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Ann Thorac Surg 1998;66:914-919
© 1998 The Society of Thoracic Surgeons

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Original articles: General Thoracic

Standardized clinical care pathways for major thoracic cases reduce hospital costs

^a Division of Thoracic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA

Address reprint requests to Dr Heitmiller, Division of Thoracic Surgery, The Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287

Presented at the Forty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Naples, FL, Nov 6–8, 1997.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Standardized clinical care pathways have been developed for postoperative management in an attempt to contain costs in an era of rising health care costs and limited resources. The purpose of this study was to assess the effect of these pathways on length of stay, hospital charges, and outcome for major thoracic surgical procedures.

Methods. All anatomic lung (segmentectomy, lobectomy, and pneumonectomy) and partial and complete esophageal resections performed from July 1991 to July 1997 were retrospectively analyzed for length of stay, hospital charges, and outcome. A prospectively developed database was used. Clinical care pathways were introduced in March 1994. Comparisons were made between the procedures performed before (group I) and after (group II) pathway implementation. Common to both pathways are early mobilization and prudent x-ray and laboratory analysis. In addition, the pathway for esophagectomies emphasizes overnight intubation with 24-hour intensive care unit care, and staged diet advancement. The discharge goal was postoperative day 10. For lung resection the emphasis is early postoperative extubation with overnight intensive care unit management. The discharge goal was postoperative day 7.

Results. Group I esophagectomies (n = 56) had significantly greater hospital charges compared with group II (n = 96) ($21,977 ± $13,555 versus $17,919 ± $5,321; p < 0.04, in actual dollars) and ($29,097 ± $18,586 versus $19,260 ± $6,000; p < 0.001, in dollars adjusted for inflation) and greater length of stay (13.6 ± 6.9 versus 9.5 ± 2.8 days; p < 0.001). Group I lung resections (n = 185) had a significantly greater length of stay compared with group II (n = 241) (8.0 ± 6.2 versus 6.4 ± 3.8 days; p < 0.002); although charges trended downward ($13,113 ± $10,711 versus $12,404 ± $7,189; not significant) in actual dollars, charges were significantly less in dollars adjusted for inflation ($17,103 ± $13,211 versus $13,432 ± $8,056; p < 0.01). The most significant decreases in charges for esophagectomies were in miscellaneous charges (61% in dollars adjusted for inflation), pharmaceuticals (60%), laboratory (42%) and radiologic (39%) tests, physical therapy charges (35%), and routine charges (34%). For lung resections the greatest savings occurred for pharmaceuticals (38%), supplies (34%), miscellaneous charges (25%), and routine charges (22%). Mortality was similar (esophagectomies: I, 3.6%; II, 0%; lung resections: I, 0.5%; II, 0.8%; not significant).

Conclusions. Introduction of standardized clinical pathways has resulted in a marked reduction of length of stay for all major thoracic surgical procedures. Total charges were reduced for both esophagectomies (34%) and lung resections (21%) with continued quality of outcome.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Consistency in providing patient care is an effective way of improving quality. Physician-directed diagnostic and therapeutic plans have been shown to be crucial in this process [1]. Clinical care pathways have been developed for a wide variety of disease processes requiring medical and surgical intervention [2–7]. Pathway implementation has been shown to reduce hospital length of stay (LOS) and significantly reduce diagnostic testing. The ability of the caregivers and the patients and their families to have clear expectations has decreased the need for defensive medicine [8]. Whether these quality of care benefits translate to costs savings in an era of rising health care costs and limited resources is less clear. We sought to assess the effect of these pathways on hospital charges, LOS, and outcome for major thoracic surgical procedures.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
All anatomic lung (segmentectomy, lobectomy, and pneumonectomy) and partial and complete esophageal resections performed from July 1991 to July 1997 were retrospectively analyzed for LOS, hospital charges, and outcome. A prospectively developed database was used. Clinical care pathways were introduced in March 1994. Comparisons were made between the procedures performed before (group I) and after (group II) pathway implementation. Charges were categorized and compared by routine charges, operating room charges, pharmaceuticals, radiologic tests, laboratory tests, supplies, physical therapy charges, and miscellaneous charges. All data presented are presented as charges.

