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Ann Thorac Surg 1997;64:299-302
© 1997 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Pulmonary Lobectomy Patient Care Pathway: A Model to Control Cost and Maintain Quality

General Thoracic Surgical Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Cost containment is a reality in thoracic surgery. Patient care pathways have proved effective in cardiac surgery to reduce length of stay and control costs.

Methods. A multidisciplinary team formulated a pulmonary lobectomy patient care pathway to standardize care, reduce length of stay and costs, and maintain quality. Variance codes were developed to collect data prospectively on reasons for prolonged stay. A patient satisfaction survey was instituted to learn patients' responses to their hospitalization.

Results. One hundred forty-seven patients underwent lobectomy in 1995 before institution of the pathway with a mean length of stay of 10.6 days and a mean cost of $16,063. The lobectomy pathway was instituted at the beginning of 1996. One hundred thirty patients underwent lobectomy in 1996 with a mean length of stay of 7.5 days (p = 0.03) and a mean cost of $14,792 (p = 0.47). Readmission and mortality rates were unchanged. Eighty-eight of 130 patients (68%) were able to be discharged by the target length of stay of 7 days in 1996 as opposed to 76 of 147 patients (52%) in 1995. The most common reason for delayed discharge was inadequate pain control. The majority of patients felt prepared for discharge by the seventh postoperative day (70 of 96 patients, 73%).

Conclusions. The institution of a lobectomy patient care pathway appeared to reduce length of stay and costs. The pathway provided a framework to begin systematic quality control measures to enhance patient care.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The current medical era is concerned with cost containment as the medical reimbursement systems shift to a capitated managed care model. Thoracic surgeons must practice cost-effective medicine to adapt to this changing environment. The quality of the delivered care must remain high despite these fiscal constraints. Thoracic surgeons must meet this challenge and guide the process rather than ignore it. Patient care pathways have been developed for common clinical conditions, including cardiac operations, to facilitate patient flow through the hospital stay [1, 2]. Our General Thoracic Surgical Unit developed a patient care pathway for patients undergoing pulmonary lobectomy to standardize care, reduce length of stay (LOS) and cost, and maintain quality of care.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
A multidisciplinary inclusive team was formed and met on a weekly basis starting in March 1995 to develop a lobectomy pathway. A thoracic surgeon led the team, which included representatives from the hospital administration, anesthesia, nursing (from the operating room, recovery room, intensive care unit, and thoracic surgical unit), chest physical therapy, and social services. Decisions were consensus driven but strongly directed by the surgical team. The hospital administration provided data regarding numbers of patients with a specific procedure code (ICD-9), LOS, and cost from their data base. The Massachusetts General Hospital has used a cost accounting system marketed by Transition Systems, Inc (Boston, MA) since 1995, which allows quantification of costs according to which cost center in the hospital provides the service or product to the patient. Unit costs are calculated for each product or service used and can be tracked with great detail through the patients' hospitalization or in a large group of patients. From a composite of costs (not charge) data from a patient's hospitalization, an insight into how cost savings might be achieved was gained. A patient care pathway was then developed that detailed daily goals for the patient and care team to achieve. Items detailed on a daily basis included assessments (test ordering and guidelines), physical therapy, medications, diet, oxygen therapy, patient education, social service and case management, pain management, chest tube management, and wound care. The pathway represented the idealized patient and allowed the clinically naive to rapidly gain an insight into the total care of the patient. The pathway was initiated on October 1, 1995, the beginning of fiscal year 1996. The pathway was attached to the patient's chart so caregivers could access it and delivered care could be recorded. Variance codes were developed for patients who were not able to be discharged by the target day (day 7), to identify what factors led to a prolonged stay. A postdischarge patient satisfaction survey questionnaire was developed and administered to patients 2 weeks after hospital discharge by the thoracic surgery floor nurses. A patient-oriented care pathway was developed and given to patients in the preadmission testing area before hospitalization so they could read it and ask questions before the operation. Thoracic surgery floor nurses also went over the care pathway with the patients to help them achieve their goals and provide additional education. The hospital administration provided data on discharge procedure code 244 (pulmonary lobectomy) from the International Classification of Diseases-9 procedural codes. Data were collected retrospectively from fiscal year 1995 and prospectively in fiscal year 1996. The cost and LOS were compared for fiscal years 1995 and 1996 using an unpaired t test.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The case mix for fiscal years 1995 and 1996 was almost identical with a mean age of 60 years and 55% men. The all-payer refined diagnosis-related group system is used at the Massachusetts General Hospital and provides a mortality and morbidity severity coding for each diagnosis-related group. The all-payer refined diagnosis-related group morbidity and mortality risks for fiscal years 1995 and 1996 were very similar (Fig 1). The mean LOS was reduced 3.1 days (p = 0.03) in fiscal year 1996 after the patient care pathway was instituted (Table 1). The mean LOS for fiscal year 1994 was 10.9 days, suggesting that the decrease in LOS in 1996 was attributable to institution of the pathway. The median LOS was reduced by 1 day. The mean cost reduction was $1,271 per patient (p = 0.47) (see Table 1). This represents a potential savings to the hospital of $165,230 in this patient group for 1 year. The mortality and 7-day emergency readmission rates were unchanged. Our target LOS was 7 days for pulmonary lobectomy. In fiscal year 1996, 68% of patients were able to be discharged by day 7, an increase of 16% from fiscal year 1995 (Fig 2). More patients were admitted on the day of operation in fiscal year 1996 (a 12% increase), thus further reducing the LOS. The mean number of days the patients were admitted preoperatively did not differ substantially, indicating that the majority of LOS reduction was in postoperative days.

