services, Critical pathways, Educational mission, Elective aneurysm patients, Exclusion criteria, First question, First year, Fluid administration, Fluid management, Fluid overload, Further analysis, Good question, Health care, Hospital charges, Intensive care unit, Journalof vascularsurgery, Median, Median charges, Modification, Mortality rate, Mortality rates, Mortality readmission rate, Multidisciplinary effort, Muluk, Other changes, Other institutions, Outcome data, Overall increase, Overload, Pathway, Pathway implementation, Pathway institution, Pathway modifications, Pathway patients, Pathway review, Patient care, Patient groups, Perioperative fluid administration, Postoperative, Postoperative parameters, Practice modifications, Preoperative, Pulmonary edema, Qual improv, Quality improvement, Readmission, Readmission rate, Readmission rates, Recipient hospital, Reference group, Regular basis, Relative charges length, Renal failure, Resource consumption, Resource utilization, Shorter hospital, Significant change, Significant decrease, Significant difference, Significant differences, Slight fall, Standard care plan, Surgery, Thorac surg, Vasc surg, Vascular, Vascular congestion, Vascular surgeon, Vascular surgery, Volume overload.
- Teeft :
- Actual costs, Aneurysm, Aneurysm patients, Aneurysm surgery, Aortic, Aortic surgery, Care mechanisms, Case management, Case manager, Case manager concept, Clinical characteristics, Clinical features, Clinical outcomes, Clinical paths, Clinical pathway, Clinical pathways, Consecutive series, Critical care services, Critical pathways, Educational mission, Elective aneurysm patients, Exclusion criteria, First question, First year, Fluid administration, Fluid management, Fluid overload, Further analysis, Good question, Health care, Hospital charges, Intensive care unit, Journalof vascularsurgery, Median, Median charges, Modification, Mortality rate, Mortality rates, Mortality readmission rate, Multidisciplinary effort, Muluk, Other changes, Other institutions, Outcome data, Overall increase, Overload, Pathway, Pathway implementation, Pathway institution, Pathway modifications, Pathway patients, Pathway review, Patient care, Patient groups, Perioperative fluid administration, Postoperative, Postoperative parameters, Practice modifications, Preoperative, Pulmonary edema, Qual improv, Quality improvement, Readmission, Readmission rate, Readmission rates, Recipient hospital, Reference group, Regular basis, Relative charges length, Renal failure, Resource consumption, Resource utilization, Shorter hospital, Significant change, Significant decrease, Significant difference, Significant differences, Slight fall, Standard care plan, Surgery, Thorac surg, Vasc surg, Vascular, Vascular congestion, Vascular surgeon, Vascular surgery, Volume overload.
Abstract
Abstract: Purpose: We reviewed our experience with a clinical pathway instituted in December 1993 for all nonurgent abdominal aortic aneurysm (AAA) surgery.Methods: We analyzed a reference group of 49 consecutive pre-pathway AAA patients (group I) and the 44 patients enrolled in the first year of the pathway (group II). On the basis of the interim review of data collected during the first year, pathway modifications were made, and 34 patients enrolled after these modifications (group III) were also analyzed.Results: Comparison of groups I and II showed that institution of the pathway resulted in a marginally significant reduction in mean charges of 14.7% ( p = 0.09), and a slight fall in mean length of stay (LOS) (13.8 vs 13.1 days, NS) and mortality rate (4.1% vs 2.3%, NS). For group II, a significant correlate ( p < 0.05) of increased charges was fluid overload as diagnosed by chest radiograph. This recognition led to active efforts to reduce perioperative fluid administration. Comparison of groups II and III revealed that the practice modifications led to marked reduction in the incidence of fluid overload (73% vs 24%; p < 0.01), mean charges (30.4% reduction; p < 0.05), mean LOS (13.1 vs 10.2 days; p < 0.05), and median LOS (11 vs 8 days). Multiple regression analysis of all pathway patients showed that preoperative renal insufficiency is a significant predictor of both increased LOS ( p < 0.01) and charges ( p < 0.01), but that age, sex, and coronary disease were not predictive. Of the postoperative parameters analyzed, important correlates of increased charges were acute renal failure ( p < 0.01) and fluid overload ( p < 0.01).Conclusions: Institution of a clinical pathway for AAA repair resulted in significant charge reduction and a slight reduction in stay. Practice modifications based on interim data analysis yielded further significant reductions in charges and LOS, with overall per-patient charge savings (group I vs III) of 40.6% ( p < 0.05) and overall LOS reduction of 3.5 days ( p < 0.05). The reduction in actual charges was seen despite an overall increase in the hospital rate structure. Comparing groups I, II, and III, we found no indication of increasing mortality rate. Ongoing analysis has identified correlates of increased charges, potentially permitting identification of high-cost subgroups and more focused cost-control efforts. Rather than restricting management, clinical pathways with periodic data analysis may improve quality of care. (J Vasc Surg 1997;25:84-93.)
Url:
DOI: 10.1016/S0741-5214(97)70324-0
Links to Exploration step
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<front><div type="abstract" xml:lang="en">Abstract: Purpose: We reviewed our experience with a clinical pathway instituted in December 1993 for all nonurgent abdominal aortic aneurysm (AAA) surgery.Methods: We analyzed a reference group of 49 consecutive pre-pathway AAA patients (group I) and the 44 patients enrolled in the first year of the pathway (group II). On the basis of the interim review of data collected during the first year, pathway modifications were made, and 34 patients enrolled after these modifications (group III) were also analyzed.Results: Comparison of groups I and II showed that institution of the pathway resulted in a marginally significant reduction in mean charges of 14.7% ( p = 0.09), and a slight fall in mean length of stay (LOS) (13.8 vs 13.1 days, NS) and mortality rate (4.1% vs 2.3%, NS). For group II, a significant correlate ( p < 0.05) of increased charges was fluid overload as diagnosed by chest radiograph. This recognition led to active efforts to reduce perioperative fluid administration. Comparison of groups II and III revealed that the practice modifications led to marked reduction in the incidence of fluid overload (73% vs 24%; p < 0.01), mean charges (30.4% reduction; p < 0.05), mean LOS (13.1 vs 10.2 days; p < 0.05), and median LOS (11 vs 8 days). Multiple regression analysis of all pathway patients showed that preoperative renal insufficiency is a significant predictor of both increased LOS ( p < 0.01) and charges ( p < 0.01), but that age, sex, and coronary disease were not predictive. Of the postoperative parameters analyzed, important correlates of increased charges were acute renal failure ( p < 0.01) and fluid overload ( p < 0.01).Conclusions: Institution of a clinical pathway for AAA repair resulted in significant charge reduction and a slight reduction in stay. Practice modifications based on interim data analysis yielded further significant reductions in charges and LOS, with overall per-patient charge savings (group I vs III) of 40.6% ( p < 0.05) and overall LOS reduction of 3.5 days ( p < 0.05). The reduction in actual charges was seen despite an overall increase in the hospital rate structure. Comparing groups I, II, and III, we found no indication of increasing mortality rate. Ongoing analysis has identified correlates of increased charges, potentially permitting identification of high-cost subgroups and more focused cost-control efforts. Rather than restricting management, clinical pathways with periodic data analysis may improve quality of care. (J Vasc Surg 1997;25:84-93.)</div>
