Ann Thorac Surg 1995;59:822-824
© 1995 The Society of Thoracic Surgeons
Patent Ductus Arteriosus Ligation: Are We Doing Better?
William M. Novick, MD,
Donald C. Watson, Jr, MD,
Bruce S. Alpert, MD,
Judith A. Becker, MD,
Thomas G. DiSessa, MD,
John C. Ring, MD,
Stuart E. Birnbaum, MD,
Nancy A. Chase, MD
Departments of Pediatric Cardiology and Pediatric Cardiovascular Surgery, LeBonheur Children's Medical Center, The University of Tennessee, Memphis, Tennessee
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Abstract
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Limitation on health care resource use is stimulating critical evaluation of previous preoperative standards. We retrospectively reviewed the clinical and hospital financial records of all children admitted for patent ductus arteriosus ligation from July 1984 to April 1994 for age, perioperative length of stay, readmissions for postoperative surgical problem, and hospital charges adjusted to 1994 dollars. Patients with an isolated patent ductus arteriosus, greater than 3 months of age, without preoperative or postoperative complications were included in this study and stratified into two groups based on date of operation. Group I had operation before January 1, 1991, and group II had operation on or after January 1, 1991. Comparison of these two groups revealed a significant difference in perioperative length of stay (group I, 3.9 +/- 1.2 days [mean +/- standard deviation]; group II, 2.7 +/- 0.9 days; p < 0.0001) and in hospital charges (group I, $8,700 +/- $2,100; group II, $6,600 +/- $1,000; p < 0.0001). These data support the premise that children older than 3 months undergoing elective ligation of a patent ductus arteriosus have been treated with improved efficiency and less charge without an increase in postdischarge morbidity. Health care policy decisions have forced us to evaluate the standards of perioperative care more critically.
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Introduction
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See also page 824.
Rising hospitalization costs and limits in health care funding demand a critical evaluation of routine surgical procedures to identify factors that may improve efficiency and reduce cost. Costs, effectiveness, and efficacy of the surgical treatment of congenital heart disease have been a long-term concern to physicians [1]. The recent implementation of the critical pathway method (CPM) in the field of medicine addresses some of these issues. The concept of CPM suggests that directed diagnostic and therapeutic protocols can reduce variations in patient care and thereby reduce hospital costs and length of stay (LOS) [2]. Recently the CPM has been applied to the surgical management of congenital heart disease [3]. The current study evaluates the experience of a single institution with a common congenital heart disease problem, where CPM was emerging as an identifiable concept, to determine whether practice changes can decrease patient LOS and hospital charges (HC) without affecting postoperative morbidity.
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Material and Methods
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We retrospectively reviewed the hospital charts, billing records, and outpatient clinic records of all patients who were 4 months of age or greater and admitted from July 1984 to April 1994 for elective ligation of an isolated patent ductus arteriosus. The study population was restricted to patients without preoperative or postoperative complications.
The patients were stratified into two groups based on the date of operation. Group I consisted of patients receiving operation before January 1, 1991, and group II, those receiving operation on or after January 1, 1991. This date was chosen because a decision was made to emphasize admission of postoperative patients to the recovery room and then to a telemetry room rather than the intensive care unit. The hospital records were reviewed for age, LOS, HC, and readmission (within 30 days). The number of preoperative days was obtained by subtracting the operative date from the admission date. Hospital charges were adjusted to 1994 dollars [4] (Table 1
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Analysis of the above variables was performed using Fisher's exact test and 
2 analysis for grouped data and regression analyses to investigate associations.
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Results
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The total number of patients who underwent elective operation was 140. Three patients had significant postoperative complications: in group I 1 patient had chylothorax and 1 had ileus and vomiting, whereas in group II 1 patient had ileus and vomiting. These 3 patients were eliminated from any further consideration and are not in the study population.
The total number of patients in group I was 76, of whom 51 were female and 25 were male. Ages in group I ranged from 4 to 160 months with a mean of 33 months. The length of stay for group I patients ranged from 3 to 7 days with a mean of 3.9 days. Evaluation of preoperative days in group I revealed an average of 1.2 days, and 8 patients underwent catheterization preoperatively during the hospitalization for operation. Hospital charges for group I patients ranged from $5,700 to $15,800 (1994 dollars) with a mean of $8,700. No patient from group I was readmitted to the hospital within 30 days.
