Implementing pediatric inpatient asthma pathways.

OBJECTIVE: Pathways are succinct, operational versions of evidence-based guidelines. Studies have demonstrated pathways improve quality of care for children hospitalized with asthma, but we have limited information on other key factors to guide hospital leaders and clinicians in pathway implementation efforts. Our objective was to evaluate the adoption, implementation, and reach of inpatient pediatric asthma pathways. METHODS: This was a mixed-methods study of hospitals participating in a national collaborative to implement pathways. Data sources included electronic surveys of implementation leaders and staff, field observations, and chart review of children ages 2-17 years admitted with a primary diagnosis of asthma. Outcomes included adoption by hospitals, pathway implementation factors, and reach of pathways to children hospitalized with asthma. Quantitative data were analyzed using descriptive statistics and multivariable regression. Qualitative data were analyzed using thematic content analysis. RESULTS: Eighty-five hospitals enrolled; 68 (80%) adopted/completed the collaborative. These 68 hospitals implemented pathways with overall high fidelity, implementing a median of 5 of 5 core pathway components (Interquartile Range [IQR] 4-5) in a median of 5 months (IQR 3-9). Implementation teams reported a median time cost of 78 h (IQR: 40-120) for implementation. Implementation leaders reported the values of pathway implementation included improvements in care, enhanced interdisciplinary collaboration, and access to educational resources. Leaders reported barriers in modifying electronic health records (EHRs), and only 63% of children had electronic pathway orders placed. CONCLUSIONS: Hospitals implemented pathways with high fidelity. Barriers in modifying EHRs may have limited the reach of pathways to children hospitalized with asthma.

Secondary overtriage of isolated facial trauma.

DESIGN: Retrospective chart review. SETTING: Academic, tertiary care, level I trauma center in a rural state. BACKGROUND: Unnecessary transfer of certain facial trauma patients results in a burden of time, money, and other resources on both the patient and healthcare system; identification and development of outpatient treatment pathways for these patients is a significant opportunity for cost savings. OBJECTIVES: To investigate the treatment and disposition of un-complicated, stable, isolated facial trauma injuries transferred from outside hospitals and determine the significance of secondary overtriage. METHODS: Retrospective chart review utilizing our institutional trauma database, including patients transferred to our emergency department between January 2012 and December 2017. Patients were identified by ICD9 or ICD10 codes and only those with isolated facial trauma were included. RESULTS: We identified 538 isolated facial trauma patients who were transferred to our institution during the study period. The majority of those patients were transferred via ground ambulance for an average of 76 miles. Overall, 82% of patients (N = 440) were discharged directly from our institution's emergency department. Almost 30% of patients did not require any formal treatment for their injuries; the potential savings associated with elimination of these unnecessary transfers was estimated to be between $388,605 and $771,372. CONCLUSIONS: We identified a high rate of patients with stable, isolated facial trauma that could potentially be evaluated and treated without emergent transfer. The minimization of these unnecessary transfers represents a significant opportunity for cost and resource utilization savings. LEVEL OF EVIDENCE: 2b- Economic and Cost Analysis.

Cervical spine evaluation in pediatric trauma: A cost-effectiveness analysis.

OBJECTIVE: The emergent evaluation of children with suspected traumatic cervical spine injuries (CSI) remains a challenge. Pediatric clinical pathways have been developed to stratify the risk of CSI and guide computed tomography (CT) utilization. The cost-effectiveness of their application has not been evaluated. Our objective was to examine the cost-effectiveness of three common strategies for the evaluation of children with suspected CSI after blunt injury. METHODS: We developed a decision analytic model comparing these strategies to estimate clinical outcomes and costs for a hypothetical population of 0-17 year old patients with blunt neck trauma. Strategies included: 1) clinical pathway to stratify risk using NEXUS criteria and determine need for diagnostic testing; 2) screening radiographs as a first diagnostic; and 3) immediate CT scanning for all patients. We measured effectiveness with quality-adjusted life years (QALYs), and costs with 2018 U.S. dollars. Costs and effectiveness were discounted at 3% per year. RESULTS: The use of the clinical pathway results in a gain of 0.04 QALYs and a cost saving of $2800 compared with immediate CT scanning of all patients. Use of the clinical pathway was less costly and more effective than immediate CT scan as long as the sensitivity of the clinical prediction rule was greater than 87% and when the sensitivity of x-ray was greater than 84%. CONCLUSION: A strategy using a clinical pathway to first stratify risk before further diagnostic testing was less costly and more effective than either performing CT scanning or screening cervical radiographs on all patients.