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<abstract>Abstract: Purpose: We reviewed our experience with a clinical pathway instituted in December 1993 for all nonurgent abdominal aortic aneurysm (AAA) surgery.Methods: We analyzed a reference group of 49 consecutive pre-pathway AAA patients (group I) and the 44 patients enrolled in the first year of the pathway (group II). On the basis of the interim review of data collected during the first year, pathway modifications were made, and 34 patients enrolled after these modifications (group III) were also analyzed.Results: Comparison of groups I and II showed that institution of the pathway resulted in a marginally significant reduction in mean charges of 14.7% ( p = 0.09), and a slight fall in mean length of stay (LOS) (13.8 vs 13.1 days, NS) and mortality rate (4.1% vs 2.3%, NS). For group II, a significant correlate ( p > 0.05) of increased charges was fluid overload as diagnosed by chest radiograph. This recognition led to active efforts to reduce perioperative fluid administration. Comparison of groups II and III revealed that the practice modifications led to marked reduction in the incidence of fluid overload (73% vs 24%; p > 0.01), mean charges (30.4% reduction; p > 0.05), mean LOS (13.1 vs 10.2 days; p > 0.05), and median LOS (11 vs 8 days). Multiple regression analysis of all pathway patients showed that preoperative renal insufficiency is a significant predictor of both increased LOS ( p > 0.01) and charges ( p > 0.01), but that age, sex, and coronary disease were not predictive. Of the postoperative parameters analyzed, important correlates of increased charges were acute renal failure ( p > 0.01) and fluid overload ( p > 0.01).Conclusions: Institution of a clinical pathway for AAA repair resulted in significant charge reduction and a slight reduction in stay. Practice modifications based on interim data analysis yielded further significant reductions in charges and LOS, with overall per-patient charge savings (group I vs III) of 40.6% ( p > 0.05) and overall LOS reduction of 3.5 days ( p > 0.05). The reduction in actual charges was seen despite an overall increase in the hospital rate structure. Comparing groups I, II, and III, we found no indication of increasing mortality rate. Ongoing analysis has identified correlates of increased charges, potentially permitting identification of high-cost subgroups and more focused cost-control efforts. Rather than restricting management, clinical pathways with periodic data analysis may improve quality of care. (J Vasc Surg 1997;25:84-93.)</abstract>
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<notesStmt><note>Reprint requests: Satish C. Muluk, A-1011 PUH, 200 Lothrop St., Pittsburgh, PA 15213.</note>
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<note type="content">Table I: Comparison of demographic and clinical features</note>
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<author xml:id="author-0000"><persName><forename type="first">Satish C.</forename>
<surname>Muluk</surname>
</persName>
<roleName type="degree">MD</roleName>
<affiliation>Pittsburgh Pa.</affiliation>
</author>
<author xml:id="author-0001"><persName><forename type="first">Lisa</forename>
<surname>Painter</surname>
</persName>
<roleName type="degree">MSN</roleName>
<affiliation>Pittsburgh Pa.</affiliation>
</author>
<author xml:id="author-0002"><persName><forename type="first">Saba</forename>
<surname>Sile</surname>
</persName>
<roleName type="degree">BS</roleName>
<affiliation>Pittsburgh Pa.</affiliation>
</author>
<author xml:id="author-0003"><persName><forename type="first">Robert Y.</forename>
<surname>Rhee</surname>
</persName>
<roleName type="degree">MD</roleName>
<affiliation>Pittsburgh Pa.</affiliation>
</author>
<author xml:id="author-0004"><persName><forename type="first">Michel S.</forename>
<surname>Makaroun</surname>
</persName>
<roleName type="degree">MD</roleName>
<affiliation>Pittsburgh Pa.</affiliation>
</author>
<author xml:id="author-0005"><persName><forename type="first">David L.</forename>
<surname>Steed</surname>
</persName>
<roleName type="degree">MD</roleName>
<affiliation>Pittsburgh Pa.</affiliation>
</author>
<author xml:id="author-0006"><persName><forename type="first">Marshall W.</forename>
<surname>Webster</surname>
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<roleName type="degree">MD</roleName>
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<abstract xml:lang="en"><p>Purpose: We reviewed our experience with a clinical pathway instituted in December 1993 for all nonurgent abdominal aortic aneurysm (AAA) surgery.Methods: We analyzed a reference group of 49 consecutive pre-pathway AAA patients (group I) and the 44 patients enrolled in the first year of the pathway (group II). On the basis of the interim review of data collected during the first year, pathway modifications were made, and 34 patients enrolled after these modifications (group III) were also analyzed.Results: Comparison of groups I and II showed that institution of the pathway resulted in a marginally significant reduction in mean charges of 14.7% ( p = 0.09), and a slight fall in mean length of stay (LOS) (13.8 vs 13.1 days, NS) and mortality rate (4.1% vs 2.3%, NS). For group II, a significant correlate ( p < 0.05) of increased charges was fluid overload as diagnosed by chest radiograph. This recognition led to active efforts to reduce perioperative fluid administration. Comparison of groups II and III revealed that the practice modifications led to marked reduction in the incidence of fluid overload (73% vs 24%; p < 0.01), mean charges (30.4% reduction; p < 0.05), mean LOS (13.1 vs 10.2 days; p < 0.05), and median LOS (11 vs 8 days). Multiple regression analysis of all pathway patients showed that preoperative renal insufficiency is a significant predictor of both increased LOS ( p < 0.01) and charges ( p < 0.01), but that age, sex, and coronary disease were not predictive. Of the postoperative parameters analyzed, important correlates of increased charges were acute renal failure ( p < 0.01) and fluid overload ( p < 0.01).Conclusions: Institution of a clinical pathway for AAA repair resulted in significant charge reduction and a slight reduction in stay. Practice modifications based on interim data analysis yielded further significant reductions in charges and LOS, with overall per-patient charge savings (group I vs III) of 40.6% ( p < 0.05) and overall LOS reduction of 3.5 days ( p < 0.05). The reduction in actual charges was seen despite an overall increase in the hospital rate structure. Comparing groups I, II, and III, we found no indication of increasing mortality rate. Ongoing analysis has identified correlates of increased charges, potentially permitting identification of high-cost subgroups and more focused cost-control efforts. Rather than restricting management, clinical pathways with periodic data analysis may improve quality of care. (J Vasc Surg 1997;25:84-93.)</p>
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<ce:floats><ce:table id="tab1" colsep="0" rowsep="0" frame="topbot"><ce:label>Table I</ce:label>
<ce:caption><ce:simple-para id="simple-para0005">Comparison of demographic and clinical features</ce:simple-para>
</ce:caption>
<tgroup cols="4"><colspec colname="col1" colsep="0"></colspec>
<colspec colname="col2" colsep="0"></colspec>
<colspec colname="col3" colsep="0"></colspec>
<colspec colname="col4" colsep="0"></colspec>
<thead><row rowsep="1"><entry align="center"><ce:italic>Parameter</ce:italic>
</entry>
<entry align="center"><ce:italic>Group I (n = 49)</ce:italic>
</entry>
<entry align="center"><ce:italic>Group II (n = 44)</ce:italic>
</entry>
<entry align="center"><ce:italic>Group III (n = 34)</ce:italic>
</entry>
</row>
</thead>
<tbody><row><entry align="center">Age (years)</entry>
<entry align="center">70.6</entry>
<entry align="center">69.9</entry>
<entry align="center">72.2</entry>
</row>
<row><entry align="center">Sex (% female)</entry>
<entry align="center">26.5%</entry>
<entry align="center">20.5%</entry>
<entry align="center">32.4%</entry>
</row>
<row><entry align="center">History of</entry>
<entry align="center"></entry>
<entry align="center"></entry>
<entry align="center"></entry>
</row>
<row><entry align="center">Coronary artery disease</entry>
<entry align="center">57.1%</entry>
<entry align="center">54.5%</entry>
<entry align="center">67.6%</entry>
</row>
<row><entry align="center">Coronary bypass</entry>
<entry align="center">20.4%</entry>
<entry align="center">22.7%</entry>
<entry align="center">26.5%</entry>
</row>
<row><entry align="center">Pulmonary dysfunction</entry>
<entry align="center">32.7%</entry>
<entry align="center">34.1%</entry>
<entry align="center">41.2%</entry>
</row>
<row><entry align="center">Liver dysfunction</entry>
<entry align="center">2.0%</entry>
<entry align="center">9.1%</entry>
<entry align="center">2.9%</entry>
</row>
<row><entry align="center">Smoking history</entry>
<entry align="center">77.6%</entry>
<entry align="center">84.1%</entry>
<entry align="center">79.4%</entry>
</row>
<row><entry align="center">Renal dysfunction</entry>
<entry align="center">6.1%</entry>
<entry align="center">11.4%</entry>
<entry align="center">8.8%</entry>
</row>
<row><entry align="center">Diabetes</entry>
<entry align="center">20.4%</entry>
<entry align="center">25.0%</entry>
<entry align="center">14.7%</entry>
</row>
<row rowsep="1"><entry align="center">Hypertension</entry>
<entry align="center">67.3%</entry>
<entry align="center">63.6%</entry>
<entry align="center">58.8%</entry>
</row>
<row><entry namest="col1" nameend="col4" align="center"></entry>
</row>
</tbody>
</tgroup>
<ce:legend><ce:simple-para id="simple-para0015">Group I, pre-pathway reference group; group II, patients enrolled during first year of pathway; group III, patients enrolled after pathway modifications. No significant differences among groups in any of the parameters, by χ<ce:sup>2</ce:sup>