The esophagectomy clinical pathway emphasizes overnight intubation and 24- to 36-hour intensive care unit care. Patients are on telemetry, and vital signs and hemodynamics are continuously monitored, including blood pressure, central venous pressure, pulmonary artery pressure and cardiac output in selected patients, O₂ saturation, and end-tidal CO₂. Analgesia is patient controlled by means of an epidural catheter or intravenously. On postoperative day (POD) 2, monitoring lines, neck drain, and Foley catheter are discontinued and the patients are transferred to the ward. On POD 3, enteral tube feedings are begun at 10 mL/h and advanced to 30 mL/h over 2 days. Supplemental O₂ is weaned and physical therapy is initiated. If a chest tube is used it is removed on POD 4. On POD 5 or 6 a video esophagogram is performed, and a four-stage esophageal diet is commenced. The discharge goal is POD 10. Perioperative antibiotics are continued for 24 hours. Medications throughout postoperative course include H₂ histamine blockers and analgesics; simethicone and stool softener are started on POD 6. Laboratory tests are performed on PODs 1, 2, and 4.

The thoracotomy clinical pathway emphasizes operating room extubation and 12- to 24-hour intensive care unit care. Patients are on telemetry and their vital signs continuously monitored. Postoperative analgesia is patient controlled by means of an epidural catheter or intravenously. A postoperative chest film is obtained. Thereafter, one chest film per day is obtained until the chest drains are discontinued on POD 3 or 4. On POD 1 the patient is transferred to the ward. Oral intake is commenced. Supplemental O₂ is weaned. Laboratory testing is performed on POD 1, and only if necessary thereafter. Early mobilization is stressed beginning the night of the operation. Perioperative antibiotics are continued for 24 hours. Medications throughout postoperative course include H₂ histamine blockers and analgesics. Inhalation agents are used as needed. The goal for discharge is POD 6.

Adjustment for constant charge dollars was made using the approved Maryland Health Services Cost Review Commission methodology (Table 1). This methodology adjusts charges annually by an approved price increase. The Health Services Cost Review Commission rate year is October 1 to September 30. The number was then converted to the fiscal year at The Johns Hopkins Hospital, July 1 to June 30. The charge increases were compounded yearly. Statistical analysis comparing hospital charges, LOS, and mortality rates was performed using the two-tailed Student’s t test. Significance was accorded to p values of less than 0.05.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Group I esophagectomies (n = 56) were admitted to The Johns Hopkins Hospital between July 1991 and March 1994 and group II (n = 96) between April 1994 and July 1997. Ages were similar (group I, 59.5 ± 11.6 years versus group II, 57.4 ± 13.5 years). Groups I (n = 185) and II (n = 241) lung resection corresponded to similar dates. Ages were not significantly different (group I, 61.8 ± 11.7 years versus group II, 63.7 ± 11.5 years). Procedures performed are categorized in Table 2.

View larger version (23K): [in this window] [in a new window]   Fig 1. Total hospital charges for esophagectomy patients, in actual dollars and constant dollars adjusted for inflation according to Table 1.

View larger version (31K): [in this window] [in a new window]   Fig 2. Categorized hospital charges for esophagectomy patients in actual dollars (A) and in constant dollars adjusted for inflation (B). (lab = laboratory charges; OR = operating room charges; other = miscellaneous charges; pharm = pharmaceutical charges; PT = physical therapy charges; rad = radiology charges; supp = supplies.)

View larger version (23K): [in this window] [in a new window]   Fig 3. Decreasing charges of esophagectomy patients year by year, in actual and constant dollars adjusted for inflation according to Table 1.

View larger version (15K): [in this window] [in a new window]   Fig 4. Total hospital charges for anatomic lung resection patients, in actual dollars and constant dollars adjusted for inflation according to Table 1.

