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Impact of clinical pathways on hospital costs

and early outcome after major

vascular surgery

K e i t h D . C a l l ig a r o, M D , M a t t h e w J . D o u g h e r t y , M D , C a r o l A . R a v i ol a , M D ,

D a v i d J. M u s s er , M D , a n d D o m i n i c A . D e L a u r e n t i s , M D , Philadelphia, la.

Purpose: The purpose of th is s tudy was to determine whether major vascular surgery couldbe p erform ed safely and with s ignificant hospital cost savings by decreasing length of s tayand implem entation o f vascular clinical pathways.2Vlethods:Morb idity, m ortality, readmission rates , same-day admissions, length o f s tay, andhospital costs were compared between patients who were electively admitted betweenSeptember 1, 1992, and August 30, 1993 (group 1), and January i t o December 31, 1994(group 2), for extracranial, infrarenal abdominal aortic, and lower extremity arterial

surgery. For group 2 patients , vasodar crit ical pathways were insti tuted, a dedicatedvascular ward was established, and outpatient preoperative arteriography andanesthesiology-cardiology evaluations were performed. Length -of-s tay goals were 1 da yfor extracranial, 5 days for aortic, and 2 to 5 days for Iower extremity surgery. Emergencyadmissions, inpatients referred for vascular surgery, patients transferred from otherhospitals , and patients who required prolonged preoperative treatment were excluded.Results: W ith this s trategy same-day adm issions were s ignificantly increased (80%[145/177] vs 6.2% [9/145]) (p < 0.00 01), and average lengt h of stay was significantlydecreased (3.8 vs 8.8 days) (p < 0.0001 ) in group 2 versus grou p 1, respectively. Ther ewere no s ignificant differences between group I and group 2 in terms o f overall morta lityrate (2.1% [3/145] vs 2.3% [4/177]) , cardiac (3.4% [5/145] vs 4.0% [7/177]) , pu lmo nary(4.1% [6/145] vs 1.7% [3/177]), or neurologic (1.4% [2/145] vs 0% [0/177]) complica-tions, or readmission within 30 days (11.3% [16/142] vs 9.2% [16/173]) (p > 0.05).

There were also no differences in m orbidity or morta lity rates whe n each type of surgerywas compa red. Ann um hospital cost savings totalled $1,267,445.Conclusion: Same-day admission and early hospital discharge for patients under-goin g elective m ajor vascular surg ery can result in significant hospital co st savingswi tho ut app arent increase in morb idity or mort ality rates . (J VASC SURG 1995;22:649-60.)

Risin g healt h care costs represent a crit ical issue in

the Uni ted Sta tes today . Surgeons in par t icu lar are

under s ignificant pressure to decrease expenses and

el iminate unnecessary spending by opt imizing re-

source use . Managed carc organizat ions are p laying

an increas ingly impor tant ro le in the del ivery of

From the Section of Vascular Surgery, Pennsylvania Hospi-tal/Thomas JeffersonMedicalCollege,Philadelphia.

Presented at the Ninth A nnualMeeting of the Eastern VascularSociety, Buffalo,N.Y., May 4-7, 1995.

Supported by a grant from the John F. CounellyFoundationandthe PennsylvaniaHospital Funds.

Reprint requests: Keith D. Caltigaro,MD, 700 Spruce St., Suite101, Philadelphia,PA, 19106.

Copyright © 1995 by The Society for Vascular Surgery andInternationalSociety or CardiovascularSurgery,North Ameri-

can Chapter.0741-5214/95/$5.00 + 0 24/6/68377

heal th care and wil l no t perm it pat ien ts to be admit-

ted to medical centers tha t can not del iver heal th care

at lower cos ts compared wi th compet ing hospi ta ls .

This is especially true for tertäary care centers .l,2 Lo w

reimbursements for lower ex tremity ar ter ia l recon-

structions for l imb salvage has already been docu-men ted . 3

A pr incip le me tho d to decrease hospi ta l cos ts in-

cludes redu ctio n o f inpati ent days. 4,~ In dealing w ith

this probl em of spiraling health-care costs and at-

t emp t ing to m a in ta in con t ro l o f ou t pa t i en t s ' car e, we

and o thers have a l tered the per ioperative t rea t rnent of

patients tm der goi ng ma jor vascular surgery. 6-12 The

pu rpose o f th i s r epo r t was to de te rmine whe the r ma-

jor väscular operat ions could be per forme d safe ly and

wit h s ignificant hospi ta l cos t -savings b y sho r ten ing

length of hospi ta l s tay wi th wel l -def ined s t rateg ies to

649



JOURNAL OF VASCULAR SURGERY

6 5 0 C a l l i g a r o e t a l. December 1995

ach ieve these goals . These s t ra teg ies on ly app ly to

cost sav ings in the acu te care se t t ing and do no t

address ou tpa t ien t costs.

P A T IE N T S A N D M E T H O D SB etween Sep tem b er 1 an d Decem b er 3 1 , 1 9 9 3 ,

the Sect ion of Vascu lar Surgery a t Pennsy lvan ia

Hospi ta l in Ph i ladelph ia , Pa . , ins t i tu ted changes in

th e t r ea tm en t o f p a t ien t s tm d er g o in g m a jo r v ascu lar

surgery to decrease hosp i ta l costs in a safe and

r easo n ab le m an n e r . W e co m p ar ed p a t i en t s u n d e r -

go ing e lec t ive major vascu lar surgery fo r a 1 -year

p e r io d b e fo r e (g r o u p 1 : Sep tem b e r 1, 1 9 9 2 - A u g u s t

3 0 , 1 9 9 3 ) an d a f t e r ( g r o u p 2 : Jan u a r y 1 - D ecem b er

31 , 199 4) th is in terval. Pa t ien ts unde rw ent e lec tive

extracranial ar ter ial surgery, infrarenal aortic surgery

for aneurysm al o r occlusive disease , and lower

ex tremity ar ter ia l revascu lar iza t ion procedures

(Table I) . Clinical r isk factors and indications for

su r g e r y wer e s im i l a r b e tween th e two g r o u p s ( Tab le

I I ) . Same-day admissions , average leng th of s tay

(LOS) , morb id i ty , mor ta l i ty , readmission ra tes , and

hosp i ta l costs were compared . Pat ien ts who re-

q u i r ed em e r g en cy su r g er y , p a t ien t s t r an s fe r r ed f r o m

other hosp i ta ls , and pat ien ts who requ ired pro-

lo n g ed p r eo p e r a t iv e t r ea tm en t i n c lu d in g in t r av e -

nous an t ib io t ics o r an t icoagula t ion were excluded

from analysis (Table III) .

W h en ev e r p o ss ibl e , we a t t em p ted to d ec r ease

LOS and hospital costs with 10 specif ic strategies

(Table IV) . Fi r s t , p reopera t ive ar ter iograms were

obta ine d on an o u tpat ien t basis , e re n i f ba l loon

an g io p la s ty was p e r f o r m ed , wh ich h as b een in -

creasingly ac cepte d as safe an d cost-effecUve. 12 If a

pat ien t 's base l ine crea t in ine was less than 2 .0 mg /d l ,

we p r o ceed ed wi th o u tp a t i en t a r t e r io g r ap h y an d

adminis tered in t ravenous f lu ids dur ing the p roce-

dure and for 4 hours af ter the s tudy . This speci f ic

s t ra tegy has no t req u ired add i t ional costs because ,

as the nu m ber o f hosp i ta l inpat ien ts has decreased ,

nurses who prev iously cared for inpat ien ts are now

avai lab le to care fo r pa t ien ts undergo ing ou tpat ien t

testing.

Second , card io logy and anesthesio logy evalua-

t ions were a lso per formed on an ou tpat ien t basis .

Third , opera t ions in g roup 2 pa t ien ts were

p e r f o r m ed th e d ay o f ad m issio n s wh en th i s ap p r o ach

d id n o t p o se u n d u e r i sk to t h e p a t i en t . Pa t i en t s wer e

ad m i t t ed a t l e a s t 1 h o u r b e f o r e su r g e r y to a w ar d

d ed ica t ed to p r ep a r in g th e p a t i en t f o r su r g e r y an d

th en w er e t r an s f e rr ed to a h o ld in g a r ea wh e r e a r te r ia l

and in t ravenous l ines were inser ted . As prev iously

m en t io n ed , t h i s a sp ec t o f o u r s t r a t eg y h as n o t

requ ired add i t ional expenses because nurses who

prev iously we re car ing for inpat ien ts w ere avai lab le to

f u n c t io n in a n ew cap ac ity d i r ec t ed to wa r d sam e- d ay

adrnissions a nd out pa tien t testing. All patients in

g r o u p s 1 an d 2 wh o u n d e r wen t ex t r ac r an ia l an d

aor t ic surgery rece ived genera l anesthet ics , and mo st

p a t i en t s wh o u n d e r wen t l o wer ex t r em i ty a r t e r i a lsurgery rece ived reg ional anesthet ics . Group 1 pa-

t ien ts were ge nera l ly adrn i t ted a t leas t 1 day before

surgery fo r in t ravenous hydra t ion , card io logy and

anesthesio logy c learance , p reopera t ive labora tory

tes t ing , and ar ter iography .

Fo ur th , decreasing LO S was a lso accompl ished

for g roup 2 pa t ien ts th rough inst i tu t ion of "c l in ica l

p a th way s , " o r " ca se m an ag em en t p r o to co l s" an d

' care-maps."5 Clinical pathw ays for each o f the th ree

m o s t c o m m o n l y p e r f o rm e d t yp e s o f v a s c u la r s u r g e ry

(ex tracran ia l , aor t ic , and lower ex t remity) were

developed af ter in tensive and leng thy d iscussionsam ong vascu lar surgeons, anesthesio log is ts , card io lo-

g is ts , hosp i ta l admin is t ra to rs , nurs ing represen ta-

t ives , and heal th -care consu l tan ts wi th exper t i se in

th is f ie l& I t should be no ted tha t our hosp i ta l

adm in is t ra t ion was the impetus fo r th is p ro jec t . Dai ly

postopera t ive goals were es tab l ished , and e l iminat ion

of unnecessary rou t in e postopera t ive b lo od tes ts ,

r ad io g ram s , an d p h a r m acy u se wer e ag r eed o n b y th e

physic ians . O n the basis o f these d iscussions , o rder

forms wi th s tandard postopera t ive ins t ruc t ions fo r

each type of vascu lar surgery were ma de avai lab le to

the nu rs ing a nd surg ica l house s taff .