testing.</ce:simple-para>
</ce:legend>
</ce:table>
</ce:floats>
<head><ce:article-footnote><ce:label>☆</ce:label>
<ce:note-para>Reprint requests: Satish C. Muluk, A-1011 PUH, 200 Lothrop St., Pittsburgh, PA 15213.</ce:note-para>
</ce:article-footnote>
<ce:article-footnote><ce:label>☆☆</ce:label>
<ce:note-para>0741-5214/97/$5.00 + 0 <ce:bold>24/6/78228</ce:bold>
</ce:note-para>
</ce:article-footnote>
<ce:title>Utility of clinical pathway and prospective case management to achieve cost and hospital stay reduction for aortic aneurysm surgery at a tertiary care hospital</ce:title>
<ce:presented>Presented at the Fiftieth Annual Meeting of The Society for Vascular Surgery, Chicago, Ill., June 11-12, 1996.</ce:presented>
<ce:author-group><ce:author><ce:given-name>Satish C.</ce:given-name>
<ce:surname>Muluk</ce:surname>
<ce:degrees>MD</ce:degrees>
</ce:author>
<ce:author><ce:given-name>Lisa</ce:given-name>
<ce:surname>Painter</ce:surname>
<ce:degrees>MSN</ce:degrees>
</ce:author>
<ce:author><ce:given-name>Saba</ce:given-name>
<ce:surname>Sile</ce:surname>
<ce:degrees>BS</ce:degrees>
</ce:author>
<ce:author><ce:given-name>Robert Y.</ce:given-name>
<ce:surname>Rhee</ce:surname>
<ce:degrees>MD</ce:degrees>
</ce:author>
<ce:author><ce:given-name>Michel S.</ce:given-name>
<ce:surname>Makaroun</ce:surname>
<ce:degrees>MD</ce:degrees>
</ce:author>
<ce:author><ce:given-name>David L.</ce:given-name>
<ce:surname>Steed</ce:surname>
<ce:degrees>MD</ce:degrees>
</ce:author>
<ce:author><ce:given-name>Marshall W.</ce:given-name>
<ce:surname>Webster</ce:surname>
<ce:degrees>MD</ce:degrees>
</ce:author>
<ce:collaboration><ce:text>From the Division of Vascular Surgery, University of Pittsburgh Medical Center.</ce:text>
</ce:collaboration>
<ce:affiliation><ce:textfn>Pittsburgh Pa.</ce:textfn>
</ce:affiliation>
</ce:author-group>
<ce:date-received day="14" month="6" year="1996"></ce:date-received>
<ce:date-accepted day="23" month="9" year="1996"></ce:date-accepted>
<ce:abstract><ce:section-title>Abstract</ce:section-title>
<ce:abstract-sec><ce:simple-para id="simple-para0025"><ce:italic>Purpose:</ce:italic>
We reviewed our experience with a clinical pathway instituted in December 1993 for all nonurgent abdominal aortic aneurysm (AAA) surgery.</ce:simple-para>
<ce:simple-para id="simple-para0035"><ce:italic>Methods:</ce:italic>
We analyzed a reference group of 49 consecutive pre-pathway AAA patients (group I) and the 44 patients enrolled in the first year of the pathway (group II). On the basis of the interim review of data collected during the first year, pathway modifications were made, and 34 patients enrolled after these modifications (group III) were also analyzed.</ce:simple-para>
<ce:simple-para id="simple-para0045"><ce:italic>Results:</ce:italic>
Comparison of groups I and II showed that institution of the pathway resulted in a marginally significant reduction in mean charges of 14.7% ( <ce:italic>p</ce:italic>
= 0.09), and a slight fall in mean length of stay (LOS) (13.8 vs 13.1 days, NS) and mortality rate (4.1% vs 2.3%, NS). For group II, a significant correlate ( <ce:italic>p</ce:italic>
< 0.05) of increased charges was fluid overload as diagnosed by chest radiograph. This recognition led to active efforts to reduce perioperative fluid administration. Comparison of groups II and III revealed that the practice modifications led to marked reduction in the incidence of fluid overload (73% vs 24%; <ce:italic>p</ce:italic>
< 0.01), mean charges (30.4% reduction; <ce:italic>p</ce:italic>
< 0.05), mean LOS (13.1 vs 10.2 days; <ce:italic>p</ce:italic>
< 0.05), and median LOS (11 vs 8 days). Multiple regression analysis of all pathway patients showed that preoperative renal insufficiency is a significant predictor of both increased LOS ( <ce:italic>p</ce:italic>
< 0.01) and charges ( <ce:italic>p</ce:italic>
< 0.01), but that age, sex, and coronary disease were <ce:italic>not</ce:italic>
predictive. Of the postoperative parameters analyzed, important correlates of increased charges were acute renal failure ( <ce:italic>p</ce:italic>
< 0.01) and fluid overload ( <ce:italic>p</ce:italic>
< 0.01).</ce:simple-para>
<ce:simple-para id="simple-para0055"><ce:italic>Conclusions:</ce:italic>
Institution of a clinical pathway for AAA repair resulted in significant charge reduction and a slight reduction in stay. Practice modifications based on interim data analysis yielded further significant reductions in charges and LOS, with overall per-patient charge savings (group I vs III) of 40.6% ( <ce:italic>p</ce:italic>
< 0.05) and overall LOS reduction of 3.5 days ( <ce:italic>p</ce:italic>
< 0.05). The reduction in actual charges was seen despite an overall <ce:italic>increase</ce:italic>
in the hospital rate structure. Comparing groups I, II, and III, we found no indication of increasing mortality rate. Ongoing analysis has identified correlates of increased charges, potentially permitting identification of high-cost subgroups and more focused cost-control efforts. Rather than restricting management, clinical pathways with periodic data analysis may improve quality of care. (J Vasc Surg 1997;25:84-93.)</ce:simple-para>
</ce:abstract-sec>
</ce:abstract>
</head>
<body><ce:sections><ce:para id="para0005">Of the many recent changes in health care in the United States, one of the most prominent has been the increasing use of clinical pathways and case management. Pathways provide a standardized diagnosis-specific multidisciplinary care plan, and case management involves a focused effort to optimize resource utilization for each patient.</ce:para>
<ce:para id="para0015">The driving force behind these changes has been the need for hospitals to remain financially competitive in an era of managed care and capitation. Although an extensive body of literature describes development of pathways in a variety of clinical settings, definitive study of the impact of clinical pathways has been more limited, especially in the area of vascular surgery. Available reports examining major vascular procedures<ce:cross-ref refid="bib1"><ce:sup>1</ce:sup>
</ce:cross-ref>
and abdominal aortic aneurysm (AAA) operations<ce:cross-ref refid="bib2"><ce:sup>2</ce:sup>
</ce:cross-ref>
have not definitively shown an economic benefit of pathway implementation when both inpatient and outpatient costs are considered.</ce:para>
<ce:para id="para0025">In addition to cost savings, another potential benefit of pathways and case management is improvement in quality of care. Although it has been argued that reduction of variation in the provision of a service is the most effective way to improve quality,<ce:cross-ref refid="bib3"><ce:sup>3</ce:sup>
</ce:cross-ref>
there is a legitimate concern that inflexible care plans and the cost-reduction focus of pathways may lead to reduced quality of care. The issue has not been definitively resolved.</ce:para>
<ce:para id="para0035">We report herein our experience with a clinical pathway and case management for elective AAA surgery instituted in 1993. We have studied the impact of these changes on resource utilization and clinical outcomes, as well as on our ability to improve quality of care in this group of patients.</ce:para>
<ce:section id="section0005"><ce:section-title>MATERIALS AND METHODS</ce:section-title>
<ce:section id="section0015"><ce:section-title>Pathway implementation</ce:section-title>
<ce:para id="para0045">Pathway development at University of Pittsburgh Medical Center (UPMC) began in the early 1990s because of a major hospital-wide initiative. The AAA pathway was developed by an 16-member committee chaired by a vascular surgeon. Other members included a case manager and representatives from hospital administration and nursing. After a 2-month development phase and approval by the medical executive committee, the pathway and case management were instituted in December 1993, and more than 97% of all elective infrarenal AAA patients since then have been enrolled. The only exclusion criteria were another planned major surgical procedure performed simultaneously with the AAA surgery, and recurrent AAA above a previous repair. Enrollment in the pathway led to the application of a standardized, multidisciplinary care plan. A case manager monitored each enrolled patient to ensure compliance and facilitate discharge planning. However, variation from the standard care plan was permitted whenever necessary in the judgment of the responsible attending or house officer. An important aspect of pathway institution at UPMC is review of outcome data and modification of the pathway, if needed. Such a review was undertaken 1 year after pathway implementation, and modifications were made, as detailed later.</ce:para>
<ce:para id="para0055">UPMC clinical case managers generally have either a baccalaureate or masters degree in nursing, and their salaries are paid by the hospital. The case manager salary was not factored in our calculations of the fiscal impact of pathway implementation. However, it is noteworthy that the clinical case manager for vascular surgery was also responsible for other surgical services, including the large renal transplant service. Therefore, the impact of factoring in her salary would be quite small.</ce:para>