A Combination of Robotic Approach and ERAS Pathway Optimizes Outcomes and Cost for Pancreatoduodenectomy.

OBJECTIVE: To determine the impact of enhanced recovery after surgery (ERAS) pathway implementation on outcomes, and cost of robotic and open pancreatoduodenectomy. BACKGROUND: ERAS pathways have shown benefit in open pancreatoduodenectomy (OPD). The impact of ERAS on robotic pancreatoduodenectomy (RPD) is unknown. METHODS: Retrospective review of consecutive RPD and OPDs in the pre-ERAS (July, 2014-July, 2015) and ERAS (July, 2015-July, 2016) period. Univariate and multivariate logistic regression was used to determine impact of ERAS and operative approach alone, or in combination (pre-ERAS + OPD, pre-ERAS + RPD, ERAS + OPD, ERAS + RPD) on length of hospital stay (LOS) and overall cost. RESULTS: In all, 254 consecutive pancreatoduodenectomies (RPD 62%, OPD 38%) were analyzed (median age 67, 47% female). ERAS patients had shorter LOS (6 vs 8 days; P = 0.004) and decreased overall cost (USD 20,362 vs 24,277; P = 0.001) compared with non-ERAS patients, whereas RPD was associated with decreased LOS (7 vs 8 days; P = 0.0001) and similar cost compared with OPD. On multivariable analysis (MVA), RPD was predictive of shorter LOS [odds ratio (OR) 0.33, confidence interval (CI) 0.16-0.67, P = 0.002), whereas ERAS was protective against high cost (OR 0.57, CI 0.33-0.97, P = 0.037). On MVA, when combining operative approach with ERAS pathway use, a combined ERAS + RPD approach was associated with reduced LOS and optimal cost compared with other combinations (pre-ERAS + OPD, pre-ERAS + RPD, ERAS + OPD). CONCLUSION: ERAS implementation is independently associated with cost savings for pancreatoduodenectomy. A combination of ERAS and robotic approach synergistically decreases hospital stay and overall cost compared with other strategies.

Referral pathways for patients with NAFLD based on non-invasive fibrosis tests: Diagnostic accuracy and cost analysis.

BACKGROUND/AIMS: Non-invasive fibrosis tests (NITs) can be used to triage non-alcoholic fatty liver disease (NAFLD) patients at risk of advanced fibrosis (AF). We modelled and investigated the diagnostic accuracy and costs of a two-tier NIT approach in primary care (PC) to inform secondary care referrals (SCRs). METHODS: A hypothetical cohort of 1,000 NAFLD patients with a 5% prevalence of AF was examined. Three referral strategies were modelled: refer all patients (Scenario 1), refer only patients with AF on NITs performed in PC (Scenario 2) and refer those with AF after biopsy (Scenario 3). Patients in Scenarios 1 and 2 would undergo sequential NITs if their initial NIT was indeterminate (FIB-4 followed by Fibroscan®, enhanced liver fibrosis (ELF)® or FibroTest®). The outcomes considered were true/false positives and true/false negatives with associated mortality, complications, treatment and follow-up depending on the care setting. Decision curve analysis was performed, which expressed the net benefit of different scenarios over a range of threshold probabilities (Pt). RESULTS: Sequential use of NITs provided lower SCR rates and greater cost savings compared to other scenarios over 5 years, with 90% of patients managed in PC and cost savings of over 40%. On decision curve analysis, FIB-4 plus ELF was marginally superior to FIB-4 plus Fibroscan at Pt ≥8% (1/12.5 referrals). Below this Pt, FIB-4 plus Fibroscan had greater net benefit. The net reduction in SCRs was similar for both sequential combinations. CONCLUSIONS: The sequential use of NITs in PC is an effective way to rationalize SCRs and is associated with significant cost savings.