Fi f th , leng th-of -s tay goals fo r each type of surg ery

(ex tracran ia l, aor t ic , low er ex t remity) w ere based on

safe and reasonable expecta t ions o f the vascu lar

surgeons. These goals inc luded 1 day ( inc lud ing an

overn igh t s tay) fo r pa t ien ts undergo ing ex t racran ia l

surgery , 5 days fo r aor t ic surgery , and 0 to 5 days fo r

pat ien ts undergo ing lower ex t remity revascu lar iza-

t i o n d ep en d in g o n th e ex ten t o f su r g e r y an d th e

ex ten t o f t i ssue necrosis .

S ix th , an a t t em p t was m a d e to l im i t u se o f t h e

in tensive care un i t as ano ther means of decreasing

hosp i ta l costs . Ge nera l ly pa t ien ts who und erw ent

lower ex t remity revascu lar iza t ion were t ransfer red

d irec t ly to the w ard af ter observat ion in the recov ery

r o o m , p a t ien t s wh o u n c le r wen t ao r ti c su r g e r y wer e

t ransfer rec l to the w ard the f i r s t postopera t ive day ,

an d p a t i en t s wh o u n d e r wen t ex t r ac r an ia l su r g e r y

wer e d i sch a r g ed d i rec t ly to h o m e f r o m th e in t en s iv e

care un i t the f i rs t postopera t ive day .

Sev en th , a n u r s in g co o r d in a to r i n t e r ac t ed wi th

the vascu lar surgeons on a regu lar basis to develop

goals and establish daily protocols to achieve early

d ischarge and ensure adequate nurs ing care fo r

pat ien ts in the in tensive care un i t and on the wards .

Because of fewer inpat ien ts , nurses have been avai l-

able to function as clinical coordinators for various



JOURNAL OF VASCULARSURGERYVolume 22, Number 6 Calligaro et al. 651

T a b le I . T y p e o f o p e ra t ion

Group I Group I I

Extracranial 40 51

Carot id endarterectomy 38 (95.0%) 48 (94%)CCA -ECA bypass 1 (2.5%) 0ICA -ICA bypass 1 (2.5%) 0Subclavian-brachia l bypass 0 1 (2%)CCA-subclavian bypass 0 1 (2%)

Aortic 37 43Aneurysm 26 (70%) 34 (79%)Aortofe mora l (occlusive disease) 11 (30%) 9 (21%)

Low er extremity 68 83Femoropopliteal 19 (28%) 29 (35%)Femorotibial 20 (30%) 24 (29%)Popliteal-distal 14 (20%) 17 (20%)Vein patch fairing graft 9 (13%) 6 (7%)Fem orofem oral cross-over 4 (6%) 3 (3%)Femoral interposition/profundoplasty 2 (3%) 4 (6%)

Tot al 145 177

C C A, Common carotid artery; ECA, external carotid arte ry;/C A, internal carotid artery.

Table II. Comparison of patient populations in groups I and II

Risk factors Group I (145) Group Ff (177)

Sex

Men 84 (58%) 120 (68%)Wom en 61 (42%) 57 (32%)

RaceWh ite 124 (86%) 152 (86%)Black 21 (14%) 25 (14%)

Age 68 (50-91) 67 (49-95)Hype rtensi on 106 (73%) 133 (75%)

Diabetes mellitus 52 (36%) 56 (32%)Smo king (current) 38 (26%) 62 (35%)Corona ry artery disease~ 64 (44%) 98 (55%)Serum creatinine (mg/dl)

<2 .0 126 (87%) 151 (86%)2.0-3.0 9 (6%) 13 (7%)>3 .0 10 (7%) 13 (7%)

Epidu ral analgesia (aortic surgery) 24 (65%) 38 (88%)Indicat ions for surgeryExtracranial 40 (100%) 51 (100%)

Asymptomatic 12 (29%) 22 (43%)Amaurosis fugax 4 (11%) 10 (19%)Transient ischemic attack

Hemisphe ric 11 (27%) 7 (15%)Nonhemispheric 5 (13%) 5 (9%)

Stroke 8 (20%) 7 (14%)

Aorti c 37 (100%) 43 (100%)Aneurysm 26 (70%) 34 (79%)Aortofe moral (occlusive disease) 11 (30%) 9 (21%)

Low er extremity 68 (100%) 83 (100%)Lim b salvage 45 (66%) 58 (70%)

Rest pain 20 23Ulcer/gangrene 25 30

Disabling claudication 12 (18%) 17 (21%)Failing graft 9 (13%) 6 (7%)Peripheral aneurysm 2 (3%) 2 (2%)

* Coronary artery disease includes history o f myocardial infarction, congestive he art failure, ventricular arrhythmias, angina, S3 heart sound,aortic stenosis, coronary art ery bypass, or coronary balloon angioplasty.

specialties in our hospital , and this has no t req uired

increased hospital costs.

E ighth, a dedicated vascular ward was established

where patients were transferred after observation in

the recovery room or intensive care unit . Establish-

ment of a vascular ward did not require extra costs

because this ward was already fully staffed before it

was con verted to a vascular ward. O ther specialties



JOURNAL OF VASCULAR SURGERY6 5 2 C a l l i g a r o e t a l . December 1995

T ab le I I I . Pa t i en t s n o t i n c lu d ed in s tu d y ana ly si s wh o u n d e r w en t m a jo r va scula r su r g e r y

R e qu ir e d pr o longe dE l ec t iv e E m e r g en c y I n p a ti e nt s T r a n s f e r s p r e o p e r a t i v eta y

G r o u p IExtracranial 40A o r t i c 3 7L o w e r e x t r em i t y 6 8Tota l g rou p I (276) 145

G r o u p I IExtracranial 51A o r t i c 4 3L o w e r e x t r e m i ty 8 3T o t a l g r o u p I I ( 2 8 5 ) 1 7 7

T o t a l g r o u p I + I I5 6 1 ( 1 0 0 % )

0 11 5 24 3 2 3

25 38 14 2429 52 21 29

0 12 4 02 3 2 3

22 27 13 2024 42 19 23

322 (57 .4%) 53 (9 .4%) 94 (16 .8%) 40 (7 .1%) 52 (9 .3%)

T ab le I g . Me th o d s to d ec r ea se l en g th o f s t ay an d l im i t cos t s o f m a jo r v a scula r su r g e r y

Outpa t ien t p reopera t ive a r te r iographyOu tpati ent preo perativ e cardiac and anaesthesia evalu ationSam e-day adm iss ionClinical pathways for each type of ma jor vascular surgeryEs tab l i sh leng th o f s tay goa lsL im i t in tens ive ca re un i t daysN u r s i n g c o o r d i n a t o rVascular wardSkilled care unit and home health care (nursing visits , physical therapy, wound care)Com m u nica te expec ted da te o f d ischarge to pa t ien t and fam i ly

t ransfer red the i r pa t ien ts to o the r wards ass igned to

those special ties . Th e vascu lar wa rd d id no t have any

special c a r d io p u lm o n a r y m o n i to r in g in s t r u m en t s .N in th , p a t i en t s we r e d i sch a r g ed f r o m th e acu te

care hosp i ta l ear l ie r by use o f a sk il led care un i t and

visit ing nurses. The skil led care unit is a separate

fac i l i ty ad jacen t to the ach te care hosp i ta l where

pat ien ts wi th s tab le condi t ion s no t requ ir ing spec ia l

ca r e b u t n o t y e t r e ad y f o r d i sch a r g e to h o m e can

u n d e r g o f u r th e r p h y s i ca l t h e r ap y an d wo u n d ca r e .

The cost o f a bed per day in the sk i l led care un i t i s

$500 or approx im ate ly ha l f o f the ac u te care hosp i ta l.Pa t ien ts who requ ired foUow-up care were d is-

charged f rom the acu te care hosp i ta l o r sk i l led care

u n i t w i th a r r an g em en t s f o r t r a in ed p e r so r m e l t op r o v id e n u r s in g ca r e an d th e r ap y o n an o u tp a t i en t

basis wi th o f f ice v is it s to the vascu lar su rgeon m ore

f r eq u en t ly th an p r evio u sly . V i s i ti n g h o m e n u r se co s t swe re $100 per v isi t. Genera l ly on ly pa t ien ts wi th

wo u n d p r o b lem s o r t i s su e n ec r o s i s o f t h e lo wer

ex trem ity requ ired v is i t ing nurses . Vis i ts w ere m adetwice a day to several pa t ien ts fo r 1 o r 2 weeks, bu t

most pa t ien ts wi th foo t les ions requ ired on ly da i ly

visits for 1 to 6 weeks af ter discharge.Ten th , these goals and expecta t ions we re carefu lly

and repea ted ly exp la ined to the pa t ien t and family

during preoperative discussions.

Cl in ica l da ta were co l lec ted p rospect ive ly and

r eco r d ed in a co m p u te r i zed r eg i s t r y d a t ab ase . No

pat ien ts were los t to fo l low-up .Hos p i ta l co st ana lysis was per fo rme d wi th the

f o Uo win g m e th o d . Pa t i ent s we r e co n s id e r ed " o u t -

l ie rs" in g roups 1 and 2 w ho exper ienced unusual ly

p r o lo n g ed L OS a s a r esu l t o f co m p l ica t io n s o r

prob lems wi th t ransfer to long- term care fac i l i t ies .

These p ro longed hosp i ta l iza t ions were arb i t ra r i ly

def ined as mo re th an 10 days fo r ex t racran ial su rgery ,

m o r e th an 2 5 d ay s f o r ao r ti c su r ge r y , an d m o r e th an

30 days fo r low er ex t rem ity revascu lariza t ion . Th is

m e th o d i s w id e ly accep ted wh en p e r f o r m in g co s t

analysis because pa t ien ts who had compl ica t ions

wo uld unfa i r ly g rea tly increase the average LOS , and

p a t i en t s wh o d ied sh o r t ly a f t e r su r g e r y wo u ld u n -

fa i r ly decrease the average LOS. These pa t ien ts w ere

ex c lu d ed f r o m L O S co m p ar i so n b u t n o t f r o mmorbid i ty and mor ta l i ty ana lysis . Nat ional average

b en ch m ar k s we r e co m p i l ed f r o m th e m o s t cu r r en t

2-year per iod of hosp i ta l c la ims da ta fo r eachdiagnosis-related group. Cost analysis for patients

u n d e r g o in g o p e r a t io n a t o u r h o sp i t al was b a sed o n

p a t i en t b il li ng . F r o m th e s u m m a r y o f ch ar g es, t h ehealth-care advising specialists applied variable costra t io o f cost to charges suppl ied by the hosp i ta l . Th e

analysis was per formed dur ing the in i t ia l base l ine




Volume 22, Number 6 Calligaro et al. 65 3

period and at t he final tracking period, which enables

consistency in any cost analysis m etho d used. A nnual

cost savings refers only to the inpatient, acute care

setting. It should be noted that third-party payors

currently emphasize costs in the acute care hospitalonly, and therefore costs of the skilled care unit and

outpatient setting were n ot included in this analysis.