</ce:section>
<ce:section id="section0025"><ce:section-title>Patient groups</ce:section-title>
<ce:para id="para0065">Applying the exclusion criteria cited above for the pathway patients, we identified a reference group of 49 consecutive infrarenal AAA patients treated immediately before pathway implementation (group I) (<ce:cross-ref refid="fig1">Fig. 1</ce:cross-ref>
).<ce:display><ce:figure id="fig1"><ce:label>Fig. 1</ce:label>
<ce:caption><ce:simple-para id="simple-para0065">Patient groups in relation to institution of pathway and pathway modifications.</ce:simple-para>
</ce:caption>
<ce:link locator="gr1"></ce:link>
</ce:figure>
</ce:display>
The 44 patients enrolled in the first year of the pathway were studied (group II), along with 34 consecutive patients enrolled immediately after the pathway modifications were made (group III). Our series includes patients transferred to our service directly from another institution, as well as some patients who were admitted initially to another service within our hospital and then transferred to our service for same-stay AAA repair. We designated all such patients as <ce:italic>transferred</ce:italic>
patients. Group I included 11 transferred patients, and groups II and III each contained nine transferred patients. In all cases, length of stay (LOS) was measured from the date of admission to our hospital.</ce:para>
</ce:section>
<ce:section id="section0035"><ce:section-title>Data collection and analysis</ce:section-title>
<ce:para id="para0075">Demographic, clinical, and resource utilization data were collected from UPMC's computerized medical record and fiscal data base. Elements of patients' medical history that were not available in the database were obtained by direct chart review. Statistical analysis was performed using a spreadsheet program (Excel) and a statistical package (GB Stat) on a personal computer. Hospital charges are presented in relative terms, using group I charges as a baseline of 100%, in compliance with hospital policy.</ce:para>
</ce:section>
</ce:section>
<ce:section id="section0045"><ce:section-title>RESULTS</ce:section-title>
<ce:para id="para0085"><ce:cross-ref refid="tab1">Table I</ce:cross-ref>
shows demographic and clinical characteristics of the patient groups.<ce:float-anchor refid="tab1"></ce:float-anchor>
Patients were predominantly male, with a mean age near 70 years. Clinical features were typical of AAA patients in many large series. There were no statistically significant differences between groups for any of the parameters, by χ<ce:sup>2</ce:sup>
analysis.</ce:para>
<ce:para id="para0095">To assess the initial effects of pathway implementation, we compared groups I and II. <ce:cross-ref refid="fig2">Fig. 2</ce:cross-ref>
shows a marginally significant decrease in relative mean charges (100% to 85.7%; <ce:italic>p</ce:italic>
= 0.09), as well as a slight decrease in mean length of hospital stay (13.8 to 13.1 days; NS).<ce:display><ce:figure id="fig2"><ce:label>Fig. 2</ce:label>
<ce:caption><ce:simple-para id="simple-para0075">Impact of pathway implementation: comparison of Groups I and II (see text for details). *Difference from group I marginally significant (<ce:italic>p</ce:italic>
= 0.09).</ce:simple-para>
</ce:caption>
<ce:link locator="gr2a"></ce:link>
<ce:link locator="gr2b"></ce:link>
</ce:figure>
</ce:display>
Median charges also fell (100% to 93%), and there was no change in median LOS (11 days). There was no significant change in 30-day operative mortality or 30-day readmission rates.</ce:para>
<ce:para id="para0105">At the 1-year pathway review (November 1994) several postoperative parameters in group II patients were examined for correlation with charges and LOS: myocardial infarction, arrhythmia, fluid overload, gastrointestinal bleeding, acute renal failure, and ileus. As shown in <ce:cross-ref refid="fig3">Fig. 3</ce:cross-ref>
, the sole parameter found to correlate significantly (<ce:italic>p</ce:italic>
< 0.05) with increased charges and LOS was fluid overload, defined as moderate or severe pulmonary vascular congestion by chest roentgenogram (CXR) on postoperative day 1 or 2.<ce:display><ce:figure id="fig3"><ce:label>Fig. 3</ce:label>
<ce:caption><ce:simple-para id="simple-para0085">Importance in group II of volume overload by CXR. *Significant difference between groups (p < 0.05).</ce:simple-para>
</ce:caption>
<ce:link locator="gr3a"></ce:link>
<ce:link locator="gr3b"></ce:link>
</ce:figure>
</ce:display>
The CXR criterion was used to define fluid overload because of its relative objectivity in comparison with clinical criteria for fluid overload, and its ease of retrieval from the medical database. The fluid overload data led us to initiate a multidisciplinary effort (surgery, anesthesiology, and critical care services) to reduce perioperative fluid administration. These changes were facilitated by the fact that the anesthesia and critical care services were directly involved in the AAA-pathway committee. Other changes were also made to the pathway: reduction in the number of units of blood set up for AAA patients from 6 to 4, because no more than 4 units had ever been necessary in group II; and streamlining of the process of arranging preadmission local accommodations for same-day surgery patients who lived more than 3 hours distant from UPMC.</ce:para>
<ce:para id="para0115">The effect of the pathway modifications was assessed by comparing groups II and III. As <ce:cross-ref refid="fig4">Fig. 4</ce:cross-ref>
shows, there was a sharp decrease in the incidence of fluid overload (73% vs 23%; <ce:italic>p</ce:italic>
< 0.01) and mean intensive care unit (ICU) stay (4.3 vs 2.6 days; <ce:italic>p</ce:italic>
< 0.05).<ce:display><ce:figure id="fig4"><ce:label>Fig. 4</ce:label>
<ce:caption><ce:simple-para id="simple-para0095">Impact of pathway implementation and interim changes in pathway: comparison of groups I, II, and III (see text for details). &, Difference from group I marginally significant (<ce:italic>p</ce:italic>
= 0.09); *, value significantly different from group I value (<ce:italic>p</ce:italic>
< 0.05); <ce:italic>#,</ce:italic>
value significantly different from group II value (<ce:italic>p</ce:italic>
< 0.05); <ce:italic>ns,</ce:italic>
value not significantly different from group I value; <ce:italic>n/a,</ce:italic>
data not available for group I.</ce:simple-para>
</ce:caption>
<ce:link locator="gr4"></ce:link>
</ce:figure>
</ce:display>
In addition, relative mean charges decreased significantly (85.7% vs 60%; <ce:italic>p</ce:italic>
< 0.05), as did mean LOS (13.1 vs 10.2 days; <ce:italic>p</ce:italic>
< 0.05). Reductions in median charges (93% vs 77%) and median LOS (11 vs 8 days) were also observed. A slight fall in mortality rate and a small increase in readmission rate were not significant. The mortality and readmission rate differences between groups I and III were also not significant.</ce:para>
<ce:para id="para0125">The 29 transferred patients (as defined in the Methods section) had a longer LOS than the patients who were directly admitted from an outpatient setting (17.1 vs 11.1 days; <ce:italic>p</ce:italic>
< 0.01). Virtually all of this difference was attributable to a longer preoperative stay for the transferred patients (6.2 vs 0.7 days; <ce:italic>p</ce:italic>
< 0.001). There was no significant difference between groups I, II, and III with respect to the preoperative LOS (2.1 vs 1.9 vs 1.7 days; NS), indicating that the impact of the transferred patients was equivalent in all three patient groups.</ce:para>
<ce:para id="para0135">Further analysis has included multiple linear regression analysis of data for all pathway patients (groups II and III) to identify parameters that correlate with increased resource utilization and adverse events. We examined both preoperative variables (age, sex, coronary, artery disease, pulmonary disease, smoking, diabetes, hypertension, and chronic renal insufficiency), and the postoperative variables (enumerated above in the description of the 1-year pathway review). The sole preoperative parameter that was predictive (<ce:italic>p</ce:italic>
< 0.01) of increased charges and LOS was chronic renal insufficiency (preoperative serum creatinine level >2.0 mg/dl). The two postoperative parameters that correlated (<ce:italic>p</ce:italic>
< 0.01) with increased charges were fluid overload (as expected), and acute renal failure (any postoperative serum creatinine elevation of 0.5 mg/dl over the preoperative level). Interestingly, preoperative renal insufficiency did not correlate with development of postoperative acute renal failure.</ce:para>
</ce:section>
<ce:section id="section0055"><ce:section-title>DISCUSSION</ce:section-title>