Cost-comparison analysis of FIB-4, ELF and fibroscan in community pathways for non-alcoholic fatty liver disease.

BACKGROUND: The identification of patients with advanced liver fibrosis secondary to non-alcoholic fatty liver disease (NAFLD) remains challenging. Using non-invasive liver fibrosis tests (NILT) in primary care may permit earlier detection of patients with clinically significant disease for specialist review, and reduce unnecessary referral of patients with mild disease. We constructed an analytical model to assess the clinical and cost differentials of such strategies. METHODS: A probabilistic decisional model simulated a cohort of 1000 NAFLD patients over 1 year from a healthcare payer perspective. Simulations compared standard care (SC) (scenario 1) to: Scenario 2: FIB-4 for all patients followed by Enhanced Liver Fibrosis (ELF) test for patients with indeterminate FIB-4 results; Scenario 3: FIB-4 followed by fibroscan for indeterminate FIB-4; Scenario 4: ELF alone; and Scenario 5: fibroscan alone. Model estimates were derived from the published literature. The primary outcome was cost per case of advanced fibrosis detected. RESULTS: Introduction of NILT increased detection of advanced fibrosis over 1 year by 114, 118, 129 and 137% compared to SC in scenarios 2, 3, 4 and 5 respectively with reduction in unnecessary referrals by 85, 78, 71 and 42% respectively. The cost per case of advanced fibrosis (METAVIR ≥F3) detected was £25,543, £8932, £9083, £9487 and £10,351 in scenarios 1, 2, 3, 4 and 5 respectively. Total budget spend was reduced by 25.2, 22.7, 15.1 and 4.0% in Scenarios 2, 3, 4 and 5 compared to £670 K at baseline. CONCLUSION: Our analyses suggest that the use of NILT in primary care can increases early detection of advanced liver fibrosis and reduce unnecessary referral of patients with mild disease and is cost efficient. Adopting a two-tier approach improves resource utilization.

Fits, faints, falls and funny turns: cost and capacity savings in Queensland from the accelerated transient attack pathway initiative (ATAP).

BACKGROUND: falls, seizures, syncope and transient ischaemic attacks (TIA) are common presentations to emergency departments sharing overlapping clinical features and diagnostic uncertainties. These transient attacks can be markers of serious adverse outcomes and are associated with high admission rates. We evaluated the effects of an integrated suite of pathways for transient attacks designed to improve adherence to best practices and reduce costs through fewer admissions. METHODS: a suite of clinician-designed pathways based on initial presenting diagnosis was developed to support ambulant care in a large hospital in Queensland, Australia. We performed a set of regression analyses to identify the differences in total cost and length of stay (LOS) before and after implementation. We conducted a Monte Carlo simulation to estimate the cost savings of the freed capacity in the patient cohort. RESULTS: pathway implementation was associated with reduced admitted LOS and costs. Falls patients admitted LOS declined by 32.5%, and admission costs by 19.5%. Syncope, seizure, and TIA patients admitted LOS declined by 22% with no change in admitted costs. Despite a small increase in 90-day representations, total emergency department LOS was unchanged. Emergency department costs were similar between falls and non-falls patients. The Monte Carlo analysis showed that the most likely outcome was a cost savings in freed capacity of $71 per patient episode. CONCLUSION: the ATAP suite of pathways was associated with reduction in LOS, release of capacity and reduction in costs. Further study is needed to evaluate mechanisms and clinical outcomes in this vulnerable population.