This method has routinely been applied when

comp aring length of hospital stay and acute care costs

amo ng medical centers across the Uni ted States.

R E S U L T S

Sam e-d ay admiss ions. There was a significant

increase in the rate of same-day admissions from

6.2% (9 of 145) for group 1 to 80.0% (141 of 177)

for group 2 (p < 0.0001) (Table V). Twen ty percent

of patients in group 2 were admitte d before the dayof surgery because they were referred from fardistances and were unable to travel repeatedly for

outpatien t evaluations.

Hosp ita l LO S. There were f ive "outliers" in

group 1 (two extracranial, one aortic, two lower

extremity) and one in group 2 (1 aortic) who were

excluded from LOS comparison. The average acute

care hospital LOS for the remaining patients signifi-

cantly decreased from 8.8 days for group 1 patients

to 3.8 days for gro up 2 patients (p = 0.0001) (Table

V). After implem enting these strategies, the average

LO S for patients at our institution versus the national

average was 1.7 days versus 3.9 days for extracranial

surgery, 5.9 days versus 10.7 days for aortic surgery

and 3.9 days versus 7.4 days for lower extremity

revascularization, respectively. There were no majordifferences in the two groups regarding indications

for lower extremity revascularization in terms of

ischemic ulcers or ga ngrene (Table II).

M ort ali ty rates. Despite a dramatic increase in

same-day admissions and decrease in LOS, there

were no major differences in mortality and m orbidity

rates. The mortality rate for group 1 was 2.1% (3 of

145) and 2.3% (4 of 177) in group 2. The three

deaths in group i were due to stroke associated with

carot id endarterectomy and pneumonia mad myocar-

dial infarction after lower extremity revasculariza-

tions. The four deaths in group 2 were all due to

myocardial infarctions and occurred after aortic

surgery in two patients and low er extremity revascu-larizations in two patients.

Cardiac complicat ions . There was no major

difference in cardiac complications between g roup 1(3.4% [5 of 145]) and group 2 (4.0% [7 of 177]).

Cardiac complications were defined as postoperativemyocardial infarctions, unstable angina, ventricular

arrhythmias, or congestive heart failure. In gr oup 1,the five cardiac complications included four myocar-

dial infarctions (three after low er extrem ity revascu-

larizations, with one resulting in death as previously

noted, and one after carotid endarterectomy) andventricular arrhythmia in one patient resulting in

congestive heart failure after aortic surgery. In grou p

2, the seven cardiac complications included six

myocardial infarctions (four resulting in death as

previously noted, two after lower extremity revascu-

larizations) and one cardiac arrest during aortic

surgery.Pu lm onary compl ica t ions . There was no ma jo r

difference in pulmonary complications (pneumonia

or reintubation) between group i (4.1% [6 of 145])

and group 2 (1.7% [3 of 177]). In group 1, six

patients had developm ent of postoperative pneum o-

nia after aortic surgery (n = 3), carotid endarterec-

tom y (n = 2), and lower extremity revascularization

(n = 1), the latter resulting in death. In gr oup 2 all

three pu lmon ary complications occurred after aortic

surgery.Neu rolog ic complicat ions . There was no major

difference in perioperative stroke rates between

group 1 (1.4% [2 of 145]) and group 2 (0%). Two

patients in group i had strokes after extracranial and

lower extremity surgery.Rea dmis sion ra tes . There was no major d iffer-

ence in readmission rates within 30 days of surgery

between group 1 (11.3% [16 of 142]) and group 2

(9.2% [16 of 173]) surviving patients. O f the 16

patients readrnitted in group 1, four were readmitted

after aortic surgery for atrial fibrillation (LOS = 3

days), persistent rest pain tha t re quir ed a distal bypass

(LO S = 5 days), incisional wo und problem (LOS =

5 days), and pneumo nia (LOS = 5 days). The other12 patients in group 1 were readmitted after lower

extremity revascularization for incisional wound

problems (n = 4) (average LO S = 5 days), contin-

ued care for foo t lesions (n = 3) (average LO S = 8

days), occlud ed bypasses (n = 3) (average LO S = 9

days), a failing bypass (n = 1) (LO S = 3 days), and

an ischemic ulcer that required a m ore distal bypass

(n = 1) (LOS = 8 days).

O f 16 pat ients readmit ted in group 2 , two were

readmitted after aortic surgery for an incisional

wou nd problem (LOS = 14 days) and for myocar-

dial infarction (LO S = 8 days), one after extracranialsurgery for pnem nonia (LO S = 5 days) and 13 after

lower extremity revascularization for incision prob-lems (n = 5) (average LO S = 6 d ays), occlude d

bypasses (n = 4) (average LOS = 8 days), failingbypasses (n = 2) (average LO S = 3 days) and per-



JOURNALOF VASCULARSURGERY654 Calligaro et aL December 1995

Tab le V. O u tcom e o f s u rge ry fo r g roups I and I I

Group EC Ao rtic Bypass Total p Value

Same-day admissions

I 5.0% (2/40) 5.4% (2/37)II 94.0% (48/51) 67. 0% 29/43)Average length o f hospital

stay (days)1 5.1 11.2II 1.7 5.9

MortafityrateI 2.5% (1/40) 0% (0/37)II 0% (0/51) 2.3% (1/43)

Cardiac eventsI 2.5% (1/40) 2.7% (1/37)II 0% (0/51) 4.7% (2/43)

Pulmonary eventsI 5% (2/40) 8.1% (3/37)II 0% (0/5I) 7.0% (3/43)

Neurologic events

I 2.5% (1/40) 0% (0/37)II 0% (0/51) 0% (0/43)Readmission rate (in sur-

vivors)I 0% (0/39) 10.8% (4/37)II 2.0% (2/51) 4.8% (2/42)

Mean per patient cost (foreach type of surgery)I $23,231 $45,694II $17,721 $34,198diff $5,510 $11,496

Annual hospital cost sav-ings (total for eachtype of surgery)[I $281,010 $494,328

7.4% (5/68) 6.2% (9/145)77.1% (64 /83 ) 80 .0 % 141/177) p < 0.0001

9.6 8.83.9 3.8 p < 0.0001

2.9% (2/68) 2.1% (3/145)3.6% (3/83) 2.3% (4/177) NS

4.4% (3/68) 3.4% (5/145)6.0% (5/83) 4.0% (7/177) NS

1.5% (1/68) 4.1% (6/145)0% (0/83) 1.7% (3/177) NS

1.5% (1/68) 1.4% (2/145)0% (0/83) 0% (0/177) NS

18.2% (12/6 6) 11 .3% 16/142)15.0% (12/80) 9.2% (16/173) NS

$32,867$26,938

$5,929

$492,107 $1,267,445

EC , Extracraniat;BYPASS, lower extremity.

s is ten t gangrene requir ing amputat ion s (n = 2) (av-

erage LO S = 9 days) .

Overal l there were no major d i f ferences in mor-

ta l i ty , morbid i ty , or readmiss ion ra tes in surv ivors

when each type of operat ion , namely extracrania l ,

aor t ic , and lower ex tremity surgery , was compared

between groups 1 and 2 (Table V) .

Co s t s av ings. Im p lemen ta t ion o f these gu ide-

l ines resu l ted in es t imated annual hospi ta l cos t

savings of $1 ,267,445 for patien ts undergo ing major

vascular surgery in group 2 comp ared wi t h group 1

with the method previous ly presented (Table V) .

There were cos t savings of $5510 per pat ien t wh o

und erw ent ex tracrania l surgery , $11,496 per pat ien t

for aor t ic surgery , and $5929 per pat ien t for lower

extremity revascularization. Costs of the skilled care

uni t , v is i t ing home nurses , and extra t ime required

by the phys ic ian and of f ice personnel to evaluate

pat ien ts more f requent ly in the pos toperat ive per iod

were n ot included in th is analysis .

D I S C U S S I O N

Costs for th i rd-par ty payors are subs tant ia l ly

increased wi t h longer L O S ) Similar ly , hospi ta ls

desire shorte r LO S because this increases the average

income per bed-day , wi th the mos t lucra t ive days

being the ear ly days? By increas ing volume, the

overall cost per case is reduced)

The resu l ts of th is s tudy sugges t that the mos t

com mo nly per form ed e lect ive major vascular opera-

t ions can be per formed in a safe manner wi th

s ignificant cos t savings by decreas ing leng th of hos -

p i ta l s tay . Others have noted s imilar resu l ts wi th

decreased LOS, but these o ther repor ts focused on

ei ther ex tra cra ni al 6,8,~°,12 or lower ex tremity sur -gery7'n only.

Factors that predispose to ex tended LOS for

lower ex tremity bypass include age greater than 74

years , his tory of cerebrovascular disease, and limb

salvage surgery. 7 Ag e increases L O S because the

elder ly have o ther d iseases that contr ibute to & pen -



JOURNAL OF VASCULARSURGERY

Volume 22, Number6 C a l l i g a r o e t a l. 65 5

dency and are less l ike ly to have adequate homesupp or t systems. 13 Th e e lder ly have a funct ional

dec l ine dur ing ho sp i ta l iza t ion as a resu l t o f decreased

m u sc le s t r en g th , d im in i sh ed p u lm o n a r y v en f tl a fto n ,

and a l te red se nsa t ion and appet i te , t4 '~5 M ore thanwit h any o t her surg ica l special ty , vascu lar su rgeons

care fo r pa t ien ts wi t h these an d o th er r i sk fac to rs. I t

sh o u ld b e em p h as i zed th a t s l i g h tly m o r e th an h a l f o f

th e m a jo r v a scu la r o p e r a t io n s p e f f o r m ed a t o u r

h o sp i t a l we r e a f f ec t ed b y o u r ch an g e in s t r a t eg y

( T ab le I I I ) . T h i r d - p a r ty p ay o rs m u s t b e awar e th a t

l im i t in g l en g th o f h o sp i t a l s t ay i s b ey o n d th e c o n t r o l

of vascu lar su rgeons to a la rge degree fo r pa t ien ts

t ransfer red f rom o ther hosp i ta ls , pa t ien ts requ ir ingem er g en cy o p e r a fto n s , p a f t en ts r eq u i r in g p r eo p e r a -

t ive admission fo r in fec t ion or an t icoagula t ion , o r

pa t ien ts wh o u l t ima te ly requ ire vascu lar su rgery af te rleng th y preopera t ive hosp i ta l s tays on o the r serv ices.