<ce:para id="para0145">Adapted from other fields such as engineering, pathways in health care were used initially to simplify documentation and to reduce variation in nursing care. Economic pressures have led hospitals to expand the scope of pathways to include the entire treatment process for selected patient groups. By delineating the processes of care for a typical patient, pathways theoretically allow hospitals to better predict the costs associated with a particular patient subset.<ce:cross-ref refid="bib4"><ce:sup>4</ce:sup>
</ce:cross-ref>
This is an important consideration in the current era of capitation and managed care. However, the chief economic benefit of pathways is reduction of cost by formulating a standard care plan that minimizes unnecessary resource use.<ce:cross-refs refid="bib3 bib4 bib5"><ce:sup>3-5</ce:sup>
</ce:cross-refs>
In general, case management has proven to be a crucial adjunct to pathways, to ensure compliance with the case plan and to facilitate patient discharge. The utility of this approach in reduction of resource utilization has been demonstrated for pneumonia,<ce:cross-ref refid="bib6"><ce:sup>6</ce:sup>
</ce:cross-ref>
thoracotomy,<ce:cross-ref refid="bib7"><ce:sup>7</ce:sup>
</ce:cross-ref>
acute leukemia,<ce:cross-ref refid="bib8"><ce:sup>8</ce:sup>
</ce:cross-ref>
cardiac surgery,<ce:cross-refs refid="bib9 bib10 bib11"><ce:sup>9-11</ce:sup>
</ce:cross-refs>
and stroke.<ce:cross-ref refid="bib12"><ce:sup>12</ce:sup>
</ce:cross-ref>
Despite previous reports about vascular surgery pathways,<ce:cross-refs refid="bib1 bib2 bib13"><ce:sup>1,2,13</ce:sup>
</ce:cross-refs>
definitive demonstration of a reduction in resource consumption is lacking.</ce:para>
<ce:para id="para0155">An additional unresolved issue is the relationship between pathways and quality improvement. Cost-focused pathways, with emphasis on reduced hospital stays and potential loss of physician independence, may conceivably result in reduced quality and more readmissions. However, it has been speculated that standardization of medical care is a key aspect of quality improvement.<ce:cross-refs refid="bib3 bib5 bib14"><ce:sup>3,5,14</ce:sup>
</ce:cross-refs>
The few studies that have critically examined this question have found that pathways help the process of quality improvement.<ce:cross-refs refid="bib7 bib11 bib12"><ce:sup>7,11,12</ce:sup>
</ce:cross-refs>
</ce:para>
<ce:para id="para0165">In this study, we found that institution of a pathway and case management for AAA surgery was followed by a marginally significant (<ce:italic>p</ce:italic>
= 0.09) reduction in mean hospital charges (15% reduction) and a nonsignificant reduction in mean length of stay (<ce:cross-ref refid="fig2">Fig. 2</ce:cross-ref>
). Although this was not a randomized controlled study, the control group (group I) was a consecutive series of patients treated just before institution of the new measures, and groups I and II had very similar demographic and clinical characteristics. Thus it seems likely that the pathway and case management implementation caused the observed decrease in charges. The lack of significant decrease in LOS with initial pathway implementation may reflect the fact that our service had initiated same-day AAA admission and early discharge planning even before pathway implementation. Of importance is that pathway institution did not result in any significant change in mortality or readmission rate (<ce:cross-refs refid="fig2 fig4">Figs. 2 and 4</ce:cross-refs>
). In this series, the number of patients who required readmission was small, and evaluation of a larger series of patients may be necessary to document whether decreasing LOS is associated with increase in readmission rates.</ce:para>
<ce:para id="para0175">In addition to studying the initial impact of the pathway, we studied quality improvement in the setting of the new care mechanisms. Collection of clinical outcome data was believed to be as important as collection of fiscal data with implementation of pathways at UPMC. The clinical data included a number of preoperative risk factors and postoperative endpoints. The existence of a centralized computerized clinical database aided this process greatly. Data analysis 1 year after pathway implementation showed that the finding of pulmonary vascular congestion by CXR correlated strongly (<ce:italic>p</ce:italic>
< 0.05) with increased charges and LOS (<ce:cross-ref refid="fig3">Fig. 3</ce:cross-ref>
). We used the endpoint of vascular congestion on CXR because this was more reproducible and easily retrieved than the clinical diagnosis of pulmonary edema. Only a few high-risk patients had pulmonary artery catheters, so cardiac filling pressure data were not appropriate as criteria for fluid overload. We speculated that volume overload was contributing to delayed extubation, prolonged intensive care unit (ICU) stay, and increased charges. Therefore, a multidisciplinary effort to reduce postoperative fluid administration was initiated. The anesthesia and critical care services played a central role in instituting the desired changes in fluid management. Because these services had been actively involved from the beginning in the AAA pathway committee, it was not difficult to bring about these changes. The change in fluid administration philosophy, along with other minor pathway changes (see Results section), was followed by sharp declines in the incidence of volume overload, ICU stay, as well as mean LOS and mean charges (<ce:cross-ref refid="fig4">Fig. 4</ce:cross-ref>
).</ce:para>
<ce:para id="para0185">Because group II and III patients had very similar demographic and clinical features, our data suggest that the pathway modifications led directly to the beneficial changes in fiscal and clinical endpoints. We noted also in comparing groups I, II, and III that the trends in median charges (100% vs 93% vs 77%) and median LOS (11 vs 11 vs 8 days) closely paralleled the changes in the means. This suggests that the data were not skewed by a few outliers.</ce:para>
<ce:para id="para0195">The relationship between hospital charges and actual costs is a highly complex one, because of issues such as how to incorporate fixed costs. At our institution, there is currently insufficient accounting data to allow accurate calculation of actual costs for an individual patient. The Medicare cost-to-charge ratio has been used by some authors, but its utility has been questioned.<ce:cross-ref refid="bib15"><ce:sup>15</ce:sup>
</ce:cross-ref>
Following the example of other authors,<ce:cross-refs refid="bib10 bib12 bib16"><ce:sup>10,12,16</ce:sup>
</ce:cross-refs>
we used hospital charges as a proxy for actual costs. Between February 1993 and December 1995, there was an overall increase of 5% in hospital charges for most services. Therefore, the reductions observed in patient charges subsequent to pathway introduction are actually <ce:italic>understated</ce:italic>
. We elected not to adjust charge values for the inflation because of the complexities of adjusting for different percentage increases in different types of services, and because of difficulties in determining when various charge increases were applied. Any such adjustment would only have <ce:italic>strengthened</ce:italic>
our conclusions about charge reductions after pathway implementation.</ce:para>
<ce:para id="para0205">As in other tertiary care centers, we treat many patients who are transferred from other institutions. The mean LOS was markedly greater for transferred patients (17.1 vs 11.1 days), and this difference was almost entirely attributable to prolonged preoperative stay (6.2 vs 0.7 days) for these patients. Thus the transferred patients do not have a prolonged postoperative course, but their LOS is increased by preoperative factors such as medical evaluation and scheduling constraints. These factors are often beyond the control of the vascular surgeon.</ce:para>
<ce:para id="para0215">In this consecutive series of AAA patients, the overall mortality rate was only 2.4% (three deaths out of 127 patients). Contrary to the notion that pathway implementation may lead to reduced quality of care, we observed <ce:cross-ref refid="fig4">(Fig. 4) a</ce:cross-ref>
nonsignificant trend toward <ce:italic>decreased</ce:italic>
mortality rates in groups I, II, and III (4.5% vs 2.3% vs 0%).</ce:para>
<ce:para id="para0225">The pathway and case management mechanisms were not essential per se for the collection and analysis of outcome data. However, the decision to focus on outcomes, and the help of the case manager to collect data (both of which accompanied pathway implementation), were vital.</ce:para>
<ce:para id="para0235">Further analysis of the pathway patients (groups II and III) reveals a potentially important predictor of high resource utilization (i.e., preoperative renal insufficiency) and another postoperative correlate of increased charges (i.e., acute renal failure). These data will allow us to focus future cost control and quality improvement efforts.</ce:para>
