Standardized clinical care pathways for major thoracic cases reduce hospital costs

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.

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.

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).

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.