We have adopted severa l s t ra teg ies to ach ieve

shor t ened len g th o f hosp i ta l s tays, sam e-day admis-

s ions , and decreasing hosp i ta l costs fo r pa t ien ts

r eq u i r in g e l ec f tv e m a jo r v a scu la r su r g e r y wi th o u t

sacr if ic ing pa t ien t safe ty . O utpa t ien t a r te r iograph y

h as b eco m e r o u t in e an d i s a sso c ia t ed wi th m in im a lcompl ica t ions . 12 W hen pa t ien ts requ ire ba l loon an-

g iop las ty o r s teh t p lacement , they are genera l ly

d i sch a r g ed th e sam e d ay a f t e r 4 h o u r s o f o b se r v a t io n

o n an o u tp a t i en t w a r d d e sp i t e t h e u se o f l a r ge r

shea ths and ca the ters . Al l pa t ien ts in g roups 1 and 2

wh o h ad ex t rac r an ia l an d ao r ti c su r g e r y u n d e r we n t

preoperaf tve ar te r iography , a l though our po l icy has

r ecen t ly ch an g ed , an d we a r e cu r r en t ly o b ta in in g

arter iograms on a more selective basis. We also

r o u t in e ly o b ta in o u tp a t i en t c a r d io lo g y an d an es th e -

s io logy evalua t ions . Th is change in s t ra tegy has

r e su l ted in m o r e in t en s iv e ef f or t s o n th e p a r t o f o u r

of f ice nurs in g and secre taria l s ta f f to schedule these

o u tp a t i en t s tu d ie s . T h u s f a r we h av e n o t n ee d ed to

h ire ex t ra o f f ice personnel to handle these ex t ra

duf tes , hu t ins tead o u t o f f ice nurse has sh i f ted mu ch

o f h e r tim e f r o m th a t o f a n u r se to th a t o f a sec re t a ry .As a r e su l t, t h e p h y s ic i an s p e r f o r m m o r e o f t h e

nur sing duties in the off ice, have less t im e available to

p e r f o r m o th e r d u f t e s , an d th e r e f o r e sp en d ex ten d ed

t ime in the o f f ice and hosp i ta l to g uaran tee ade quate

patient care.

Im plem enta f ton of cl in ica l pa thways has a l lowedus to develop goals and gu ide l ines fo r pa t ien tsrequ ir ing major vascu lar su rgery . By es tab l ish ing

g o a ls f o r L O S an d d a i ly p r o g re ss i n t e r m s o f d i e t an dam b u la t io n , a m o r e d i sc ip l in ed m an ag em en t h a s

been ad opte d by the s ta f f su rgeons a nd hou se s taf f.

O th e r s h av e d o cu m en ted th a t i n t en s iv e ca r e m ay b e

m in im ized a f t e r c a ro f td a r t e ry su r g e r y wi th o u t d e t -r imenta l e f fec t s.ö,8,12 I n v i ew o f t h e se s tu d ies , we h av e

r ecen t ly b een t r an s f e r r in g p a t ien t s u n d e r g o in g u n -compl ica ted ex t racran ia l su rgery to the f loor a f te r

in i fta l observa t ion fo r 6 ho urs in th e recove ry room ,

but these paf ten ts were no t inc luded in th is ser ies .

Contra ind icaf tons to d i rec t t ransfer to the regu lar

f loor a f te r th is observa t ion per iod inc lude lab i le

b lood pressure , h is to ry o f s ign i f ican t card iopulmo-

nary d isease , a ny neuro log ic sym ptom s, o r s ign i f ican t

n eck h em a to m as . Pa f t en t s w i th s t ab le co n d i t io n s a r e

t r an s f e r r ed to th e v a scu la r wa r d in r o o m s im m ed i -

a t e ly ad jacen t t o t h e n u r s in g s t a t io n an d m o n i to r edwi th te lem etry . Similar ly , pa t ien ts wi th s tab le condi-

t ions tmdergo ing lower ex t remity revascu lar iza t iona r e t ran s f e r red to th e f lo o r f r o m th e r eco v e r y r o o m ,

an d e f fo r ts a r e m ad e to t r an sf e r pa t i en t s u n d e r g o in g

aor f tc surgery to the w ard on the f i r s t postopera t ive

day . Essen t ia l to th is s t ra tegy is es tab l ishment o f a

vascu lar wa rd ded ica ted to car ing fo r paf ten ts under -

g o in g v ascu lar su r g e r y wi th t r a in ed n u r s in g p e r so n -

nel. A n urs ing supe rv isor in terac ts wi th the surge ons

to en su r e a sm o o th t r an s it i o n wh i l e t h e se ch an g es a r e

ad o p ted . 9 W e h av e f o u n d th a t d i scu ss ion w i th th e

p a t i en t an d f am i ly co n ce r n in g th e ex p ec ted L OS is

k ey to m ax im iz in g p a t i en t co o p e r a f to n .

On e co n ce r n o f e a r l i e r d i sch a r g e f o r p a t i en t s

u n d e r g o in g m a jo r su r g e r y i s h ig h e r r ead m iss io n

rates . 15 Ho we ver , o the r au thors ha ve rep or ted tha t

r ead m iss io n ra t es h av e n o t b een h ig h e r wh en c a r o t id

artery S urgery alone w as cons idered . 12 Similar ly, ou r

resu l ts fo r paf ten ts undergo ing ex t racran ia l , aor t ic ,

an d lo wer ex t r em i ty su r g e r y d id n o t su p p o r t t h i s

co n ce r n .

As a n am ral sequela o f ear lie r d ischarge f rom th e

acu te care hosp i ta l , w e d ramat ica l ly increased the use

o f o u r ski ll ed ca r e u n i t an d h o m e h ea l th ca r e

p e r so n n e l f o r wo u n d ca r e , p h y s i ca l t h e r ap y , an d

other nurs ing needs . Th is change in s t ra tegy repre-sen ts cost sh i f f tng f rom an inpat ien t to an o u tpa t ie n t

se t t ing o r to a less in tensive hosp i ta l se t t ing . P a t ien ts

or th i rd -par ty payors wi l l need to cover these costs .

As a r e su l t o f p r e ssu r e ex e r t ed b y m a n ag ed h ea l th ca r e

systems, we have dramat ica l ly decreased hosp i ta l

costs to re ma in comp et i t ive wi th loca l hosp i ta ls , bu t

obviously ou tpä t ie n t expenses have increased . Dai lynurs ing v is i t s cost ing $100 are much less expensive

than da i ly acu te care hosp i ta l costs bu t o f f se t our

ca lcu la ted annual hosp i ta l sav ings . More f requent



JOURNAL OF VASCULAR SURGERY6 5 6 C a l l i g a r o e t a L December 1995

off ice v is it s a re essen t ia l to m on i to r ou tpa t ien t

progress , which again places an increased burden and

expense on the surgeon and of f ice s ta f f . More

f requ ent postopera t ive o f f ice v is it s a re ano ther ex-

am p le o f co s t sh i ft i n g f r o m th e in p a t ien t se t t i n g toth e p h y s i c i an wh o is n o t r e im b u r sed f o r t h e f ir s t 3

mo nths a f te r su rgery . The refore , a l though o ur resu l ts

suggest d rarna t ic sav ings in the acu te care hosp i ta l

sett ing, costs have b een sh if ted to the skil led care unit ,

ou tpa t ien t se t t ing , and physic ian .

T h i s sm d y d o es n o t co n c lu s iv ely p r o v e th a t o u r

ch an g e in s t r a t eg y r eg a r d in g sam e- d ay ad m iss io n s

and ear ly d ischarges is as safe as ex tended pe r ioper -

ative hosp ital stays. The re was so m e selection bias in

grou p 2 pa t ien ts in tha t ind iv iduals consid ered to be

a t p o o r r isk f o r m a jo r su r g e r y we r e ad m i t t ed th e d ay

b e f o r e su r g e r y f o r a p e r io d o f i n t r av en o u s h y d r a t io nan d o b se r v a t io n . Ho wev e r , n o n e h ad p u lm o n a r y

a r t e r y m o n i to r in g ca th e te r s p l aced b e f o r e th e d ay o f

surgery (Table I I I ) . O f the 23 g roup 2 pa t ien ts

who requ ired p reoperaUve s tays , on ly one pa t ien twh o u n d e r w en t ao r ti c su r g e ry an d two p a t ien t s wh o

u n d e r wen t l o wer ex t r em i ty r evascula ri zat io n s we r e

ad m i t t ed b e f o r e th e d ay o f su r g e r y f o r h y d r a t io n an d

o b se r v at io n . M o s t o f th e p a t ien t s i n g r o u p 2 ad m i t t ed

b e f o r e th e d ay o f su r g e r y r e f u sed sam e- d ay ad m iss io n

because they t rave l led rar d is tances to the hosp i ta l .

Use o f d i sco u n ted n ea r b y h o te l s i s a so lu t io n o u r

hosp i ta l has recen t ly used as a so lu t ion to th is

p r o b lem . Gr o u p 2 p a t i en t s wh o u n d e r wen t ao r t i c

surgery rece ived ep idura l ana lgesics m ore f requen t ly

( 3 8 o f 4 3 o r 8 8 %) th an g r o u p 1 p a ti en ts ( 2 4 o f 3 7

o r 6 5 %) , wh ich m ay acco u n t i n p a r t f o r l e s s

postopera t ive pa in , ear l ie r ambula t ion , and possib ly

ear l ie r d ischarge . We are cur ren t ly eva lua t ing fac to rs

tha t migh t he lp p red ic t which pa t ien ts , espec ia l ly

th o se u n d e r g o in g ao r t ic su r g e r y , sh o u ld b e ad m i t t ed

b e f o r e th e d ay o f su r g e r y f o r m o r e in t en s iv e an d

p r o lo n g ed ca r d io p u lm o n a r y m o n i to r in g .

Our cost ana lysis shows tha t expenses remain

h ig h f o r p a t ien t s u n d e r g o in g v ascu lar su r g e r y a t o u r

hosp i ta l desp i te these in terven t ions (Table V) . U rba n

teach ing hosp i ta ls a re mor e expensive than s uburb anan d r u r a l co m m tm i ty h o sp i ta l s f o r m a n y r ea son s . T o

be competit ive on a cost-basis analysis, cooperativeef for ts a rnong physic ians and hosp i ta l ad min is t ra to rs

a t tmivers i ty medica l cen ters must be in i t ia ted to

lessen expenses . Geo graphic loca t ion an d da i ly roomcharges at värying hospitals also play a large role in

overa ll expenses . C ost o f und ergo ing a femo-ropopl i tea l bypass a t an o ther m ajor teach ing hosp i ta lin a d i f f e ren t g eo g r ap h ic a r ea th an o u r s was a lm o s t

$ 1 0 ,0 0 0 l es s ex p en siv e co m p ar ed wi th o u t g r o u p 2

patients. 17 A lth ou gh this difference in c ost is pa rtly

expla ined because the ear l ie r s tudy cor rec ted i t s

ca lcu la t ions accord ing to 1990 do l la r s , the average

L OS a t t h e o th e r c en te r was 1 1 .3 d ay s co m p a r ed wi th

3 .9 days a t our hosp i ta l . 17 This ma rked d iscrepancy incosts was p r imar i ly due to h igher costs per day fo r

in tensive care and ward beds a t our insf i tu t ion

co m p ar ed wi th th e o th e r t e ach in g h o spi ta l .