More cost-effective management of patients with musculoskeletal disorders in primary care after direct triaging to physiotherapists for initial assessment compared to initial general practitioner assessment.

BACKGROUND: A model for triaging patients in primary care to provide immediate contact with the most appropriate profession to treat the condition in question has been developed and implemented in parts of Sweden. Direct triaging of patients with musculoskeletal disorders (MSD) to physiotherapists at primary healthcare centres has been proposed as an alternative to initial assessment by general practitioners (GPs) and has been shown to have many positive effects. The aim of this study was to evaluate the cost-effectiveness from the societal perspective of this new care-pathway through primary care regarding triaging patients with MSD to initial assessment by physiotherapists compared to standard practice with initial GP assessment. METHODS: Nurse-assessed patients with MSD (N = 55) were randomised to initial assessment and treatment with either physiotherapists or GPs and were followed for 1 year regarding health-related quality of life, utilization of healthcare resources and absence from work for MSD. Quality-adjusted life-years (QALYs) were calculated based on EQ5D measured at 5 time-points. Costs for healthcare resources and production loss were compiled. Incremental cost-effectiveness ratios (ICERS) were calculated. Multiple imputation was used to compensate for missing values and bootstrapping to handle uncertainty. A cost-effectiveness plane and a cost-effectiveness acceptability curve were construed to describe the results. RESULTS: The group who were allocated to initial assessment by physiotherapists had slightly larger gains in QALYs at lower total costs. At a willingness-to-pay threshold of 20,000 €, the likelihood that the intervention was cost-effective from a societal perspective including production loss due to MSD was 85% increasing to 93% at higher thresholds. When only healthcare costs were considered, triaging to physiotherapists was still less costly in relation to health improvements than standard praxis. CONCLUSION: From the societal perspective, this small study indicated that triaging directly to physiotherapists in primary care has a high likelihood of being cost-effective. However, further larger randomised trials will be necessary to corroborate these findings. TRIAL REGISTRATION: ClinicalTrials.gov NCT02218749 . Registered August 18, 2014.

Bundled Payment "Creep": Institutional Redesign for Primary Arthroplasty Positively Affects Revision Arthroplasty.

BACKGROUND: Revision total joint arthroplasty (TJA) is associated with increased readmissions, complications, and expense compared to primary TJA. Bundled payment methods have been used to improve value of care in primary TJA, but little is known of their impact in revision TJA patients. The purpose of this study is to evaluate the impact of a care redesign for a bundled payment model for primary TJA on quality metrics for revision patients, despite absence of a targeted intervention for revisions. METHODS: We compared quality metrics for all revision TJA patients including readmission rate, use of post-acute care facility after discharge, length of stay, and cost, between the year leading up to the redesign and the 2 years following its implementation. Changes in the primary TJA group over the same time period were also assessed for comparison. RESULTS: Despite a volume increase of 37% over the study period, readmissions declined from 8.9% to 5.8%. Use of post-acute care facilities decreased from 42% to 24%. Length of stay went from 4.84 to 3.92 days. Cost of the hospital episode declined by 5%. CONCLUSION: Our health system experienced a halo effect from our bundled payment-influenced care redesign, with revision TJA patients experiencing notable improvements in several quality metrics, though not as pronounced as in the primary TJA population. These changes benefitted the patients, the health system, and the payers. We attribute these positive changes to an altered institutional mindset, resulting from an invested and aligned care team, with active physician oversight over the care episode.

Process Improvement in Patient Pathways: A Case Study Applying Accelerated Longitudinal Design With Decomposition Method.