View larger version (17K): [in this window] [in a new window]   Fig 1. . Distribution of morbidity and mortality severity coding within the all-payer refined diagnosis related group (APR-DRG) system for fiscal years (FYs) 1995 and 1996.

View larger version (14K): [in this window] [in a new window]   Fig 2. . Distribution of length of stay (LOS) in fiscal years 1995 and 1996.

Patient satisfaction surveys were completed and analyzed in the first 96 patients of fiscal year 1996. Eighty-three patients (86%) were discharged to home and 13 (14%) were discharged to a rehabilitation facility. Seventy patients (73%) felt prepared for discharge by the seventh postoperative day. Patients rated preparation for discharge by verbal instruction from the surgeon higher (85 patients satisfied [89%]) than from the printed instruction materials (69 patients satisfied [72%]). After patients were home, 68 (71%) were bothered by pain, 55 (57%) by dyspnea, 51 (53%) by constipation, and 21 (22%) by nausea.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
In the past, surgeons have been concerned only with traditional measures of results such as morbidity and mortality rates and late adverse event-free survival. Length of stay, cost, and patient satisfaction have not been emphasized. For better or worse, medical care systems are changing with capitated care, putting hospitals and physicians at financial risk for assuming patient care. Delivering good care at a predictable and reasonable cost will be necessary in this new era. The concept of continuous quality improvement, borrowed from industry, can be applied to surgical care to both improve results and control costs [3, 4]. The basic model involves achieving consensus on the goals and the process, monitoring end points, and critically analyzing results to determine changes that can be made to improve the process. For years surgeons have done this individually in an anecdotal fashion by reflection and the morbidity and mortality conference. Admittedly, these two ways are imperfect at best and leave much to be desired. As a beginning step in this process, patient care pathways have been developed and reported upon, notably from cardiac surgery units [1, 2]. This process makes most sense to implement in high-volume, relatively standardized procedures such as coronary artery bypass grafting. We were concerned about our historically lengthy hospital stay (10.9 days, fiscal year 1994) for pulmonary lobectomy, our most common major thoracic procedure. Accordingly, we decided to formulate and implement a patient care pathway in an effort to standardize care, reduce LOS and cost, and maintain quality care.