<ce:para id="para0245">It is important to note that pathway design, areas for potential quality improvement, and the magnitude of achievable gains in resource use are likely to be highly institution-specific.</ce:para>
</ce:section>
<ce:section id="section0065"><ce:section-title>CONCLUSION</ce:section-title>
<ce:para id="para0255">On the basis of our experience with patients undergoing AAA repair, we conclude that implementation of a pathway and case management can lead to significant reductions in resource consumption without significant change in mortality and readmission rates. Rather than restricting management decisions, clinical pathways with periodic review of outcome data can result in quality improvement.</ce:para>
</ce:section>
</ce:sections>
<ce:appendices><ce:section id="section0075"><ce:section-title>DISCUSSION</ce:section-title>
<ce:section id="section0085"><ce:section-title>Dr. George Andros (Encino, Calif.)</ce:section-title>
<ce:para id="para0265">The convulsive changes that now strain the American health care system to the breaking point are driven by macroeconomics. Our society, and in particular its business leaders, have concluded that the rising percentage of the Gross Domestic Product for health care to more than 14% is unacceptable.</ce:para>
<ce:para id="para0275">Attempts to curb these increases through two major federal legislative initiatives, diagnosis related groups (DRGs) and resource-based relative value systems (RB-RVS), have clearly failed.</ce:para>
<ce:para id="para0285">New non-Medicare health insurance schemes based on the 1974 ERISA Act have resulted in the increasing prevalence of health maintenance organizations (HMOs). Going beyond clinical guidelines, HMOs have been empowered to introduce contracting, capitation, and other managed care mechanisms that many are coming to regard as being draconian. Meanwhile, and perhaps causally, the rate of growth of health care costs seems to be slowing.</ce:para>
<ce:para id="para0295">At a microeconomic level, new approaches such as case management and clinical pathways are being applied increasingly to rationalize resource utilization, optimize and hopefully improve patient care, and reduce financial costs.</ce:para>
<ce:para id="para0305">Dr. Muluk and his associates have reviewed their experience with consecutive, nonurgent AAA operations over 3 years. They found that the institution of clinical pathways and case management, after a baseline year, produced a decrease in hospital charges and overall LOS and a downward trend in mortality rates, which they suggested might be an indicator of improved patient care. By refining the pathway, further reductions in these parameters were achieved. Predictors of increased resource utilization were shown to be renal insufficiency and fluid overload. The cost and LOS, as well as the shape and content of their clinical pathway, which was also kindly provided to me, resemble the information that we presented at one of the breakfast sessions of these meetings last year.</ce:para>
<ce:para id="para0315">Although the database and the number of measured parameters are small, the implications of this paper are enormous. Your decreasing trend in mortality rate was accompanied by a trend in decreased numbers of cases. Was this annual decline in utilization driven by capitation or other HMO forces? Was there a change in your aneurysm practice guidelines? Is it possible that your program to improve cost/benefit ratios may have led you to intervene on fewer and less-sick patients? You refer to costs, but measured charges with a disclaimer for inflation adjustment of charges. We all know that reliable cost data are nearly impossible to acquire. Has your cost-to-charge ratio remained constant over the 3-year period? Did the introduction of the pathway improve the net income of the hospital on this group of Medicare-age patients? In our hospital we have witnessed a small improvement in net income on DRG 110 (aneurysm) on noncapitated patients, but this profit improvement does not extend to capitated patients within the overall case mix. We have used an in-house vascular extended care facility to reduce charges in these patients during the latter part of their hospitalization. Have you used this strategy? Might its application have obviated your observed increase the in readmission rate?</ce:para>
<ce:para id="para0325">Finally, your group and ours achieved measurable improvements in charge and LOS, but we differ in one critical aspect that causes me deep concern. How has your cost-cutting program affected your educational mission?</ce:para>
<ce:para id="para0335">Same-day admissions deprive students and house officers of the opportunity to perform preoperative workups, and in consequence deny them the experience of learning to form meaningful doctor-patient relationships. Furthermore, does the interpolation of a case manager curtail the house officer's autonomy and decision-making authority that is so essential to the development of clinical maturity? This paper is profoundly important for its host of practical and socioeconomic implications, and I thank the Society for the opportunity to discuss it.</ce:para>
</ce:section>
<ce:section id="section0095"><ce:section-title>Dr. Satish C. Muluk</ce:section-title>
<ce:para id="para0345">I will try to address your questions one by one. Your first question related to the change in volume that we noted between groups II and III. I would note that group III constitutes a slightly smaller number of months—I think it was 10 months—as opposed to the previous groups, which each covered 12 months. There was no real change in our indications for operating on aneurysm patients, so I can only attribute this change, which is relatively small, to fluctuations that we encounter on a regular basis in our practice.</ce:para>
<ce:para id="para0355">The other important issue is that of cost versus charges. Certainly we would have liked to have looked at actual cost, but, as you pointed out, it is extremely difficult to get actual cost information. What the hospital does provide is a cost-to-charge ratio, which allows us to get some rough estimate of cost. Using those cost-to-charge ratios would change our data slightly, but not in a major way over those 3 years. We still find that our costs have declined in a similar fashion as I have depicted. The reason we chose to use charges, though, was that those numbers were more reliable, and we were not entirely clear where the cost-to-charge ratios were coming from.</ce:para>
<ce:para id="para0365">The third issue you raised was the issue of whether net DRG income has improved for the hospital for this diagnosis. That is a very good question. I don't have the answer to that because we don't have that information from the hospital, but we will try to obtain that.</ce:para>
<ce:para id="para0375">Another important issue that you raise is that of the educational mission of the hospital. I don't know that the pathway is a critical issue in terms of affecting the educational mission, but I think that certainly all of the other changes that are occurring are profoundly affecting the educational mission. We have tried to compensate for the fact that our residents cannot see the patients beforehand by having them come on a regular basis to the office to see patients as at least a partial way of compensating for this problem. But I agree with you that focusing on the educational mission is going to be a key issue as we make all of these changes. Unfortunately, it appears that the forces that are causing these changes are too powerful for us to really stop.</ce:para>
</ce:section>
<ce:section id="section0105"><ce:section-title>Dr. Keith D. Calligaro (Philadelphia, Pa.)</ce:section-title>
<ce:para id="para0385">I would also like to congratulate Dr. Muluk and his associates from the University of Pittsburgh on an outstanding presentation. On the other side of the state, in Philadelphia, our group previously reported results of implementation of clinical pathways for vascular surgery. We similarly recently analyzed patients who underwent aortoiliac surgery and there were about 70 patients in each group. We came to similar conclusions as your group did regarding the safety of shorter hospital LOS for these patients.</ce:para>
<ce:para id="para0395">I have two questions. What percent of patients who undergo aortic surgery could not be entered into your clinical pathways? You mentioned that you excluded patients who required emergent surgery or had other factors. In our analysis, 20% of all patients could not be entered into clinical pathways. Those included patients who were transferred from other hospitals who at the time of arrival in our hospital had not undergone appropriate cardiac workup, or who were very sick and required other investigation, and therefore, obviously could not enter the same pathway as the people who were electively admitted the same day as their surgery. I think that it is important to document this so that third-party payers do not expect shorter hospital LOS and decreased costs for all patients who undergo aortic surgery.</ce:para>