The total number of patients in group II was 61, of whom 41 were female and 20 were male. Ages ranged from 4 to 121 months with a mean of 30 months. Average LOS for the group was 2.7 days with an average of 0.8 preoperative days. Hospital charges ranged from $5,100 to $10,400 (1994 dollars) with a mean of $6,600. No patient from group II was readmitted to the hospital within 30 days. The ages of the two groups were similar; however, all other variables examined were significantly different. The LOS decreased between the two periods by 1.2 days. Preoperative admission days decreased 0.4 days between the two groups. The decrease in HC by $2,100 (1994 dollars) represents a 29% reduction in charges and reflects the changes made in the efficiency of clinical care for these patients.
Statistical analysis of each of the variables is tabulated in Table 2.
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Comment
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The days of the best health care available regardless of cost are coming to an end in the American medical industry. We are now expected, and rightfully so, to produce the same patient care results in a more economically efficient manner. Institutions and organizations involved in health care delivery by the year 2000 will have to become more cognizant of efficiency if they are to survive [5].
We evaluated the ability to manage patients with a single congenital cardiovascular defect efficiently and effectively after a physician-directed change in routine. The conscious effort to send patients to the recovery room and subsequently a telemetry-monitored bed after elective patent ductus arteriosus ligation resulted in a significant decrease in LOS and HC. Assessment of patient care as judged by early readmission revealed no increase in patient morbidity related to decreased LOS. The recent decrease in use of a preoperative day is most likely reflected by a decreased HC and LOS.
Critical pathway method in its fullest form as an identifiable practical concept is not reflected in this study population, but the philosophy of CPM has been embraced. Physician-directed diagnostic and therapeutic plans or CPMs now are being implemented throughout the country in such diverse areas as neurosurgical, orthopedic, neonatal, and coronary bypass units. In some studies the implementation and adherence to these predetermined plans were found to be predictors of postoperative LOS [2, 6–8]. Recently, even the area of congenital heart disease has been subjected to CPM, and its implementation resulted in a decrease in intensive care unit LOS and overall hospital LOS [3]. A restriction of health care dollars will certainly lead us to become efficient.
However, CPM also may affect adversely the emergence of new and innovative treatment plans. A recent comparison of cost and clinical outcomes between surgical and transcatheter closure of patent ductus arteriosus revealed a net $2,400 increase in catheter versus surgical management and more perioperative complications and transfusions in the catheter group [9]. In other studies, the use of innovative surgical techniques [10] that may decrease postoperative mortality and the implementation and adherence to CPM has improved efficiency without changing patient care [11, 12].
Busy cardiothoracic units have practiced the concept of CPM for years out of necessity. We all have asked ourselves the critical question daily, ``What are we doing for this patient that cannot be done at home or outside the intensive care unit?'' But now we can approach this question in a more disciplined and critical way and must embrace the concept to survive in this new age of shrinking health care resources.
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Footnotes
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Presented at the Forty-first Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 10--12, 1994.
Address reprint requests to Dr Novick, The Heart Center, 777 Washington, Suite P215, Memphis, TN 38105.
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References
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- Bureau of Labor Statistics. Consumer Expenditure Survey. Washington, DC: Bureau of Labor Statistics, 1994.
- Hart R, Musfeldt C. MD-directed critical pathways: it's time. Hospitals 1992;66:56.[Medline]
- Richards JS, Sonda LP, Gaucher E, Kocan MJ, Ross DA. Applying critical pathways to neurosurgery patients at the University of Michigan Medical Center. Qual Lett 1993:8--10.
- Metcalf EM. The orthopaedic critical path. Orthopaedic Nurs 1991;10:25–31.
- Neidig JR, Megel ME, Koehler KM. The critical path: an evaluation of the applicability of nursing case management in the NICU. Neonatal Network 1992;11:45–52.[Medline]
- Gray DT, Flyer DC, Walker AM, Weinstein MC, Chalmers TC. Clinical outcomes and costs of transcatheter as compared with surgical closure of patent ductus arteriosus. N Engl J Med 1993;329:1517–23.[Abstract/Free Full Text]
- Karwande SV, Rowles JR. Simplified muscle-sparing thoracotomy for patent ductus arteriosus ligation in neonates. Ann Thorac Surg 1992;54:164–5.[Abstract]
- Crummer MB, Carter V. Critical pathways-the pivotal tool. J Cardiovasc Nurs 1993;7:30–7.[Medline]
- Hofmann PA. Critical path method: an important tool for coordinating clinical care. Joint Comm Qual Improv 1993;19:235–46.
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Abstract
Introduction