In conc lusion , these resu lts suggest tha t sam e-day

admissions , ear ly d ischarges, and im plem enta t io n of

c l in ica l pa thways fo r pa t ien ts undergo ing major

vascu lar su rgery resu lts in s ign i fican t apparen t hos-

p i ta l cost - sav ings wi thout increase in morb id i ty o r

m o r t a l i t y ra t es . W e b e li eve we h av e d em o n s t r a t ed

tha t cost -ef fec tiveness and qual i ty pa t ien t care a re no t

mutually exclusive. We f irmly believe vascular sur-

geons should take a lead ing ro le in he lp ing todecrease hea l th care expenses. Ho we ver , th i rd -par ty

p ay o r s an d h ea l th m an a g em en t o r g an iza t io n s sh o u ld

rea lize tha t th is chang e in s t ra tegy can app ly on ly to

a se lec t popu la t ion of pa t ien ts requ ir ing ma jor

vascu lar su rgery , and som e o f the cost- sav ings are

sh i f ted to the ou tpa t ien t se t t ing . In the fu tu re the

v ascu la r su r g eo n wi l l sp en d m o r e t im e an d e f f o r t

car ing fo r these c r i t ica l ly i ll pa t ien ts in an ou tpa t ien t

se t t ing w i th less p rofess ional sa ti sfac tion and d imin-

ished f inancia l re imb ursem ents .

Special thanks to Michelle Mann, Vice President, LBAHealth Car e Managem ent Products, Englewood, Colo.,the Adm inistration o f Pennsylvania Hospital, and PatriceMiller, RN , for assistance in providing financial data fo rthis study.

R E F E R E N C E S

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2 . Edwards W H, M orr i s HA Jr , Jenk ins JM, Bass SM, McK enzie

EJ. Ev alua ting quality, cost-effective health care: vascular

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1991;213: 433-9 .

3. Gup ta SK, V eith FI. In adequ acy of the diagnosis related

group (DRG ) re imbursements fo r l imb sa lvage lower ex t rem-ity arterial reconstructions. J VASC SUR 6 199 0;11:3 48-5 7.

4 . Ravio la CA, Nich te r LS, Baker ID, B usu t t i l RW , Machleder

HI , Moore WS. Cos t o f t rea t ing advanced leg i schemia :

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495 -6.

5. Rhod es RS , Krasniak CL» lone s PK. Factors affecting length

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D R G s . N E n g l J M e d 1 9 8 6 ; 3 1 4 : 15 3 - 7 .

6 . Hoyle RM , Jenk ins JM, Edwards W H Sr , Edwards W H Jr ,

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7 . K a lman PG, Johns ton W, W alker PM, L indsay TF. Preop-

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Volume 22, Number 6 Calligaro et aL 6 5 7

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SuI~6 1994;20:403-10.

9. Moher D , Weinberg A, Hanlo n R, Runnalls K. Effects of a

medical team coordinator on lenth of hospital stay. Can Med

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10. O'Brien M S, Ricotta JJ. Con serving resources afte r carotidendarterectomy : selective use of he intensive care unit. J Va sc

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11. Rosenthal D, Dickson C, Rodriquez FJ, et al. Infrainguinalendovascular in situ saphenous vein bypass: ongoing results.

VASC SURG 1994;20:389-95.12. Collier PE. C arotid endarterectom y: a safe and cost-efficient

approach. J VASCSUR~ 1992;16:926-33.

13. Rock woo d K. Delay s in the discharge of elderly patients.

J C lin Epidemiol 1990;43:971-5.14. Creditor M C. Hazards o f hospitalization of the elderly. An n

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15. McAleese P, Odling-Smee W. T he effect of complicat ions on

length of stay. Ann Surg 1994;220:740-44.16. Hu aink MG M, Cullen KA, Donaldson MC. Hospital costs of

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Submitted May 11, 199 5; accepted Aug. 3, 1995.

D I S C U S S I O N

D r . J e f f r e y L . K a u f m a n ( S p ri n g fi e ld , M a ss .) . G e o r g e

S a n t a y a n a s a i d t h a t t h o s e w h o c a n n o t r e m e m b e r t h e p a s t

a r e c o n d e m n e d t o r e p e a t it . M u c h o f w h a t w e d o i n s u r g er y

i s de r i ved f r o m t he anal ys is o f pa s t com pl i ca t i ons , l e ad i ng

t o w ha t C ha r l e s B osk desc r i bed a s no r ma t i ve va l ues .

Pos t ope r a t i ve ca r e s t anda r ds a r e p r omi nen t exampl es o f

t hese va l ue sys t ems . R i ghf f u l l y so , t hey a r e s t r ong l y he l d

and d i f f i cu l t t o change because t hey p r o t ec t ou r pa t i en t s .

A qu i e t r evo l u t i on i n t he se no r ma t i ve va l ues i s ove r -

t ak i ng vascu l a r su r ge r y . T he g r oup f r om t he Pennsy l van i a

H o s p i t a l h a s d e m o n s t r a t e d t h e s a fe t y o f a n e w p h i l o s o p h y :

t h a t i f p a t ie n t s a r e d o i n g w e i l, d o n ' t h o l d t h e m b a c k o u t o ff e a r t h a t s o m e t h i n g m i g h t g o w r o n g , b e c a us e i t p r o b a b l y

w o n ' t .

D r . C a l l i g a r o ' s g r o u p h a s m a d e t h e m o s t c o m p r e h e n -

s ive s t udy t o da t e ac r os s a b r oad spec t r um o f a r te r i al

r econs t r uc t i on t o d emo ns t r a t e t he u t i l it y o f c r it ic a l pa t h -

w ays t o sho r t en hosp i t a l i za t i on , and t hey have admi r ab l y

show n t ha t t he r e i s a s i gn i t i can t a s soc i a t ed cos t s av i ngs

f r o m t h is p h i l o s o p h y . T h e r e a r e o n l y a b o u t a h a l f a d o z e n

go od s t ud i e s addr e s s i ng si mi la r is sues. I n D ecem ber 1993 ,

m y g r o u p b e g a n a s i m i la r s tu d y .

W e e x a m i n e d 8 9 c a r o t i d a r t e r y p r o c e d u r e s , a n d w e

used v i r ma l l y t he s ame " f a s t t r ack" appr oach . W e ach i eved

a 1 - day pos t ope r a t i ve s t ay f o r 39% of t he pa t ien t s , and w ea r e ce r t a i n t ha t upw ar ds o f 60% can have a 1 - day s t ay a f te r

s u r g er y . O n e o u t c o m e o f o u r s t u d y w a s t h a t t h e r e w a s a

m u c h h i g h e r p r o b a b i l it y o f a v o i d i n g t h e i n te n s iv e c a r e u n i t

and ach i ev i ng a 1 - day s t ay i f t he ca r o t i d a r t e r y su r ge r y w as

s c h e d u le d f o r th e m o r n i n g . W e h a v e b r o u g h t t h e se d a t a t o

o u r h o s p i t a l o p e r a t i n g r o o m c o m m i t t e e , a n d w e h a v e

d e m o n s t r a t e d t h a t t h e r e is a la r g e a m o u n t o f m o n e y t h a t

can be s aved by g i v i ng us p re f e r en ti a l ope r a t i ng r o om t i me .

W h y is t h e P e n n s y l v an i a H o s p i t a l s t u d y s o i m p o r t a n t ?

T he ma i n r ea son i s t ha t t h i nk t anks a r e p r epa r i ng manua l s

t ha t t e il i n su r e r s t ha t t he l eng t h o f s t ay w il l be mi r acu l ous l y

shor t , bu t t he r e a r e no s c i en t i f i c da t a beh i nd t hese

p r o t oco l s . T he a u t hor s o f t he se t h i nk - t anks have e r en

p r o m o t e d t h e i d e a o f a 2 - d a y a c u t e h o s p it a l iz a t io n f o r

ao r t i c aneur ysm r epa ir ! I n po i n t o f f ac t, t he l i st o f

consu l t an t s f o r t he manu a l i nc l udes on l y one s u r geo n l is t ed

b y t h e A m e r i c a n C o l le g e o f S u r g e o n s a s a m e m b e r o f a

vascu l a r soc i e t y , and t he r e w as no i npu t f r om t he ma j o r

na t i ona l o r r eg i ona l va scu l a r soc i e ti e s a t a l l . M or eove r , i f

o n e r e v i ew s t h e a c t u al L O S d a t a f r o m t h e W e s t e r n r e g i o n ,

w h i ch has t he shor t e s t s t ays i n t he U n i t ed S t a te s , one f i nds

t ha t ba r e l y any pa t i en t s a r e ach i ev i ng t hese p r o j ec t ed ve r y

shor t s t ays . T he da t a a r e o r gan i zed t o sho w t he pe r cen t i le s

o f t h e t o t a l p o p u l a t i o n o f p a t ie n t s a c h i e v in g a g i v e n L O S

b y a g e. T h e d a t a f r o m t h e W e s t a re n o t t h a t g o o d . F o r

exampl e , f o r ca r o t i d enda r t e r ec t omy, i n t he age 65 - p l usp o p u l a t i o n i n 1 9 9 3 t o 1 9 9 4 , a 2 - d a y L O S w a s a c h ie v e d b y

on l y 10 % of pa t i en ts . F o r l ow er ex t r emi t y r evascu la r iza -

t i on , t he 50 t h pe r cen t i l e L O S f o r t he age 65 - p l us popu l a -

t i on i s 6 days , and on l y 10% ach i eved a 3 - day L O S . Fo r

ao r t i c su r ge r y , t he 50 t h pe r cen t i l e L O S w as 9 days , t he

earl ies t d i scharge was a t 6 days . N o one i s l eaving the

hosp i t a l i n 2 days , bu t t he i n su r e r s w an t t o p r e s su r e us i n t o

ach i ev i ng t h is sh o r t s t ay. T he r e i s muc h m y t h i n t he

u t i l i z a t i on sys t em t ha t w e a r e be i ng he l d accoun t ab l e t o ,

and i t i s t i me t ha t busy su r g i ca l g r ou ps do qua l i t y s tud i e s

such a s t he on e yo u have j u s t s een t o c l a r i fy t he pos s i b l e and

sa f e f r om t he i mposs i b l e and unsa f e . T he 1995 U .S .

na t i ona l da t a pub l i shed b y St . A n t hon y ' s i n B os t o n ,M a s s a c h u s e t t s , s h o w t h e t r u e a v e r a g e L O S f o r m a j o r

vascu l a r p r ocedur es , and t hese a r e s ti ll no t ab l y l onge r t han

w h a t t h e P e n n s y l v an i a H o s p i t a l g r o u p h a s a c h i ev e d : T h e

m e a n L O S f o r c a r o t i d e n d a r t e r e c t o m y i s 5 . 6 d a y s . T h e

aor t i c s t ays have a mean o f I 2 .2 days , and o t he r bypas ses

have a mean s t ay o f 9 .5 days .