<ce:para id="para0405">My second question is, how many of your patients in group III were admitted the same day as surgery? We have not found any increased morbidity rate with this change in strategy, although the concern exists regarding education for residents. But I agree with you, I doubt third-party payers are going to sacrifice admitting patients the day before surgery simply so our residents can see the patients.</ce:para>
</ce:section>
<ce:section id="section0115"><ce:section-title>Dr. Muluk</ce:section-title>
<ce:para id="para0415">The question about the percentage of aneurysm patients not entered into the study is an important one. Of patients who underwent elective aneurysm surgery, 98% were entered. The only ones who were excluded were redo aneurysm patients and those who underwent another procedure, like a nephrectomy, for example, that was planned at the same time as the aneurysm surgery.</ce:para>
<ce:para id="para0425">The issue of patients being transferred from another hospital is a key one for us as well. We actually included those patients in the study if they were elective. And indeed, our LOS figures are influenced by that. Our average LOS is indeed higher than our average LOS for patients who are admitted on a same-day basis for that reason. But we did want to include those patients in the pathway. So the pathway began at the moment that the aneurysm surgery was decided on.</ce:para>
<ce:para id="para0435">On the issue of the same-day admission, we now have a high percentage of our elective aneurysm patients coming in on a same-day basis. Of the elective aneurysm patients, roughly 80% come in the same day; the other 20% probably represent transfers from another institution. And that percentage is about the same between groups II and III. It is slightly higher than the percentage for group I, which was about 70%.</ce:para>
</ce:section>
<ce:section id="section0125"><ce:section-title>Dr. James C. Stanley (Ann Arbor, Mich.)</ce:section-title>
<ce:para id="para0445">Dr. Muluk, I would like to ask you a question about resource utilization and reimbursement, and the two are quite different. At our institution we have looked at our 10 most common DRGs for vascular, and clearly identified something like pulmonary edema or renal failure as something that drives an outlier very quick to the fringes of profitability for both the hospital, but not necessarily for the physician, unless you have a capitated practice. The interesting thing is that about 15% of almost all managed care programs will allow patients to be transferred out without significant penalty from their care. The smart group that does that will transfer out these very patients who you have identified that cost a great deal of money to the recipient hospital. The second is that your hospital cannot accept a patient, at least ours can't, if they go outside the Medicaid district that they are initially assigned to. And that really jeopardizes a patient's care. Someone who has a thoracoabdominal aneurysm, that's in renal failure, cannot leave the hospital that they have been admitted to, if there is a licensed vascular surgeon there, and come to your hospital if it's outside. Your hospital will not receive one penny. They can come, you just will never be reimbursed for it, not one cent.</ce:para>
<ce:para id="para0455">The issue with us, when we looked at the most dominant cause of three of our 10 DRGs that were the big money losers for our practice, was transfer. You could subdivide it and identify what these reasons were that they were transferred, i.e., renal failure, or they came in, they were intubated, in respiratory insufficiency or something. But the bottom line was transfer. And when I looked at your variables, you had not sorted that out. And I'm curious, have you looked at that? Because for a small percentage of us in this room that have big-time tertiary care practices, that's not going to be something our hospitals can afford as moneys get tighter. I'm curious whether you have looked at that as a variable, even though it obviously has subvariables that we can define by logic terms.</ce:para>
</ce:section>
<ce:section id="section0135"><ce:section-title>Dr. Muluk</ce:section-title>
<ce:para id="para0465">We have looked at the transfer group of patients, who represented roughly 20% in this population. Obviously some of the transferred patients, in fact many of them, were emergent and were therefore excluded from this study. In Pennsylvania, the situation appears to be a little bit different in that when a patient is transferred, the recipient hospital gets the bulk of the DRG for that patient.</ce:para>
</ce:section>
<ce:section id="section0145"><ce:section-title>Dr. Stanley</ce:section-title>
<ce:para id="para0475">Not with Medicaid. They may get it with other insurance carriers.</ce:para>
</ce:section>
<ce:section id="section0155"><ce:section-title>Dr. Muluk</ce:section-title>
<ce:para id="para0485">To be honest, I am not sure of the details, but I think that applies to Medicare, at least in Pennsylvania, the way I've been told by our case manager. So that it actually is counterproductive for us, for example, to transfer a patient. Even if we transfer a patient in their last days before going to rehabilitation, our hospital would lose a good fraction of the DRG for that patient.</ce:para>
</ce:section>
<ce:section id="section0165"><ce:section-title>Dr. John W. Hallett, Jr. (Rochester, Minn.)</ce:section-title>
<ce:para id="para0495">My question concerns the case manager concept, which you seemed to emphasize. Did you add a full-time equivalent to do this? Did you factor the salary and benefits of that position into your cost analysis? How essential do you think this case manager is in this type of process?</ce:para>
</ce:section>
<ce:section id="section0175"><ce:section-title>Dr. Muluk</ce:section-title>
<ce:para id="para0505">A very good question. We did not actually factor the salary of the case manager. They were provided by the hospital. Indeed, the case manager for vascular surgery covers not only vascular surgery but also transplant and general surgery. So our vascular surgery population is a relatively small fraction of her entire workload. But we do believe that the case manager concept is critical. Although we did not have the experience of using a pathway without a case manager, our information from other institutions was that it was virtually useless to impose a pathway because of poor compliance, unless there was someone to monitor the compliance.</ce:para>
<ce:para id="para0515">We certainly did not allow the case manager to interfere with clinical decisions in cases where patients needed treatment for urgent problems. But her role was more to perhaps guide the residents in terms of what laboratory studies and procedures were recommended for the routine patient.</ce:para>
</ce:section>
<ce:section id="section0185"><ce:section-title>Dr. Marvin A. McMillen (Chicago, Ill.)</ce:section-title>
<ce:para id="para0525">I'm not sure there is really a huge difference between a clinical pathway and best clinical practice. And as a chief of surgery who happened to train in medicine before going into surgery, I find that we can go to surgeons and get them to observe a best clinical practice. As I review these issues in my own institution and try to break down the barriers between medicine and surgery, the problem actually seems to be our colleagues in medicine. Not only do these differences generate significant differences in LOS, but they also, unfortunately, generate significant morbidity. I'm curious what your involvement has been in the Department of Medicine, or do you just have total control of your vascular patients? What are your suggestions to the rest of us who oftentimes have a group of private primary care internists whose participation in the perioperative care of their patients is sometimes a little more vigorous than we would like it to be?</ce:para>
</ce:section>
<ce:section id="section0195"><ce:section-title>Dr. Muluk</ce:section-title>
<ce:para id="para0535">A very good question. I think our degree of control over the aneurysm patients is such that we are able to enroll all of the patients into the pathway without any difficulty. There has been a little bit of resistance from the Department of Medicine at the University of Pittsburgh for pathways, particularly for diagnoses like pneumonia and chronic ventilator dependence. But for even those diagnoses, now, pathways are being developed, at a slower rate perhaps though than for many of the surgical procedures, for which we now have over a hundred pathways established.</ce:para>
</ce:section>
<ce:section id="section0205"><ce:section-title>Dr. Stephen P. Murray (San Antonio, Tex.)</ce:section-title>
