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Ann Thorac Surg 1996;61:1136-1139
© 1996 The Society of Thoracic Surgeons
Minneapolis Heart Institute, Minneapolis, Minnesota
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Methods. Two hundred seventy-six DRG 107 patients who were operated on at our institutions in 1994 and registered in The Society of Thoracic Surgeons National Cardiac Surgery Database were reviewed. There were 185 patients randomly admitted to the hospital on the day of operation and 91 patients admitted 1.78 ± 1.94 days before. These patients were analyzed according to The Society of Thoracic Surgeons National Cardiac Surgery Database predicted risk group and expected operative mortality modules. Univariate analysis of all risk variables listed in The Society of Thoracic Surgeons National Cardiac Surgery Database were used to identify the difference between 176 elective procedure patients in the same-day admission group and 67 elective procedure patients in the non–same-day admission group.
Results. The same-day admission group had lower expected operative mortality (1.3% versus 2.9%), fewer female patients (17% versus 29%), younger age (62 versus 67 years), and fewer patients in the higher predicted risk group. Univariate analysis showed only age and ejection fraction variables were significantly different between the two elective groups. Comorbidities predictive of elective non–same-day admission revealed that age and New York Heart Association class IV were significant predictors. The length of stay was shorter and the total charges were less in the same-day admission group.
Conclusions. There was no increase in preoperative, intraoperative, or postoperative complications in the same-day admission patients. Same-day admission was safe and cost-effective and could be carried out as a routine admission for several selected groups of patients.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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The advent of prospective payment systems has dramatically influenced the manner in which healthcare administrators view the delivery of healthcare. With the implementation of this payment system and diagnosis-related groups (DRGs), the attention of healthcare providers has focused on the necessity for hospitalization and the length of hospital stay for various groups of patients. One of the greatest factors in total hospital charges is duration of hospitalization. Unwarranted hospitalization and excessive lengths of stay for inpatients have become prime targets in reducing healthcare costs.
High cost of healthcare has created pressures from federal and state governments to improve the efficiency of healthcare delivery. Increasingly, state and federal laws are regulating and containing hospital reimbursement. Cost containment in healthcare has become a national priority and is likely to increase. With pressures from local, state, and national agencies, healthcare providers must pursue ways of delivering quality, cost-effective care.
The move toward outpatient and same-day surgical services has been phenomenal in the past decade. Efforts in this area have focused on limiting inpatient hospitalization, reducing ancillary services, and decreasing length of stay. Procedures for permission testing of patients having elective operations have been initiated throughout the country as a means of controlling hospital costs by reducing the number of preoperative hospital days [1].
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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According to our datafile, 185 patients were randomly admitted to the hospital on the day of operation (same-day admission [SDA]). These patients were discharged from the hospital after coronary angiographic study, and it had been determined by the cardiologist, cardiac surgeon, or both that operation was not indicated during that same admission. The timing of readmission was primarily influenced by third-party payers or operation scheduling. The remaining 91 patients had had coronary angiographic studies done within the previous 6 months and were readmitted to the hospital before the day of operation non–same-day admission [nSDA]), either because of their condition or because they were prescheduled to undergo an elective interventional procedure.
Patients were defined to be SDA or nSDA depending on whether the date of admission and date of procedure were the same or not. All statistics were performed using SAS Windows NT Version 6.09 (SAS Institute Inc, Cary, NC). Rates of risk factors in each subset of the two groups were compared (SDA versus nSDA and elective [el]-SDA versus el-nSDA) by examining the p values of the Pearson 
2 statistics, unless cell counts were less than five. When cell counts were less than five, p values were calculated using Fisher's two-sided exact test. Continuous and categoric variables were tested for normality using the Shapiro-Wilk test of normality. Those variables with p values greater than 0.05 were compared using the t test, and those with p values less than 0.05 were computed using the Wilcoxon rank sum test.
Multivariate logistic regression models were created with a stepwise approach with an entry p value of 0.20 and a retention p value of 0.10. The dependent variable was el-nSDA, and all independent variables were preoperative characteristics.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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).
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When only elective groups of patients were compared, the univariate analyses revealed small differences between the el-SDA and el-nSDA groups (Table 2). The el-nSDA patients were on average 5 years older with a significant p value. The difference in mean ejection fraction between these two groups (0.56 versus 0.52) yielded a significant p value of less than 0.05; however, there probably was no clinical significance of this ejection fraction difference. The number of grafts, pump time, and number of units of red blood cells used had significant Wilcoxon p values, but this is unlikely to have any clinical importance.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Planning and implementation of the SDA program was a collaborative effort among cardiothoracic surgeons, anesthesiologists, nurse clinicians, physician assistants, and clinical support personnel. The SDA program at our institutions started in early 1992. Initially SDA criteria were complex and varied from hospital to hospital, but they have become more standardized and encompass all patients in DRG 107.
