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April
1998
Use
of Outpatient Preoperative Evaluation to Decrease Length of Stay for Vascular
Surgery
Pollard
JB, Garnerin Ph, Dalman RL; Anesth Analg 1997;85:1307-11
[ see
abstract below ]
It's hard to believe that we're reporting same day admission effects in
1997. But we are. I travel all over the country, and I don't know of virtually
anyone in any major center still admitting carotids and fem pops the day
before scheduled elective surgery, but, in case anyone is still wasting
money out there, we present the following.
At the Stanford associated Palo Alto VA, carotids had a length of stay
of 10 days (compared with current 2 day stays at a maximum everywhere
in the real world) and 14 days for fem pops (most go home in 3-4 days
max now). This was the data for 1 year prior to the beginning of preoperative
outpatient assessment and same day admission. They compared this to data
in the following one year period. To prove that institutional philosophies
were not impacting this sequential study (i.e. everyone's having a shorter
length of stay), they looked at the time effect on CABG's.
The data is primarily applicable to hospitals like the VA where warehousing
of patients preoperatively forever and forever due to a lack of accountability
and a lack of profit motive make this acceptable. Almost all cost savings
accrued to the preoperative decrease in length of stay of
5-6 days in the vascular surgery group. On a positive note, the cost calculations
were reasonably conservative and reasonably done. $900/patient was a saved.
The fact that postoperative mean length of stay was still >4 days for
carotids and >9 days for fem-pops is remarkable. Your tax dollars hard
at work!
All sarcasm aside, it is heartening to see anesthesiologists take control
of the process of care when they can and favorably impact resource utilization
without affecting patient outcome. The fact that the Palo Alto VA is slightly
off the scale in terms of postoperative length of stay is irrelevant.
The anesthesiologists addressed what they could, and fixed it well.
Unless someone requires acute hospital care (like a heparin drip) for
an ongoing problem, they never need to be in the hospital
until the day of surgery. Maybe Bill Clinton will ask Dr. Pollard to help
him make the VA a more efficient organization. He could do worse.
Return to the Current
Literature Review Front Page , or read the abstract:
ABSTRACT
Interventions
that decrease perioperative length of stay can result in considerable cost-savings.
This study assesses the impact of same-day admission using outpatient preoperative
evaluation on the lengths of stay and hospital costs for patients who underwent
carotid end-arterectomy (CEA) or lower extremity revascularization (LER).
Patient characteristics and length of stay were compared for two 1-yr periods
before and after outpatient preoperative evaluation had been implemented.
There were no significant differences before and after the initiation of
outpatient preoperative evaluation in the CEA and LER groups in mean age
and ASA physical status distributions.
The average preoperative length of stay decreased significantly from 7.0
to 1.9 days in the CEA group and from 9.0 to 2.8 days in the LER group.
This reduction in the length of stay was associated with a cost-savings
of $900 per patient and did not have an adverse effect on patient outcome.
We conclude that outpatient preoperative evaluation clinics reduce the cost
and length of stay in vascular surgery patients.
Implications: We found that outpatient preoperative evaluation and
same-day admission were associated with a decrease of 4.5 days in the preoperative
length of stay for carotid endarterectomy and lower-extremity revascularization.
This was not accompanied by increased mortality and led to hospital cost-savings
of approximately $900 per patient.
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