Our pathway was started at the beginning of fiscal year 1996 (October 1, 1995) and appeared to achieve modest reductions in LOS (3.1 days, 29%) and cost ($1,271, 8%). Cost reductions were less than stay reductions presumably because the cost of hospital care is much less at the end of the hospitalization compared with the beginning. Gross indices of quality (mortality and 7-day readmission rate) were unchanged. Almost 70% of the patients were now discharged by the target seventh day (see Fig 2). A patient satisfaction survey demonstrated the majority of patients were comfortable with earlier discharge. Changes made in patient care at the beginning of the pathway included new printed patient information (patient pathway and discharge book), hiring a physician assistant to assist inpatient care and provide more continuity of care in association with the thoracic surgical residents, the institution of chest physical therapy consultation, instruction in the preadmission testing area (as opposed to the first visit postoperatively), early discontinuation of prophylactic antibiotics, and removal of both chest tubes simultaneously (instead of one per day).

During fiscal year 1996, additional changes in the pathway were made as a result of regular multidisciplinary meetings in which outcomes were reviewed. Chest radiographs were now done and available for review on the Thoracic Surgical Unit by 7:00 AM so that decisions about chest tube management could be made before the operating room started, facilitating early removal of chest tubes. Formerly, epidural catheters were left in until the chest tubes were removed, which delayed conversion to and titration of oral analgesics. In turn, this often led to delayed discharge due to poor pain control. Epidural catheters are now removed usually the day before the chest tubes are removed so that adequate time is available to adjust to oral analgesic medication. A nausea protocol was introduced to aggressively treat nausea related to anesthesia and narcotics. These are three examples of "system" changes made by the multidisciplinary team to improve our patient care.

There are several potential advantages to a clinical pathway system. Perhaps most important, nonphysician staff participate in forming care policy and can see the results of the overall effort, but also the importance of their piece of the care pathway. Other caregivers seem to be more involved and more interested in achieving good outcomes. Our service is run by the resident staff, which changes frequently. The pathways allow the novice resident to quickly come up to speed on how the service runs and at what stage a patient should be on a given day. Our variance codes have allowed us to identify problem areas to address to facilitate uneventful recovery. Our hospital administration has supported our efforts with a project manager, as we are attempting to reduce hospital costs. This partnership with the administration has been lacking in the past, but is now recognized to be mutually beneficial.

Limitations to a clinical pathway approach most importantly include the fact that many patients cannot be squeezed into a uniform pathway because of their unique problems and needs. All patients must be treated as individuals, and we emphasize that the pathway is a general guideline and not a rigid protocol. Pathways are not particularly applicable to small groups of patients that are cared for infrequently. Pathways are probably only a temporary solution to the problem of maintaining high quality care while reducing costs.

The institution of a lobectomy patient care pathway allowed us to standardize care, reduce the LOS and cost of care, and begin quality control processes to improve our care process. The keys to the success of this approach appear to be the multidisciplinary approach, identification and control of high cost areas throughout the hospitalization, identification (and subsequent control) of reasons for prolonged stay, the provision of home-based support services, and the institution of patient satisfaction surveys.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Poster Session of the Thirty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Feb 3–5, 1997.

Address reprint requests to Dr Wright, Thoracic Surgery, Massachusetts General Hospital, Boston, MA 02114.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. O'Connor GT, Plume SK, Olmstead EM, et al. A regional intervention to improve the hospital mortality associated with coronary artery bypass surgery. JAMA 1996;275:841–6.[Abstract/Free Full Text]
2. Engelman RM, Rovsou JA, Flack JE, et al. Fast-track recovery of the coronary bypass patient. Ann Thorac Surg 1994;58:1242–6.
3. Berwick DM. Continuous quality improvement as an ideal in health care. N Engl J Med 1989;320:53–6.[Medline]
4. Berwick DM. Harvesting knowledge from improvement. JAMA 1996:275:877–8.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Cameron D. Wright John C. Wain Hermes C. Grillo Ashby C. Moncure Douglas J. Mathisen Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wright, C. D. Articles by Mathisen, D. J. Search for Related Content PubMed PubMed Citation Articles by Wright, C. D. Articles by Mathisen, D. J.