D i d yo u use the se da t a t o ob t a i n p r e f e r en t i a l s chedu l i ng

o f c a s e s in t h e o p e r a t in g r o o m t o m a k e a s h o r te r L O S m o r e

likely?

W h a t c h a n g e s i n s u r g i c a l t e c h n i q u e d i d y o u u s e t o

d e c re a s e y o u r L O S ? F o r e x a m p le , d i d y o u h a r v e st a u t o g -

e n o u s v e i n o r d o s e t h e w o u n d s d i f fe r en t ly ? W h a t d i d y o u

do t o l es sen t he l i ke l ihood o f an unex pec t ed r e t u r n t o t he

O R ?



JOURNAL OF VASCULARSURGERY6 5 8 C a l l i g a r o e t a l. December 1995

Wer e t he r e one o r t w o pa r t i cu l a r changes i n nu r s i ng ,

phys i ca l t he r apy , o r soc i a l w or k s e r v i ce s t ha t w e r e mos t

c r it ic a l t o l ow er i ng t he L O S, o r w as t he success o f t h is

p r ogr am r ea l l y based , a s w e expe r i enced , on a change o f

phys i c i an a t t i t ude and p r ac ti ce?D r . K e i t h D . C a l l i g a r o . I n d e e d w e d o h a v e p r e fe r e n -

t i a l s t a r t i ng t i mes . We have a ve r y n i ce s i t ua t i on a t

Pennsy l van i a H osp i t a l , w he r e w e have t w o vascu l a r ope r -

a t i ng r oo ms and gua r an t eed 8 AM s t a rt s 5 days a w eek i n

b o t h r o o m s . T h i s e n ab l es u s t o g e t o u r p a t ie n t s u n d e r g o i n g

c a r o t id e n d a r t e r e c to m y d i s c h ar g e d t h e v e r y n e x t m o r n i n g .

W e have no t spec if ica ll y chang ed ou r t echn i que i n t he

w a y w e d o s u r g er y . T h e o n l y w a y t h a t y o u c a n c o n s i d er

c h a n g i n g y o u r t e c h n i q u e t o g e t p a t ie n t s o u t s o o n e r m i g h t

be t o t r y pe r f o r m i ng i n s i t u bypas ses w i t h l i m i t ed i nc is i ons

and , i t i s hop ed , enab l e ea rl ie r amb u l a t i on ; w e 've t r i ed

d o i n g t h a t a n d h a v e n o t f o u n d t h a t i t h a s h e l p e d r a u c h .

T he r e has been a change i n phys i ca l t he r apy andnur s i ng backup . We ge t t he phys i ca l t he r ap i s t s i nvo l ved

m o r e . W e ' r e v e r y a g g re s si v e n o w w i t h g e t t i n g p a t i e nt s o u t

o f b e d t h e f ir st d a y , e r e n p a t i en t s w h o h a v e u n d e r g o n e

t ibia l bypasses . A year ago I bel ieved that pat ients wi th

t i b ia l bypas ses needed t o s t ay in bed f o r 4 o r 5 days o r e ls e

t he i r l eg sw e l l ing w o u l d becom e so s ever e tha t t h ey 'd neve r

a m b u l a te . W e g e t t h e m o u t o f b e d t h e v e r y fir st d a y n o w .

We a r e t r y i ng t o d i s cha r ge t he 70 - yea r - o l d pa t i en t w i t h a

s t r a i gh t f o r w ar d f emor opop l i t ea l bypas s f r om t he hosp i t a l

t he s ec ond d ay i f t hey d on ' t have any f o o t l e si ons .

D r . T h o m a s F . O ' D o n n e l l , J r . ( B o s t o n , M a s s .) . T h i s

i s a ve r y i mpor t an t s t udy t ha t expands t he p r ev i ous w or k

o f E d w a r d s f r o m N a s h v il le .Can you te i l us whether there was a s ta t i s t i ca l ly

s i gn i f i can t r educ t i on i n pos t ope r a t i ve days? I i mag i ne i n

g r o u p 1 a g r e a t p e r c e n ta g e o f y o u r d a y s w e r e c o n s u m e d

be f o r e ope r a t i on .

E v e r y o n e w o u l d a g r e e t h a t L O S i s i m p o r t a n t , b u t

t ha t ' s r ea l ly t he i n i ti a l phase o f cos t r educ t i on . Y o u

m e n t i o n e d h o s p i t a l c os ts . D i d y o u h a v e a n i m p a c t o n t h e

cos t s o f t ak i ng a pa t i en t t h r o ug h su r ge r y , t ha t i s , have you

chan ged yo ur r e sour ce u t il i z at i on? Fo r exampl e , f o r ca r o t i d

e n d a r t e r e c to m y , d i d y o u u s e a d i f fe r e n t fl o w t h r o u g h t h e

r e c o v e r y r o o m s h o r t e r t h a n i t w a s b e fo r e? H a v e y o u i n a n y

w a y c h a n g e d t h e n u m b e r o f p e r s o n n e l re q u i r e d t o t a k e c a re

o f a pa t i en t un de r g o i ng vascu l a r su rge r y?A s y o u i m p l ie d , o n e n e e d s a g o o d s u p p o r t s y s te m s o

that th e pa t ient c an leave the acute care fac i l ity early . D o

y o u u s e S N F s o r t h e V i s i t i n g N u r s e A s s o c i a t i o n ? C o u l d

you expand on how t ha t p l ays a r o l e i n ea r l y d i s cha r ge?

O n e f a c t o r t h a t w e ' v e f o u n d i m p o r t a n t i n o u r d e v e l -

op me n t o f "b es t " p r ac t ice p l ans ove r t he l as t 2 yea r s is t ha t

i n f o r m i n g t h e p a t i e n t b e f o r e o p e r a t i o n h o w l o n g t h e y w i ll

be hospi ta l ized i s cr i t i ca l . Because once the phys ic ian

emphas i ze s i t i n t he o f f i ce and t he pa t i en t ca r e t eam goes by

i n hosp i t a l and r eemphas i ze s t he expec t ed L O S, n e i t he r t he

pa t i en t no r t he f ami l y i s upse t w h en t hey a r e d i s cha r ged 2

days a f t e r ca r o t i d su r ge r y .

D r . C a l l i g a r o . W e ' r e v e r y aw a r e o f D r . E d w a r d s ' s t u d y

and r e f e r t o i t i n t he s t udy ; i t ha s led t he w a y i n man y w ays .

T he r e w er e v e r y l a rge , s i gn i f ican t d i ff e r ences i n p os t ope r -

a t iv e L O S , m o r e s o e v e n in t h e p r e o p e r at i v e L O S . W e h a v e

s i gn if i can tl y chang ed t he r e sour ce u t i l iz a t i on i n m any w ays ,

p r i mar i l y i n te r ms o f l abor a t o r y and o t he r s t ud i e s. W er ecen t l y have r ou t i ne l y been t r ans f e r r i ng pa t i en t s unde r -

go i ng ca r o t i d enda r t e r ec t omy d i r ec t l y t o t he un i t a f t e r

a b o u t 5 h o u r s o f o b s e r v a ti o n i n a r e c o v e r y r o o m .

T he v i s i ti ng nu r se a spec t o f t h i s p l ays an i m por t an t r o le .

A ga i n , w e 've w or ke d ve r y c l ose ly w i t h hosp i t a l admi n i s -

t r a t i on and nur s i ng r ep r e sen t a t i ve s , and w e no t @ t he

v i s i ti ng nu r se s t o ge r i nvo l ved a s soon a s t he pa t i en t ge t s

home , and t ha t ha s made a b i g d i f f e r ence .

L as t , I compl e t e l y ag r ee w i t h you abou t t e l l i ng t he

pa t i en t and t he f ami l y abou t w hen t he pa t i en t i s expec t ed

t o go hom e . T he r e i s r e s is t ance i n a l o t o f pa t i en ts . I f a

p a t i e n t r ef u se s , o b v i o u s l y w e d o n ' t f o r c e t h e m t o g o h o m e .

Bu t qui te f rankly, by ta lking to the m several t imes af ter thesu r ge r y , you can gene r a l l y d i scha r ge w h en yo u be li eve i t is

s af e. A n d I r ea l ly w a n t t o em phas i ze t ha t . I t ' s no t w he r e yo u

can j us t men t i on i t once an d expec t t hem t o be w i l l ing t o

g o h o m e v e r y s o o n .

D r . D a n i e l W a l s h ( L e b a no n , N . H . ) . W e f o u n d t h at

hav i ng a de d i ca t ed vascu l ar nu r se c l i n ic i an w ho coor d i na t e s

phys i ca l t he r apy and v i s i t i ng nu r se s has been ex t r eme l y

i mpor t an t i n dec r eas i ng L O S. T h i s pe r son i s t he i n s t i t u -

t i ona l memor y r a t he r t han phys i c i ans , r a t he r t han house

s t a ll , r a t he r t han a p i ece o f pa pe r t acked on a w a ll . H av e you

used t ha t appr oach?

The second ques t ion re la tes to epidural anes thes ia .

We ' r e us i ng ep i dur a l anes t hes i a r auch mor e f r equen t l y .T h i s t echn i que can compl i ca t e ea r ly pa t ien t am bu l a t i on .

W h a t h a s b e e n t h e r o l e o f e p id u r a l a n e st h es ia a m o n g y o u r

pa t i en t s unde r go i ng ao r t i c and l ow er ex t r emi t y bypas ses?

