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Do clinical pathways for major vascular surgery improve outcomes and reduce cost?
1Department of Surgery, Sewickley Valley Hospital, PA, USA.
Insights
Implementing clinical pathways for major vascular surgery significantly reduced hospital stays and costs. This approach improved patient outcomes and financial efficiency in community hospitals, aligning with Medicare standards.
Area of Science:
- Vascular Surgery
- Health Services Research
- Hospital Administration
Background:
- Major vascular procedures represent a significant cost burden in healthcare.
- Standardized care protocols, or clinical pathways, aim to optimize patient management and resource utilization.
- Evaluating the impact of clinical pathways on length of stay and hospital charges is crucial for cost-effective healthcare delivery.
Purpose of the Study:
- To assess if clinical pathways for major vascular procedures shorten length of stay and reduce hospital charges.
- To compare outcomes against established Medicare standards for specific vascular diagnosis-related groups (DRGs).
Main Methods:
- Retrospective analysis of 112 carotid endarterectomies, 42 aortic/renal procedures, and 130 lower extremity bypasses (DRGs 005, 110, 478, 479).
- Comparison of length of stay, hospital costs, morbidity, mortality, and readmission rates with Medicare standards.
- Inclusion of only Medicare patients to ensure accurate cost and reimbursement data.
Main Results:
- Significant reductions in average length of stay were observed across all studied DRGs.
- Substantial cost savings were realized, totaling $1,256,000 compared to Medicare reimbursement.
- High discharge rates on the first postoperative day were noted for carotid endarterectomy (90%) and leg bypass (23%) patients.
Conclusions:
- Clinical pathways effectively shorten length of stay and decrease inpatient charges for major vascular procedures.
- Key factors contributing to positive outcomes include outpatient arteriography, same-day admission, early ambulation, and selective ICU use.
- Adverse factors impacting outcomes were emergency admissions, inpatient arteriography, and complications requiring extended care.
Purpose:
This study was performed to determine whether the implementation of clinical pathways for patients who undergo major vascular procedures in a community hospital would shorten the length of stay and reduce charges when compared with Medicare standards.
Methods:
Length of stay, hospital costs, and morbidity, mortality, and readmission rates for the four most common vascular diagnosis-related group (DRG) categories at our institution were compared with Medicare standards. The four categories were DRG 005 (extracranial vascular procedures), DRG 110 (aortic and renal procedures), DRG 478 (leg bypass with comorbidity), and DRG 479 (leg bypass without comorbidity). Between May 1, 1994, and June 30, 1996, 112 patients underwent carotid endarterectomy, 42 patients underwent aortic or renal procedures, and 130 patients underwent lower extremity bypass procedures (68% with comorbidity). Only Medicare patients were included because exact cost/reimbursement data were available. No admissions were excluded.
Results:
The average length of stay was 1.2 days for DRG 005, 6.9 days for DRG 110, and 3.2 and 2.1 days for DRGs 478 and 479, respectively. The average cost savings when compared with the Medicare reimbursement was $4338 for DRG 005, $7161 for DRG 110, $4108 for DRG 478, and $2313 for DRG 479. Readmission was necessary for 9% of peripheral bypass patients. Ten percent of patients in DRG 005 and 86% of patients in DRG 110 needed intensive care, whereas only 2% of patients who underwent complicated bypass procedures did. Ninety percent of carotid endarterectomy patients and 23% of leg bypass patients were discharged on the first postoperative day. There were two postoperative strokes (2%) after carotid surgery. Thirty-three percent of aortic/renal patients had complications that led to care outside the clinical pathway. Twenty-five percent of leg bypass patients required home care to treat open foot wounds. Total inpatient cost savings were $1,256,000 when compared with Medicare reimbursement.
Conclusions:
Clinical pathways significantly improve the length of stay and decrease inpatient charges for major vascular surgical procedures while maintaining high standards of care. Factors that favorably affected the length of stay and hospital charges were outpatient arteriography, same-day admission, early ambulation, physical therapy, home care, use of the intensive care unit on a selective basis, and early discharge. Factors that adversely affected these outcomes were emergency admission, inpatient arteriography, thrombolytic therapy, complications, and the need for dialysis or anticoagulation.