Is continuous proximal adductor canal analgesia with a periarticular injection comparable to continuous epidural analgesia for postoperative pain after Total Knee Arthroplasty? A retrospective study.

BACKGROUND: The classic adductor canal block (ACB) is a regional technique that aims to introduce local anesthetic to the saphenous nerve as it traverses the adductor canal. It offers the benefit of preserved quadriceps strength, and is ideal for rehabilitation. Proximal ACB (PACB) allows the operator to place the block away from the surgical site, permitting preoperative placement. Our primary outcome was total opioid consumption; secondary outcomes included the highest numerical rating scale scores and total gait distance at the indicated time intervals. QUESTIONS/PURPOSES: We asked: 1) Does a Continuous Proximal ACB block with Periarticular knee injection (PACB) provide better analgesia than a Continuous Epidural (CSE)?; 2) Do PACB catheter patients do better with physical therapy compared to CSE patients?; 3) Are PACB patients discharged earlier than CSE patients? METHODS: With IRB approval we performed a retrospective chart review of patients who had underwent primary total knee arthroplasty between October 2015 and September 2016. The selected patients (n = 151) were divided into two groups: CSE group, 72 patients who received a continuous epidural catheter and the PACB group, 79 patients who received at PACB with Periarticular injection. The CSE group received a single-segment combined spinal epidural (CSE) in the operating room. The epidural catheter infusion was started with 0.1% ropivacaine at 8 mL/hour to 14 mL/hour during the post-operative period. The PACB group received a proximal adductor canal catheter with 20 ml of 0.5 % ropivacaine and maintained with ropivacaine 0.2% at 8 ml to 14 ml post operatively. Total opioid consumption, highest numeric rating scores and total gait distance travelled were recorded upon discharge from the PACU and completion of postoperative day (POD) 0, 1, and 2. RESULTS: We found that the median cumulative morphine consumption was significantly higher in the CSE group compared to the PACB group (194 (0-498) versus 126 (0-354) mg, p = 0.012), a difference that was most notable on POD 1 (84 (16-243) versus 60 (5-370) mg, p = 0.0001). Mean hospital length of stay was also shorter in the PACB group (2.6 ± 0.67 versus 3.0 ± 1.08 days, p = 0.01). CONCLUSION: PACB group used significantly lower morphine consumption compared to the CSE group; they were better participants during physical therapy and achieved longer gait distances. The mean hospital length of stay was also shorter in the PACB group.

Variability in hospital costs for carotid artery revascularization.

OBJECTIVE: The objective of this study was to understand drivers of cost for carotid endarterectomy (CEA) and carotid artery stenting (CAS) and to compare variation in cost among cases performed by vascular surgery (VS) with other services (OSs). METHODS: We collected internal hospital claims data for CEA and CAS between September 2013 and August 2015 and performed a financial analysis of all hospital costs including room accommodations, medications, medical and surgical supplies, imaging, and laboratory tests. Cases were stratified by presence of symptoms and procedure type, and costs of procedures performed by VS were compared with those performed by OSs. RESULTS: The cohort comprised 144 patients (78 asymptomatic, 66 symptomatic; 44 CAS, 100 CEA) receiving unilateral revascularization. VS (24 CAS, 70 CEA) and neurosurgery and neurointerventional radiology services (20 CAS, 30 CEA) performed all procedures. Age (71 ± 9 years vs 70 ± 11 years; P = .8) and length of stay (1.7 ± 2.1 days vs 2.2 ± 2.4 days; P = .73) were similar for VS and OSs. Symptoms were present before revascularization for 46% and were more commonly treated by OSs (78% vs 29%; P < .001). Case mix index was similar after stratifying by symptoms (asymptomatic, 1.28 ± 0.35 vs 1.39 ± 0.42 [P = .5]; symptomatic, 1.66 ± 0.73 vs 1.82 ± 0.81 [P = .9]). The largest cost components were operating room (OR)-related costs, beds, and supplies, together accounting for 76% of costs. Asymptomatic patients had 37% lower average hospital costs. For asymptomatic CAS, average index hospitalization cost was 17% less for VS compared with OSs because of 78% lower intensive care unit costs, 44% lower OR-related costs, 40% lower medication costs, and 24% lower cardiac testing costs. VS had 22% higher supply costs. For asymptomatic CEA, average index hospitalization costs were 22% lower for VS, driven by lower OR-related costs (28%), medications (28%), imaging (62%), and neurointerventional monitoring (64%). Costs were 38% higher for CAS vs CEA. For symptomatic CAS, costs were similar for both groups. For symptomatic CEA, total costs were 14% lower for VS compared with OSs, driven by 25% lower OR-related costs, 62% lower neurointerventional monitoring, 20% step-down beds, and 28% lower supply costs (and counterbalanced by 117% higher intensive care unit costs). CONCLUSIONS: VS average hospital costs were lower for asymptomatic CAS and all CEAs compared with OSs. Drivers of higher cost appear to be attributed to variation in physicians' practice as well as patients' complexity, affording an opportunity to reduce cost by establishing standard practices when appropriate.

Episode-based cost reduction for endovascular aneurysm repair.

OBJECTIVE: Effective strategies to reduce costs associated with endovascular aneurysm repair (EVAR) remain elusive for many medical centers. In this study, targeted interventions to reduce inpatient EVAR costs were identified and implemented. METHODS: From June 2015 to February 2016, we analyzed the EVAR practice at a high-volume academic medical center to identify, to rank, and ultimately to reduce procedure-related costs. In this analysis, per-patient direct costs to the hospital were compared before (September 2013-May 2015) and after (March 2016-January 2017) interventions were implemented. Improvement efforts concentrated on three categories that accounted for a majority of costs: implants, rooming costs, and computed tomography scans performed during the index hospitalization. RESULTS: Costs were compared between 141 EVAR procedures before implementation (PRE period) and 47 EVAR procedures after implementation (POST period). Based on data obtained through the Society for Vascular Surgery EVAR Cost Demonstration Project, it was determined that implantable device costs were higher than those at peer institutions. New purchasing strategies were implemented, resulting in a 30.8% decrease in per-case device costs between the PRE and POST periods. Care pathways were modified to reduce use of and costs for computed tomography scans obtained during the index hospitalization. Compared with baseline, per-case imaging costs decreased by 92.9% (P < .001), including a 99.0% (P = .001) reduction in postprocessing costs. Care pathways were also implemented to reduce preprocedural rooming for patients traveling long distances the day before surgery, resulting in a 50% decrease in utilization rate (35.4% PRE to 17.0% POST; P = .021), without having a significant impact on median postprocedural length of stay (PRE, 2 days [interquartile range, 1-11 days]; POST, 2 days [1-7 days]; P = .185). Medication costs also decreased by 38.2% (P < .001) as a hospital-wide effort. CONCLUSIONS: Excessive costs associated with EVAR threaten the sustainability of these procedures in health care organizations. Targeted cost reduction efforts can effectively reduce expenses without compromising quality or limiting patients' access.