D r . C a l l i ga r o . I ag r ee , a nu r se c l i n ic i an is ve r y , ve r y

i mpor t an t . T he r e i s a nu r s i ng supe r v i so r a t ou t hosp i t a l

w h o has pa r t i c i pa t ed i n t h is p r oces s t h r ou gh t h is en t i r e yea r

o f mee t i ngs w i t h n a t i ona l adv i so r s . W henev e r t he r e i s any

pr ob l em a t a ll , w e con t ac t he r , an d she w i l l take ca r e o f any

pr ob l ems w i t h nu r s i ng .

I n a n s w e r t o t h e s e c o n d q u e s t i o n a b o u t e p i d u r a l

anes the t ic s , w e r ou t i ne l y now a r e us i ng t hem f o r a ll ao r ti c

su r ge r y , and w e a r e ambul a t i ng pa t i en t s w ho r ece i ved t he

epidura l anes thet ic o n the f ir s t day. W e gen eral ly wi l l l eavei t i n un t i l a t l ea st t he s eco nd o r t h i r d day . A nd w e t h i nk t ha t

i s ac t ua ll y one o f the b i gge r r ea sons w e ' r e ab l e t o ge t

p a t ie n t s u n d e r g o i n g a o r ti c s u r g e ry a m b u l a t i n g s o o n e r a n d

ge t t i ng t hem ou t by t he f i f t h day .

D r . E n r i c o A s c e r ( B r o o k l y n , N . Y . ) . W e a l s o f o l l o w

t he s ame p r o t oco l t ha t you have desc r i bed . I n t e r e s t i ng l y

e n o u g h , a m o n t h a g o I r e c e iv e d a v i si t f r o m o n e o f t h e

admi n i s t r a t o r s i n m y hosp i t a l w i t h an a rt ic le , "L e ng t h o f

S t ay C os t R edu c t i on Fa ll ac ie s ." F r o m t he hosp i t a l po i n t o f

v i ew , i t ma y be t ha t b y ove r do i ng t h i s ea rl y d i s cha r ge t hey

m a y l o se m o n e y a n d m a y c h a n g e th e r e i m b u r s e m e n t f r o m

an i n - hosp i t a l pa t i en t f r om an ambul a t o r y bas i s , and

actual ly they have a l i s t of a l l the cases in which they are



J O U R N A L O F V A S C U L A R S U R G E RY

V o l u m e 2 2 , N u m b e r 6 C a l l i g a r o e t a l. 6 5 9

t e l l i ng us no t t o d i s cha r ge ea r l i e r t han t h i s because t hen

w e ' r e g o i n g t o l o se a lo t o f m o n e y . T h e t r e n d f o r c a r o t i d

e n d a r t e r e c t o m y i s 2 d a y s. S o i f y o u r a d m i n i s tr a t o r l o o k s a t

t h e a c tu a l d at a o n h o w m u c h m o n e y h e sa ve s o n t h e c a r o t id

e n d a r t e r e c to m y , o n n o n - M e d i c a r e p a t i en t s, h e m a y f i n d h el os t abo u t $1 7 ,00 0 pe r pa t ien t . S o I t h i nk t ha t we a r e be i ng

pu l l ed no w i n ano t he r way . T he r e i s no w ay t o p lease

eve r yone .

D r . C a l l i g a r o . A s u su a l , D r . A s c e r h a s m a n a g e d t o a s k

a d i ff i cu l t ques t i on . Hosp i t a l s can l ose m on ey i f yo u ge t

p a t ie n t s o u t t o o s o o n s i m p l y b e c a u se y o u h a v e a n e m p t y

bospi ta l .

I f y o u r c o m m e n t s h o l d t r u e , m a y b e w e ' Il s u g g e s t t o o u r

pa t i en ts un de r g o i ng c a r o t i d a r t e r y su r ge r y t ha t they shou l d

s tay another day and res t up a l i t t l e bi t .

D r . J e s se A . B l t u n e n t h a l ( N e w Y o r k , N . Y . ) . H o w

many admi s s i ons had t o be cance l l ed because t he pa t i en t s

w e r e e i t h er u n p r e p a r e d o r a g i t a te d o r h a d s o m e p r o b l e m s ?B ecause 75% t o 80 % of the pa t i en t s a r e be i ng t r ea t ed

f o r l im b lo ss , w h a t p e r c e n t a g e o f y o u r p a t i e n ts u n d e r g o i n g

f e m o r o p o p l i t e a l b y p a s s c a n g o h o m e w i t h i n a c o u p l e o f

days?

I t h i nk t he mos t i mpor t an t i n f l uence i n t hese t ypes o f

s t ud ie s i s t he pa t i en t s you d i dn ' t s t udy , i n o t he r wor d s , t he

p a t ie n t s u n d e r g o i n g e m e r g e n c y o p e r a t i o n s, t h e p a t i e n ts

t r ans f e r r ed f r om o t he r hosp i t a l s , t he pa t i en t s who have

spen t 10 days on t he med i ca l s e r v i ce be f o r e we see t hem,

and t he pa t i en t s w i t h pos t ope r a t i ve compl i ca t i ons . T ha t ' s

wh er e we can s ave t he m on ey becanse i t 's t he ou t l i e rs t ha t

r e al ly l o se tr e m e n d o u s a m o u n t s o f m o n e y ; h o w m a n y

pa t i en t s ' p r ocedur es wer e cance l l ed and t hen needed t o bei n t he hosp i t a l 2 o r 3 days be f o r e ope r a t i on?

D r . C a l l i g a r o . R e m a r k a b l y t h e r e w e r e r a t h e r f e w

pa t i en t s whose p r ocedur es wer e cance l l ed , a l t hough i t

ce r t a i n ly has happened . T h i s has r e su l t ed i n a g r ea t dea l

mo r e wo r k on t he pa r t o f o ur o ff ice , sec re ta ri al , and nu r s i ng

s t a f f t o t ake ca r e o f al l t h i s on an o u t pa t i en t bas is , a nd w e

d o n ' t g e t r e i m b u r s e d m o r e f o r t h at .

D r . D o m i n i c A . D e L a u r e n t i s . I t h i n k o u r c a n ce l la t io n

r a t e was a l o t l es s w i t h t h is sys t em becanse so r auch o f t he

eva l ua t i on was done on an ou t pa t i en t bas i s .

D r . C a U i g a r o . D r . B l u m e n t h a l h a d t w o o t h e r q u e s -

t i o n s . Y o u m e n t i o n e d a b o u t t h e f e m o r o p o p l i t e a l b y p a s s .

Over a l l, 85 % of our l ow er ex t r emi t y r evascu l a ri za t ionsur ge r y i s f o r l i mb sa l vage . W e don ' t ope r a t e r auch f o r

c l aud i ca t ion , an d we t r y t o d i s cha r ge t hose pa t i en t s w i t h i n

a c o u p l e o f d ay s . I f t h e y h a d a l a rg e , o p e n w o u n d o f t h e

f oo t , t hey m i gh t r equ i r e s t ay i ng a l it tl e l onge r ; bu t once i t

i s obv i ous i t i s go i ng t o hea l , we d i s cha r ge t hem and ge t

v i s i ti ng nur ses t o t ake ca r e o f t hem. A nd yo ur ques t i on

a b o u t p r e o p e r a ti v e L O S is a v e ry g o o d p o i n t . Y o u ' r e ri g h t,

pa t i en t s can be on t he med i ca l se r v ice i n our hosp i t a l f o r a

m o n t h , g e t t i n g t re a t e d f o r a v ar i et y o f t h i n g s ; w h e n t h e y ' re

f i na l l y s en t t o us , t hey need su r ge r y , and I t h i nk t ha t i s

go i ng t o be t he way t o cu t expenses .

D r . R o b e r t P . L e a t h e r ( A l b a n y, N . Y . ) . I n r e g a r d t o

1 - d a y L O S f o r p a t ie n t s u n d e r g o i n g c a r o t id a r t e r y su r g e r y ,

t ha t ' s be l ow t he mi n i mum ou t l i e r i n t he d i agnos i s - r e l a t ed

g r o u p c h a n g e s. I n o u t a r ea i t' s $ 1 5 0 0 o n d a y 1 ; i f y o u s e n d

t h e m h o m e o n t h e s e c o n d d a y y o u g e t $ 7 5 0 0 .

I wa n t t o emph as i ze t ha t w e have t h r ee n ur se c l in ic ians;

t h e y c a n a n d d o s p e n d a l o t o f ti m e w i t h t h e p a t i e n t a n d t h ef ami l y f r om t he i n i t i a l i n t e r v i ew f o r admi s s i on , r i gh t on

t h r ou gh , and t he y do a l l o f t he educa t i ona l pa r t , wh i ch t h i s

whol e sys t em d i r ec t l y depends on , a s we l l a s t he a r r ange -

m e n t s t h a t y o u ' v e a l l ud e d t o .

T he ques t i on I have pe r t a i ns t o compl i ca t ed , compl ex

f oo t p r ob l ems . I t ' s no t t he r econs t r uc t i ve su r ge r y t ha t

r e su lt s i n t he L O S t ha t ' s ex t ended , i t ' s ho w y ou t r ea t t hese

f ee t i n pa t i en t s w i t h d i abe t e s and ge t t hem ou t i n t ha t

l eng t h o f ti me . I ' d l ike t o he a r a l it tl e m or e de t a il on t ha t

s t ra tegy.

D r . C a l l i g a r o . I f t h is t u r n s o u t t o b e t r u e t h ä t w e ' re

l o s in g m o n e y a n d t h e h o s p i ta l i s lo s i n g m o n e y b y l e tt i ng

peop l e g o h om e t he f i rs t day a f te r ca r o t i d a r t e r y su r ge r y , Igues s we ' l l have t o change ou t s t r a t egy . T he r e have been

several recent ar tic les th at dem ons t ra te th e safety of

2 4 - h o u r L O S f o r c a r o t id a r t e r y su r g e ry . S o i t' s b e e n s h o w n

t o be s a fe , man y i ns t it u t i ons a r e do i ng i t, and I a s sume a l l

o f t hese ins f i t u t ions a r e go i ng t o chang e i f i t tu r ns ou t you

save money by keep i ng pa t i en t s i n t he hosp i t aL

T h e n u r s e c li n ic i an w i t h w h o m w e d e a l h a s m a d e a b i g

d i f fe r ence . I t wo u l d be n i ce i f we w ou l d have mo r e änc i l la r y

help to manage a l l these other deta i l s . I t does place ext ra

b u r d e n o n t h e r e si d en t s a n d o n u s .