EXECUTIVE SUMMARY: Evaluations of improvements in long chronic-patient pathways must include both short- and long-term effects on patients; that is, effects on the full patient pathway. Otherwise, costs might be cut without considering the long-term effects and, consequently, the overall cost of the pathway could increase. Unfortunately, current methods of evaluation present several issues: (1) they do not provide valid insights regarding the effects of a given improvement effort until several years later, (2) they provide imprecise and biased results, and (3) the aggregated results are not useful for identifying and disseminating the best practices that lead to an improvement. In this article, the accelerated longitudinal design with decomposition of total costs (ALDD) method is applied to evaluate the effects of improvement efforts on inpatient utilization for long cardiac pathways at a Danish hospital. The results show that the ALDD method can deliver valid results much faster than traditional methods and can uncover hidden improvements in the local work processes of clinical teams. Application of the ALDD method at a hospital in Denmark identified a significant reduction (15.4%) in the mean total bed utilization per cardiac pathway and revealed that this reduction was caused by improvements in the work processes.

Relationship between patient costs and patient pathways.

PURPOSE: The purpose of this paper is to identify actual (as-is) patient pathway variation among breast cancer patients and to investigate the relationship between pathways and the cost incurred by patients. DESIGN/METHODOLOGY/APPROACH: Both quantitative and qualitative methods were employed to analyze data from four Swedish hospital groups. Quantitative methods include event-log data mining and statistical analyses on the related patient cost from the Swedish breast cancer quality registry and case-costing system. Qualitative methods included collaboration with and interviewing domain experts. FINDINGS: Unique pathways, followed by only one patient, were generally costlier than the most and less frequent pathways. Earlier study findings are confirmed for mastectomy patients, with more frequent pathways having a lower cost, whereas contradicting and inconclusive results emerged for the partial mastectomy patient groups. Highest variation in pathways was identified for patients receiving chemotherapy. PRACTICAL IMPLICATIONS: The common belief - if one follows a standardized patient pathway, then the cost will be lower - should be re-examined based on the actual pathways that occur in reality. ORIGINALITY/VALUE: The relationships between patient pathways and patient cost allow more complex insights, beyond the general causal relationship between successfully implementing a "to-be" care pathway and lower cost. This highlights data-driven research's importance, where actual pathways (as-is) provide more useful information than to-be care pathways.

Essential elements of an outpatient total joint replacement programme.

PURPOSE OF REVIEW: To summarize the safety and feasibility of outpatient total joint arthroplasty (TJA) from the perspectives of short-term complications, long-term functional outcomes, patient satisfaction and financial impact, and to provide evidence-based guidance on how to establish an outpatient TJA programme. RECENT FINDINGS: TJA has been recently transitioned from an exclusively inpatient procedure for all Medicare and Medicaid patients to an outpatient surgery in properly selected total knee arthroplasty patients. This change may decrease costs while maintaining comparable rates of readmission, adverse events, positive surgical outcomes and patient satisfaction. SUMMARY: With a standardized clinical pathway, outpatient TJA can be safe and effective in a subset of patients. Essential components of a successful outpatient TJA programme include proper patient selection, preoperative patient/family education, perioperative multidisciplinary coordination and opioid-sparing analgesia, and early and effective postdischarge planning. More studies are needed to further assess and optimize this new care paradigm.

Paediatric asthma clinical pathway: Impact on cost and quality of care.

INTRODUCTION: Uncontrolled asthma may cause an increase in healthcare utilisation, hospital admission and productivity loss. With the increasing burden of asthma in Malaysia, strategies aimed at reducing cost of care should be explored. OBJECTIVE: This study aims to determine if a clinical pathway (CPW) for inpatient paediatric asthma would reduce average length of stay (ALOS), improve asthma management and decrease cost. METHODS: A quasi-experimental, pre-post study was used to evaluate the CPW effectiveness. Paediatric inpatients aged 5-18 years old, admitted for acute asthma exacerbation from September 2015 to April 2016 were prospectively recruited. Data from patients admitted from January-July 2015 were used as control. CPW training was carried out in August 2015 using standardised modules. Direct admission cost from the provider's prospective was calculated. Outcomes compared were differences in ALOS, discharge medication, readmission within 28 days of discharge and cost. RESULTS: ALOS is 26 hours lower in the CPW group for severe exacerbations and underlying uncontrolled asthma (19.2 hours) which is clinically significant as patients have shorter hospital stay. More newly-diagnosed intermittent asthmatics were discharged with relievers in the CPW group (p-value 0.006). None of the patients in the CPW group had readmissions (p-value 0.16). Mean treatment cost for patients in the intervention group is higher at RM843.39 (SD ±48.99, versus RM779.21 SD±44.33). CONCLUSION: This study found that management using a CPW may benefit asthmatic patients with uncontrolled asthma admitted with severe exacerbation. Further studies will be needed to explore CPW's impact on asthma management starting from the emergency department.