View larger version (29K): [in this window] [in a new window]   Fig 5. Categorized hospital charges for anatomic lung resection patients in actual dollars (A) and in constant dollars adjusted for inflation (B). (lab = laboratory charges; OR = operating room charges; other = miscellaneous charges; pharm = pharmaceutical charges; PT = physical therapy charges; rad = radiology charges; supp = supplies.)

View larger version (16K): [in this window] [in a new window]   Fig 6. Decreasing charges of anatomic lung resection patients year by year, in actual and constant dollars adjusted for inflation according to Table 1.

View larger version (23K): [in this window] [in a new window]   Fig 7. Decreasing length of stay in both esophagectomy and anatomic lung resection patients year by year.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Clinical care pathways, formally known as physician-directed diagnostic and therapeutic plans [1], were developed to standardize postoperative patient care. The primary impetus to develop clinical pathways was to improve quality of care. However, in this day of rising hospital costs and capitation, there has also been tremendous pressure to reduce costs while maintaining quality [9]. Clinical care pathways have been embraced as a means to accomplish both goals. The earliest applications of clinical pathways to patients undergoing joint replacement and treatment for congestive heart failure realized a significant reproducible reduction in hospital charges while improving quality [2]. Further applications of this methodology have been shown to address both concerns in areas specific to cardiothoracic surgery; coronary artery bypass surgery [5], thoracoscopic procedures [3], congenital heart surgery [7], and pulmonary lobectomies [4].

Creation and maintenance of thoracic surgical pathways at The Johns Hopkins Hospital has been a dynamic process. There were two goals set for pathway development and for ongoing adjustments. The first goal was to find out what tests and interventions were necessary to treat the ideal patient undergoing routine esophageal and anatomic lung resections. Standardizing postoperative care with deletion of superfluous tests would explain the observed initial decrease in cost of care. The second goal was to identify limiting factors in postoperative care that largely dictate length of hospital stay for a given operative procedure, and to see what could be done to optimally manage these factors. This process would explain the observed continued decrease in costs. Our premise has been that many of the benchmarks for surgical care of the patient with esophageal or lung cancer are based on historic clinical practice guidelines that have been passed down, often unchallenged, through an apprenticeship training program. Challenging these guidelines through interval meetings and dynamic modification of the pathway has been a hallmark of our system. For lung resections, factors that limit LOS include pain control, air leaks, supplemental oxygen requirement, and respiratory care. For esophagectomies, factors that limit LOS include pain control, respiratory care, anastomotic healing, and subsequent oral alimentation. Therefore, measures to improve postoperative pain control and respiratory care, techniques to reduce lung air leaks, better insight into the process of anastomotic healing, all would be expected to reduce LOS without compromising safety of care. Our data suggest the ongoing dynamic nature of the pathway and its effect on charges. In Figures 3 and 6 the charges per year show a continuous decline both in actual dollars and dollars adjusted for inflation. Although the most rapid decreases occurred in the early 90s during the time when cost containment began to be a priority, ongoing cost reduction has occurred because of changes resulting from feedback from pathway caregivers.

Pathways are particularly applicable to surgical services in large teaching hospitals where there is a steady stream of residents and fellows taking care of patients postoperatively. In these systems there is tremendous variability in what tests the caregiver believes needs to be obtained to manage the patient appropriately. Most of the interventions and tests thought necessary by caregivers are directly controlled by physicians but are categorized as laboratory, radiologic, pharmaceutical, and operating room charges. Indirectly, routine charges are under physician control, being profoundly influenced by LOS. At the New York Hospital–Cornell Medical Center, 70% of the total cost in the hospital was found to be physician controlled [10]. Loop [11] emphasizes the physician as the utilization manager in an era when hospital costs are increasing at 8% annually and reimbursements have failed to increase accordingly. Our physician-directed clinical pathway methodology addressed cost containment in all areas. The reduction in variability of charges is evidenced by the decrease in standard deviation in all categories since introduction of pathways (Figs 2, 5). Residents and fellows learn a consistent pattern of care as opposed to a trial and error approach repeated on a monthly basis as they rotate on the service.