<ce:para id="para0545">I applaud your efforts in showing the Society the benefits of instituting quality improvement in a fashion similar to that espoused by Dr. Goldstone in his address. My question has to do with implementation.</ce:para>
<ce:para id="para0555">I continue to be amazed how contentious the issue of fluid management is in our postoperative patients as evidenced by the battles that occur at our morning reports between intensivists and surgeons. You would think that after so many years of dealing with this we would have fixed that problem long ago.</ce:para>
<ce:para id="para0565">In your objective analysis you used CXR. My first question is how did you arrive at using a CXR to determine pulmonary edema given the plethora of other measures available—patient weight, Swan-Ganz data, etc.—and were the assessments of pulmonary edema on those CXRs read in a blinded fashion?</ce:para>
<ce:para id="para0575">Second, once you determine the optimal method for determining this fluid overload, how did you bring on your colleagues in anesthesia and in the ICU so as to best come to an agreement on what would be the best means of resuscitating the patient during and after surgery? Who, in other words, was in control practically and could dictate turning the fluid up or down down, giving Lasix, not giving Lasix?</ce:para>
</ce:section>
<ce:section id="section0215"><ce:section-title>Dr. Muluk</ce:section-title>
<ce:para id="para0585">The CXR criteria were picked really because of the ease of use. We were easily able to retrieve CXR data from the computerized database, more easily, for example, than central pressures or patient weight. Although we could have retrieved those data, it would have been more difficult for us. And we believed that the CXR was somewhat more objective as long as the same standards were applied throughout. And indeed, the study was blinded to the extent that the radiologists really had no idea of the progression of the pathway when they were reading the studies. Studies were routinely read in the ICU x-ray suite.</ce:para>
<ce:para id="para0595">The involvement of the anesthesiologists and the ICU staff was critical. They were actually involved from the very beginning in the development of the pathway, so it was not particularly difficult to get them to change their practice. It's actually been remarkable, after looking at objective data, how willing they were to change their method of fluid administration and to really restrict fluid administration so as to keep the urine output adequate in these patients.</ce:para>
</ce:section>
<ce:section id="section0225"><ce:section-title>Dr. Jerry Goldstone (San Francisco, Calif.)</ce:section-title>
<ce:para id="para0605">I just want to make a couple of comments and emphasize a couple of things. These practice guidelines, or whatever you choose to call them, are dynamic, they change. And the whole concept here is that you develop a system that you think is the best possible care and then you keep studying it and you keep making it better, little by little. I think everybody has the idea that once these guidelines are written down they are carved in stone. But they're not. The purpose is to keep changing it, to keep making it better; again, you continuously improve it.</ce:para>
<ce:para id="para0615">Referring to the question about education, in all these things you can set up a system whereby people can work outside the guidelines. The educational component comes when you make everybody document why they are doing that and then you discuss these things in a nonpunitive way. Every once in a while you'll find that somebody will deviate from a guideline because they've got a good idea that you haven't thought of before. So again, I think the message here is that this is a continuous process, you've got to keep doing it, make it better, little by little, all the time. As the Japanese say, “kaizen.”</ce:para>
</ce:section>
</ce:section>
</ce:appendices>
</body>
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<titleInfo type="alternative" lang="en" contentType="CDATA"><title>Utility of clinical pathway and prospective case management to achieve cost and hospital stay reduction for aortic aneurysm surgery at a tertiary care hospital</title>
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<name type="corporate"><namePart>From the Division of Vascular Surgery, University of Pittsburgh Medical Center.</namePart>
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<originInfo><publisher>ELSEVIER</publisher>
<dateIssued encoding="w3cdtf">1997</dateIssued>
<copyrightDate encoding="w3cdtf">1997</copyrightDate>
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<language><languageTerm type="code" authority="iso639-2b">eng</languageTerm>
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<abstract lang="en">Abstract: Purpose: We reviewed our experience with a clinical pathway instituted in December 1993 for all nonurgent abdominal aortic aneurysm (AAA) surgery.Methods: We analyzed a reference group of 49 consecutive pre-pathway AAA patients (group I) and the 44 patients enrolled in the first year of the pathway (group II). On the basis of the interim review of data collected during the first year, pathway modifications were made, and 34 patients enrolled after these modifications (group III) were also analyzed.Results: Comparison of groups I and II showed that institution of the pathway resulted in a marginally significant reduction in mean charges of 14.7% ( p = 0.09), and a slight fall in mean length of stay (LOS) (13.8 vs 13.1 days, NS) and mortality rate (4.1% vs 2.3%, NS). For group II, a significant correlate ( p < 0.05) of increased charges was fluid overload as diagnosed by chest radiograph. This recognition led to active efforts to reduce perioperative fluid administration. Comparison of groups II and III revealed that the practice modifications led to marked reduction in the incidence of fluid overload (73% vs 24%; p < 0.01), mean charges (30.4% reduction; p < 0.05), mean LOS (13.1 vs 10.2 days; p < 0.05), and median LOS (11 vs 8 days). Multiple regression analysis of all pathway patients showed that preoperative renal insufficiency is a significant predictor of both increased LOS ( p < 0.01) and charges ( p < 0.01), but that age, sex, and coronary disease were not predictive. Of the postoperative parameters analyzed, important correlates of increased charges were acute renal failure ( p < 0.01) and fluid overload ( p < 0.01).Conclusions: Institution of a clinical pathway for AAA repair resulted in significant charge reduction and a slight reduction in stay. Practice modifications based on interim data analysis yielded further significant reductions in charges and LOS, with overall per-patient charge savings (group I vs III) of 40.6% ( p < 0.05) and overall LOS reduction of 3.5 days ( p < 0.05). The reduction in actual charges was seen despite an overall increase in the hospital rate structure. Comparing groups I, II, and III, we found no indication of increasing mortality rate. Ongoing analysis has identified correlates of increased charges, potentially permitting identification of high-cost subgroups and more focused cost-control efforts. Rather than restricting management, clinical pathways with periodic data analysis may improve quality of care. (J Vasc Surg 1997;25:84-93.)</abstract>
<note>Reprint requests: Satish C. Muluk, A-1011 PUH, 200 Lothrop St., Pittsburgh, PA 15213.</note>
<note>0741-5214/97/$5.00 + 0 24/6/78228</note>
<note type="content">Table I: Comparison of demographic and clinical features</note>
<relatedItem type="host"><titleInfo><title>Journal of Vascular Surgery</title>
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<titleInfo type="abbreviated"><title>YMVA</title>
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<originInfo><publisher>ELSEVIER</publisher>
<dateIssued encoding="w3cdtf">199701</dateIssued>
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<identifier type="ISSN">0741-5214</identifier>
<identifier type="PII">S0741-5214(05)X7184-1</identifier>
<part><date>199701</date>
<detail type="volume"><number>25</number>
<caption>vol.</caption>
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<detail type="issue"><number>1</number>
<caption>no.</caption>
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<extent unit="issue-pages"><start>6</start>
<end>200</end>
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<extent unit="pages"><start>84</start>
<end>93</end>
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<identifier type="istex">A5091FB6EE101DA00551A49F86B665BF9EDFB549</identifier>
<identifier type="ark">ark:/67375/6H6-8538S7PT-W</identifier>
<identifier type="DOI">10.1016/S0741-5214(97)70324-0</identifier>
<identifier type="PII">S0741-5214(97)70324-0</identifier>
<accessCondition type="use and reproduction" contentType="copyright">©1997 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter</accessCondition>
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