Costs of cancer along the care continuum: What we can expect based on recent literature.

BACKGROUND: Cancer costs should be discussed by patients and providers, but information is not readily available. Results from recently published studies (in the last 5 years) on direct and indirect cancer costs may help guide these discussions. METHODS: The authors reviewed studies published between 2013 and 2017 that reported direct health care costs and indirect (productivity losses) costs. The annual mean total and net costs of cancer were summarized for all payers and for survivors only by age (ages 18-64 and ≥65 years), by phase of care (initial [ie, 12 months from diagnosis], continuing, and end-of-life [ie, 12 months before death]), or for recently diagnosed (within 1-2 years of diagnosis) and longer term survivors. RESULTS: For all payers combined, costs for cancers like breast, prostate, colorectal, and lung cancers were $20,000 to $100,000 in the initial phase, $1000 to $30,000 annually in the continuing phase, and ≥$60,000 in the end-of-life phase. Annual out-of-pocket costs to recently diagnosed survivors were >$1000 for medical care and time costs, approximately $2000 for productivity losses, and from $2500 to >$4000 for employment disability, depending on age. For longer term survivors, the cost of medical care was approximately $1500 for older survivors and $747 for younger survivors, time costs were $831 to $955 for older survivors and $459 to $630 for younger survivors, and productivity losses were approximately $800. Disability among long-term survivors was similar to that among short-term survivors. Limitations of the reviewed studies included older data and under-representation of higher cost cancers. CONCLUSIONS: Frequently updated cost information for all cancer types is needed to guide discussions of anticipated short-term and long-term cancer-related costs with survivors. Cancer 2018;000:000-000. © 2018 American Cancer Society.

Strategies That Reduce 90-Day Readmissions and Inpatient Costs After Liver Transplantation.

Liver transplantation (LT) is hospital-resource intensive and associated with high rates of readmission. We have previously shown a reduction in 30-day readmission rates by implementing a specifically designed protocol to increase access to outpatient care. The aim of this work is to determine if the strategies that reduce 30-day readmission after LT were effective in also reducing 90-day readmission rates and costs. A protocol was developed to reduce inpatient readmissions after LT that expanded outpatient services and provided alternatives to readmission. The 90-day readmission rates and costs were compared before and after implementing strategies outlined in the protocol. Multivariable analysis was used to control for potential confounding factors. Over the study period, 304 adult primary LTs were performed on patients with a median biological Model for End-Stage Liver Disease of 22. There were 112 (37%) patients who were readmitted within 90 days of transplant. The readmission rates before and after implementation of the protocol were 53% and 26%, respectively (P < 0.001). The most common reason for readmission was elevated liver tests/rejection (24%). In multivariable analysis, the protocol remained associated with avoiding readmission (odds ratio, 0.33; 95% confidence interval, 0.20-0.55; P < 0.001). The median length of stay after transplant before and after protocol implementation was 8 days and 7 days, respectively. A greater proportion of patients were discharged to hospital lodging after protocol implementation (10% versus 19%; P = 0.03). The 90-day readmission costs were reduced by 55%, but the total 90-day costs were reduced by only 2.7% because of higher outpatient costs and index admission costs. In conclusion, 90-day readmission rates and readmission costs can be reduced by improving access to outpatient services and hospital-local lodging. Total 90-day costs were similar between the 2 groups because of higher outpatient costs after the protocol was introduced.