The reduced LOS was the most significant factor in charge reduction. This is manifested in the routine charge category. Forty-four percent and 40% of the total charge reduction was realized in routine charges in esophogectomies and lung resections, respectively. Several changes were responsible for these savings. Esophagectomy patients are now admitted on the same day as the operation. The bowel preparation is done as an outpatient procedure. Several days of hospital stay of the esophagectomy patients have been reduced postoperatively by acceleration of diet advancement. In the lung resection patients postoperative LOS has been reduced by earlier discontinuation of chest tubes. The preoperative days had been eliminated before clinical pathway introduction. This was partially responsible for the decreased charges realized in 1992 and 1993 seen in Figure 6. Indirectly, improved pain management and its associated improved pulmonary function and earlier self-sufficiency has readied patients for earlier discharge. When evaluated by the year, LOS had a parallel downward trend compared with charges in both categories (Fig 7). Again, the standarization of care is evident with a marked decrease in the standard deviation in LOS since 1994.

There were several areas that were not as clearly affected by clinical pathway management: operating room charges, supplies, and physical therapy charges for esophagectomy patients; and operating room charges, radiologic and laboratory charges, and physical therapy charges for lung resection patients. Operating room charges, supply charges, and physical therapy charges were not under the influence of the physicians directing care of the thoracic patient. Charges occurring in these areas have been determined by personnel in charge of operating room supplies and the physical therapy division. These are areas that are currently being targeted for cost reduction in pathway meetings. With regards to radiologic and laboratory charges in the lung resection patients, significant reduction in utilization of these resources took place in the 2 years before official clinical pathway introduction. They had already nearly approached their limit of appropriate utilization.

Mortality has remained unaffected by these substantial changes in clinical practice. There have been no deaths in esophagectomy patients since introduction of clinical pathways and 0.8% or 2 patient deaths in the lung resection group. This maintenance of quality has been demonstrated in other similar series managed by clinical pathways [3–5, 7].

This study presents clinical pathway methodology as a dynamic process that has been effective in producing significant cost reduction for major thoracic surgical procedures. Total charges were reduced for both esophagectomies (18% in actual dollars, 34% in dollars adjusted for inflation) and lung resections (5.4%, 21%) with continued quality of outcome.

	References

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1. Hart R.I., Musfeldt C.M. MD-directed critical pathways: it’s time. Hospitals 1992;66:56.[Medline]
2. Musfeldt C., Hart R.I. Physician-directed diagnostic and therapeutic plans: a quality cure for America’s health-care crisis. J Soc Health Syst 1993;4:80-88.[Medline]
3. Patton M.D., Scaerf R. Thoracotomy, critical pathway, and clinical outcomes. Cancer Pract 1995;3:286-294.[Medline]
4. Wright C.D., Wain J.C., Grillo H.C., Moncure A.C., Macaluso S.M., Mathisen D.J. Pulmonary lobectomy patient care pathway: a model to control cost and maintain quality. Ann Thorac Surg 1997;6:299-302.
5. Velasco F.T., Ko W., Rosengart T., et al. Cost containment in cardiac surgery: results with a critical pathway for coronary bypass surgery at the New York Hospital–Cornell Medical Center. Best Pract Benchmarking Healthcare 1996;1:21-28.
6. Cohen J., Stock M., Anderson P., Everts E. Critical pathways for head and neck surgery. Development and implementation. Arch Otolaryngol Head Neck Surg 1997;123:11-14.[Abstract/Free Full Text]
7. Turley K., Tyndall M., Roge C., et al. Critical pathway methodology: effectiveness in congenital heart surgery. Ann Thorac Surg 1994;58:57-63.[Abstract]
8. Shulkin D.J., Ferniany I.W. The effect of developing patient compendiums for critical pathways on patient satisfaction. Am J Med Qual 1996;11:43-45.
9. Denton T.A., Chaux A., Matloff J.M. A cardiothoracic surgery information system for the next century: implications for managed care. Ann Thorac Surg 1995;59:486-493.[Abstract/Free Full Text]
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