The patients return a day or two before the operation to complete the preoperative work-up such as laboratory studies and chest roentgenograms. If indicated, other diagnostic procedures such as carotid ultrasound or saphenous vein mapping could be carried out as well. A complete history and physical examination is done by the family physician, cardiologist, or nurse practitioner. At this time the surgeon visits the patient to re-review and discuss the procedure, risks and benefits, and possible complications. Preoperative and postoperative routines and expectations are reviewed with the patient, family members, or significant others and then reinforced by way of an educational video produced by the institution. Time is allowed for clarification of information and final instructions on where to report the morning of the operation.
On the morning of the operation, the patient and family report to the admitting office at least 90 minutes before the scheduled time of operation. When the admission process is completed, they are escorted to the preoperative holding area. The preoperative holding room nurse is responsible for completing the patient's admission and preoperative check list. The anesthesiologist and nurse anesthetists also see the patient to review the record and make any final assessments before the patient is taken to the operating room.
Through the patient education program, the patients and families are able to understand what is going on during the preoperative period. There is ample time the morning of the operation to physically prepare patients for the operation. The mental and cognitive needs of the patients are met during the preoperative visit and again reinforced to the point that the patients are comforted and reassured about the operation. The majority of family members verbalized good feelings about having more time with the patient, both in the evening before and in the morning before the operation. Most of the patients also preferred to stay at home in their own bed the night before the operation.
The results definitely show that the nSDA patients were sicker and had higher rates of morbidity and mortality. When the nonelective group of patients was eliminated from the analysis the total LOS was still 2.9 days longer in the el-nSDA group. It was obvious that the difference in preoperative LOS was determined by the admitting plan. The remaining difference, however, may prove to be significant in a time-series analysis (LOS = LOS from admission to operation + LOS from operation to discharge), because the time from operation to discharge may not depend on time from admission to operation.
When the SDA program started, the safety issue was a prime concern of everyone. A particular concern was for the safety of the elderly patients who live far away from the hospitals and may need to get up at 2 or 3 o'clock in the morning and go through a snow storm or frigid temperatures in Minnesota to be admitted at 5:30 AM for a 7:30 case. Fortunately, both our close monitoring and the results from this study show that there was no increase in the rate of preoperative infarction or death. Postoperatively, the rates of complications such as myocardial infarction, atrial fibrillation, stroke, and pulmonary and renal insufficiencies were not greater in the SDA or el-SDA group. In fact, there were no deaths in either el-nSDA or el-SDA patients.
The Society of Thoracic Surgeons statistical model for predicting the risk of mortality was applied to each group. This revealed a mean risk of 1.28% in the el-SDA group and 1.99% mean risk in the el-nSDA group. The difference of 36% in risk between the two groups was highly statistically significant (p = 0.0002) but may be clinically nonsignificant, because both groups had no operative mortality.
Comorbidities predictive of el-nSDA were noted to be female sex, functional class IV, older age, and recent history of myocardial infarction. Further analysis revealed that only age in years and New York Heart Association class IV were statistically significant. History of recent myocardial infarction bordered significance, and female sex was not significant. Model fit was determined using the c statistic for discrimination (c = 0.696) and the Hosmer Lemeshow test for calibration (p = 0.1747). This would seem to indicate modest predictive power for these comorbidities. With the probable exception of older and New York Heart Association class IV patients, it is likely that the majority of those patients who were not admitted on the day of operation could have been admitted as SDA patients.
The study by Anderson and associates [5] in 1993 revealed that preoperative LOS for SDA patients was significantly shorter by 1.5 days. They also found that there were no differences in age, sex, or total number of comorbidity factors. Diabetes and an ejection fraction of less than 0.50 were significantly more common in the nSDA patients and were independent predictors of nSDA patients. Keithley and associates [6] studied the cost-effectiveness of same-day surgical admission and found that although these patients were expected to have a hospitalization shorter than traditionally admitted patients, they actually stayed 1.8 fewer days. A study by Loop and colleagues [7] concluded that patients' admission on the day of operation saved 2 days of hospitalization. Our study confirmed the above observations that patients in the SDA group and both elective categories had shorter LOS from operation to discharge of 1.8 days, but there was no difference in intensive care unit LOS in the elective groups of patients (Table 3).
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We concluded that when the entire populations of SDA and nSDA patients were analyzed, there was a definite distinction between two groups. The nSDA patients were older and sicker and had higher morbidity and mortality. When only elective groups of patients were compared, the differences between two subsets were small. Same-day admission does not increase the preoperative and intraoperative risk or postoperative complications, but it decreases the LOS from operation to discharge by 1.8 days. The SDA program is safe and cost-effective and could be carried out as a routine admission for several selected groups of patients.
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Acknowledgments |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Address reprint requests to Dr Arom, 920 E 28th St, Minneapolis, MN 55407.
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References |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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