Extracorporeal photopheresis for graft versus host disease: Identifying a clinical pathway and associated resource utilization.

Extracorporeal photopheresis (ECP) is an established therapy for the treatment of graft-versus-host-disease (GVHD) following an allogeneic stem cell transplant. We performed a prospective analysis of patients receiving ECP treatment for GVHD to identify a clinical pathway and resource utilization of this process. The cohort included consecutive allogeneic stem cell recipients with GVHD. ECP was performed using the CELLEX Photopheresis System or the UVAR XTS Photopheresis System (Therakos, Inc, Exton, PA). A clinical pathway was developed and a time and motion study was conducted to define the resource utilization and costs associated with ECP. Patients were treated with either CELLEX (n = 18 procedures) or UVAR (n = 4 procedures). Total time commitment for each procedure for the 2 machines differed. The time for ECP was 117 min (median, range: 91-164 min) using CELLEX and 161 min (median; range: 140-210) using the UVAR-XTS machine. Total costs of each ECP procedure were $3420.50. There is a considerable time commitment of the patient and the clinical staff when employing ECP to treat GVHD. ECP costs are significant considering this is a prolonged therapy continued for several months. With this finalized pathway and costs, we have a standardized clinical pathway for the treatment of GVHD. We are addressing minimizing resource utilization while emphasizing quality care for these patients.

Can single disease payment system based on clinical pathway reduce hospitalization costs in rural area? A case study of uterine leiomyoma in Anhui, China.

BACKGROUND: Single disease payment program based on clinical pathway (CP-based SDP) plays an increasingly important role in reducing health expenditure in china and there is a clear need to explore the scheme from different perspectives. This study aimed at evaluating the effect of the scheme in rural county public hospitals within Anhui, a typical province of China,using uterine leiomyoma as an example. METHODS: The study data were extracted from the data platform of the New Rural Cooperative Medical Office of Anhui Province using stratified-random sampling. Means, constituent ratios and coefficients of variations were calculated and/or compared between control versus experiment groups and between different years. RESULTS: The total hospitalization expenditure (per-time) dropped from 919.08 ± 274.92 USD to 834.91 ± 225.29 USD and length of hospital stay reduced from 9.96 ± 2.39 days to 8.83 ± 1.95 days(P < 0.01), after CP-based SDP had implemented. The yearly total hospitalization expenditure manifested an atypical U-shaped trend. Medicine expense, nursing expense, assay cost and treatment cost reduced; while the fee of operation and examination increased (P < 0.05). The expense constituent ratios of medicine, assay and treatment decreased with the medicine expense dropped the most (by 4.4%). The expense constituent ratios of materials, ward, operation, examination and anesthetic increased,with the examination fee elevated the most (by 3.9%).The coefficient of variation(CVs) of treatment cost declined the most (- 0.360); while the CV of materials expense increased the most (0.186). CONCLUSION: There existed huge discrepancies in inpatient care for uterine leiomyoma patients. Implementation of CP-based SDP can help not only in controlling hospitalization costs of uterine leiomyoma in county-level hospitals but also in standardizing the diagnosis and treatment procedures.

A discrete event simulation model to evaluate the treatment pathways of patients with cataract in the United Kingdom.