L as t , t he compl ex f oo t l e s i ons have r e su l t ed i n cos t

sh i f t i ng . You have t o have mor e v i s i f i ng nur ses , mor e

phys i ca l t he r ap is t s , and ma ny mo r e f r equen t o f f ice v is it st ha t t he su r ge on and y our s ecr et ar ie s and t he nur ses do no t

ge t pa i d f o r . W e wi l l need t o exami ne pa t i en t s a f t e r

o p e r a t i o n a t l e a s t o n c e ä w e e k t o k e e p a n e y e o n f o o t

w o u n d s a n d h a v e t h e m b r o u g h t b a c k t o t h e o f f i c e a s

opposed t o keep i ng t hem i n t he hosp i t a l . I t h i nk t ha t ' s

ce r t a i n l y cheape r t han keep i ng t hem i n t he hosp i t a l , bu t i t

h a s r e s u l t e d i n m u c h l o n g e r h o u r s o n o u t p a r t , o n o u r

sec re ta ri es , and o n ou t nur ses , and we don ' t ge t r e imb ur sed

for these ext ra ef for t s .

D r . J e f f r e y L . K a u f m a n ( S p ri n g fi e ld , M a s s. ). I h a v e a

po i n t o f c l a r i fi cä t i on on d i agnos i s - r e la t ed g r oups . M edi ca r e

aban don ed t he l ow - end t r i m p o i n t s ever al yea r s ago , and ä

hosp i t a l is no t pena l i zed f o r comi n g i n l ow , on Medi ca r e a tl e a s t , s o y o u d o n ' t h a v e t o w o r r y a b o u t t h a t f o r c a r o t i d

ar ter ies nor for dis ta l bypasses .

D r . D e L a u r e n t i s . I w a s s ta r tl e d t o n o t e h o w c o o p e r ä -

t iv e t h e y o u n g v a s c u la r s u r g e o n s w e r e w h i le g o i n g t h r o u g h

t h i s p r oces s . I n P h i l ade l ph i a we have a ve r y compe t i f i ve

s i t ua ti on , t he r e a r e fi ve med i ca l s choo l s , j u s t abo u t 85% of

t he empl oyees i n t ha t c i t y a r e cove r ed by hea l t h ma i n t e -

nance o r gan i za t i ons , e i t he r U .S . Hea l t h C ar e o r B l ue

C r oss / B l ue S h i e l d , and t he s t i mul us t o do t h i s was t o

become compe t i t i ve and t o deve l op p r ac f i ce p r o f i l e s t ha t

woul d be a t t r ac t i ve t o t he d i f f e r en t t h i r d - pa r t y payor s .

S econd , t hese new po l i c i e s pu t a t r emendous l oad on

y o u r o ff ic e s ta ff . W e n o w h a v e a p e r s o n w h o d o e s n o t h i n g



IOURNALOF VASCULARSURGERY6 6 0 C a l l i g a r o e t a l. December 1995

bu t s chedu l e appo i n t m en t s w i t h ca r d i o l og i s t s , ang i og r a -phe r s , and anes t he s i o l og i s t s , s pends hour s on t he phonet r y i ng t o g e t a ll s o r ts o f pe r m i s s ions f r om t h i r d pa r t i e s t ogo ahead w i t h d i f f e r en t t h i ngs , and t hen t r y i ng t o exp l a i n

e v e r y t h i n g t o p a ti e nt s . T h e s e c o s t s d o n ' t s h o w u p i n t h ecos t ana l ys i s t ha t w e p r e s en t ed t h i s m om i ng .Final ly , a d i s turbing rea l i ty i s tha t we ' re s t i l l dancing

w i t h a 3 5 0 - p o u n d p a r t ne r . S e v e n t y p e r c e n t o f o u r h o s p i ta lbudge t i s f o r pe r s onne l , i nc l ud i ng adm i n i s t r a t i on . The r ehas been no r e duc t i on t h a t I kno w o f , and s o I w as s u rp r i s edt ha t t he s av i ngs w e r e on l y $1 m i l l i on . Fo r t he e f f o r t t ha tw as expen ded du r i ng t ha t yea r I be l ieved the s av i ngs w o u l dbe a l o t m or e . A m i l l ion do l l a r s is a l o t o f m on ey , bu t I w ass u r p r i s ed t ha t t he r e w e r e no changes w i t h t he hos p i t a lm i l ie u . I ju s t d o n ' t k n o w h o w m u c h f u r t h e r w e c a n g o a ss u r geons t o t r y t o b r i ng abo u t t he s e r educed co s t s i f i t isgo i n g t o be a one - s i ded a ff ai r.

D r . R o b e r t S . W a l s k y ( E m e r s o n , N . J . ) . I h a v e as t r ong i n t e r e s t i n t he bus i ne s s a s pec t o f m ed i c i ne and amg o i n g t h r o u g h a M a s t e r o f B u si ne s s A d m i n i s t r a t io npr ogr am w i t h s pec i a l a t t en t i on t o a s s oc i a t i ng cos t s w i t hpat ient care de l ivery and pat ient care i t se l f . There are waysw e can s ave m oney , a s w i t h pa t i en t s unde r go i ng ca r o t i da r t e r y s u r ge r y by s en d i ng t he m ho m e a l it tl e e ar li er . B u taga i n I th i nk w e ' r e da nc i ng w i t h a b i g bea r tha t ' s go i ng t oc o m e b a c k t o h a u n t t h e p a t ie n t s a n d n o t u s .

W h a t I m e a n b y t h a t is , r i g h t n o w i f w e w a n t t o b r i n gi n a pa t i en t unde r go i ng ao r t i c s u r ge r y t he day be f o r es u r g e r y t o p u t i n a p u l m o n a r y c a t h e te r , y o u ' r e s a y i n g w es h o u l d . S o w h a t d o e s t h a t m e a n ? W e ' v e g o t t o w a k e a

ca r d i o l og i s t up a t 4 aM. N o w , an H M O s ays , "G r ea t , I don ' tc a r e , I 'm s av i ng m oney , " bu t t hey ' r e no t r e a l l y s av i ngm o ney ; t hey ' r e s av i ng t he i r m one y , b u t t he r e i s s ti ll a cos ton t he ca r d i o l og i s t and t he pa t i en t co m i n g i n a t 3 AM byh a v i n g th e n u r s i n g p e r s o n n e l t h er e ; t h e H M O i s j u s t n o tpay i ng f o r i t . The r e i s a b i g cos t i n yo ur o f f ic e . Tha t ' s no ta s av i n g, t h a t' s ju s t a n o n r e i m b u r s e d c o st . T h e H M O i s n o tc o u n t i n g i t b ec a u se t h e y d o n ' t w a n t t o p a y f o r i t an y m o r e .S o m o n e y i s b e i n g l o s t , a n d t i m e a n d e n e r g y a r e b e i n gs pen t . Tha t i s s om e t h i ng t ha t ' s no t c a l cu l a t ed becaus e t heH M O d o e s n ' t w a n t t o p a y f o r it. T h e y a r e c o s t s h i ft i n g att he pa t i en t ' s , t he doc t o r ' s , and t he p r ov i de r ' s expens e .

I t h i n k t h a t i f w e s e n d a p at i e n t h o m e p r e m a t u r e ly a n dc a us e t h e m t o b e a g i ta t e d b y h a v i n g t h e m c o m e i n t o o e a rl yi n t he m or n i ng , t he r e i s a cos t t o t ha t . Pa t i en ts do n ' t w an tt o pay f o r i t anym or e , t hey don ' t a ccep t i t , t hey ' r e j u s t

l ook i ng a t t he do l l a r . A nd I t h i nk w e have t o unde r s t andt h is n o w a n d s t a r t b e i n g m o r e o f a p a t ie n t a d v o c a t e a n d s a y ,t he do l l a r i s i m por t an t , bu t t he do l l a r does no t s upe r s edet h e p a t ie n t , a n d i t d o e s n o t m e a n t h a t I ' m g o i n g t o d o a lly o u r w o r k f o r n o th i n g .

A n d I t h i nk w e a ll m n s t s t ep back and s ay , "W e can doa l o t o f th i ngs o n an o u t pa t i en t ba si s, hu t w e a l s o m u s tunde r s t and t he r e a r e t h i ngs w e can ' t t r i m , " and l e r t heH M O s k n o w t ha t. A n d I t h in k y o u r d a ta d o n ' t s h o w s o m eof t ha t com i ng i n ear l y , go i n g hom e ea rl y, and c os t s h i f t ingt o ou t s i de ca r e . Th a t cos t i s n ' t t he r e and t ha t ' s w h y your $1m i l l i on i s r e a ll y an ove r s t a t em en t . I t ' s j u s t a num ber t heyw o n ' t r e i m b u r se , a n d I t h i n k w e h a v e t o w a t c h o u t f o r t h a t

very carefully.D r . C a l l i g a r o . I a g r ee w i th y o u r c o m m e n t s . A g a i n , asI s t a ted , a l o t o f t h is i s cos t s h i ft i ng . A n d o n t he o t he r ha nd ,there ha ve bee n s igni f icant rea l cos t savings . I t cos t s $1Õ0 0a day f o r a r egu l a r hos p i t a l bed i n ou r hos p i t a l , w h i ch i sp r e t t y e x p e n s i v e c o m p a r e d w i t h m a n y , s o b y g e t t i n g t h epa t i en ts o u t o f t he hos p i t a l s oone r , yo u ce r t a in l y a re go i ngt o dec r ea s e cost s , and obv i ous l y the r e ' s go i n g t o have t o bem o r e peop l e i nvo l ved w i t h t h i s t han j u s t va s cu l a r s u r geons .

T h e l a s t p o i n t I w a n t t o b r i n g u p , t h o u g h , h a s t o d ow i t h y o u r c o m m e n t a b o u t a o r t i c s u r g e r y a n d b r i n g i n gt hem i n t ha t ea rl y. W e do n ' t qu i t e have t o b r i ng t hem i n a t3 aM, bu t t hey do have t o g e t t he r e by 6 : 3 0 aM. Th e ca t he t e r

ge t s pu t i n by t he anes t he s i o l og i st ; t he ca r d i o l og i s t does no ts e e t h e m t h a t m o m i n g , t h e y s ee t h e m b e f o r e o p e r a t io n , s ot h a t h a s n o t b e e n t h a t b i g o f a p r o b le m .

The i ssue tha t we are cur rent ly looking a t has speci f i -c a ll y t o d o w i t h a o r ti c s u r g e r y a n d t r y i n g t o i d e n d f y w h e ni t r e a l l y i s s a f e t o b r i ng t hos e pa t i en t s i n t he m or n i ng o fs u r ge r y and w hen i t i s no t . The r e a r e pa t i en t s t ha t w e d i dn o t f ee l c o m f o r ta b l e a d m i t t i n g t h e m o r n i n g o f s u r g er y , s ow e a d m i t te d t h e m t h e d a y b e fo r e .

impact of clinical pathways on hospital costs and early outcome after major vascular surgery, , , ...

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