BACKGROUND: The number of people affected by cataract in the United Kingdom (UK) is growing rapidly due to ageing population. As the only way to treat cataract is through surgery, there is a high demand for this type of surgery and figures indicate that it is the most performed type of surgery in the UK. The National Health Service (NHS), which provides free of charge care in the UK, is under huge financial pressure due to budget austerity in the last decade. As the number of people affected by the disease is expected to grow significantly in coming years, the aim of this study is to evaluate whether the introduction of new processes and medical technologies will enable cataract services to cope with the demand within the NHS funding constraints. METHODS: We developed a Discrete Event Simulation model representing the cataract services pathways at Leicester Royal Infirmary Hospital. The model was inputted with data from national and local sources as well as from a surgery demand forecasting model developed in the study. The model was verified and validated with the participation of the cataract services clinical and management teams. RESULTS: Four scenarios involving increased number of surgeries per half-day surgery theatre slot were simulated. Results indicate that the total number of surgeries per year could be increased by 40% at no extra cost. However, the rate of improvement decreases for increased number of surgeries per half-day surgery theatre slot due to a higher number of cancelled surgeries. Productivity is expected to improve as the total number of doctors and nurses hours will increase by 5 and 12% respectively. However, non-human resources such as pre-surgery rooms and post-surgery recovery chairs are under-utilized across all scenarios. CONCLUSIONS: Using new processes and medical technologies for cataract surgery is a promising way to deal with the expected higher demand especially as this could be achieved with limited impact on costs. Non-human resources capacity need to be evenly levelled across the surgery pathway to improve their utilisation. The performance of cataract services could be improved by better communication with and proactive management of patients.

Adding Value to Total Joint Arthroplasty Care in an Academic Environment: The Utah Experience.

BACKGROUND: Adding value in a university-based academic health care system provides unique challenges when compared to other health care delivery models. Herein, we describe our experience in adding value to joint arthroplasty care at the University of Utah, where the concept of value-based health care reform has become an embraced and driving force. METHODS: To improve the value, new resources were needed for care redesign, physician leadership, and engagement in alternative payment models. The changes that occurred at our institution are described. RESULTS: Real-time data and knowledgeable personnel working behind the scenes, while physicians provide clinical care, help move clinical pathway redesigns. Engaged physicians are essential to the successful implementation of value creation and care pathway redesign that can lead to improvements in value. An investment of money and resources toward added infrastructure and personnel is often needed to realize large-scale improvements. Alignment of providers, payers, and hospital administration, including by means of gainsharing programs, can lead to improvements. CONCLUSION: Although significant care pathway redesign efforts may realize substantial initial cost savings, savings may be asymptotic in nature, which calls into question the likely sustainability of programs that incentivize or penalize payments based on historical targets.

Implementation of a Total Hip Arthroplasty Care Pathway at a High-Volume Health System: Effect on Length of Stay, Discharge Disposition, and 90-Day Complications.

BACKGROUND: Standardized care pathways are evidence-based algorithms for optimizing an episode of care. Despite the theoretical promise of care pathways, there is an inconsistent literature demonstrating improvements in patient care. The authors hypothesized that implementing a care pathway, across 11 hospitals, would decrease hospital length of stay (LOS), decrease postoperative complications at 90 days, and increase discharges to home. METHODS: A multidisciplinary team developed an evidence-based care pathway for total hip arthroplasty (THA) perioperative care. All patients receiving THA in 2013 (pre-protocol, historical control), 2014 (transition), and 2015 (full protocol implementation) were included in the analysis. Multivariable regression assessed the relationship of the care pathway to 90-day postoperative complications, LOS, and discharge disposition. Cost savings were estimated using previously published postarthroplasty episode and per diem hospital costs. RESULTS: A total of 6090 primary THAs were conducted during the study period. After adjusting for the covariates, the full protocol implementation was associated with a decrease in LOS (mean ratio, 0.747; 95% confidence interval [CI; 0.727, 0.767]) and an increase in discharges to home (odds ratio, 2.079; 95% CI [1.762, 2.456]). The full protocol implementation was not associated with a change in 90-day complications (odds ratio, 1.023; 95% CI [0.841, 1.245]). Payer-perspective-calculated theoretical cost savings, including both index admission and postdischarge costs, were $2533 per patient. CONCLUSION: The THA care pathway implementation was successful in reducing LOS and increasing discharges to home. The care pathway was not associated with a change in 90-day complications; further targeted interventions in this area are needed. Despite care standardization efforts, high-volume hospitals and surgeons had higher performance. Extrapolation of theoretical cost savings indicates that widespread THA care pathway adoption could lead to national healthcare savings of $1.2 billion annually.