Cost-effectiveness analysis of a resource-intensive approach versus minimally invasive strategy for high-risk transcatheter aortic valve replacement patients.

Aortic stenosis has a high mortality rate in patients who do not receive aortic valve replacement. Previously, transcatheter aortic valve replacement (TAVR) was an intervention reserved for individuals deemed high-risk for surgery. Since that time, TAVR has increasingly been offered to lower risk patients, yet it is unclear whether TAVR will meet an acceptable cost-effectiveness threshold in this group. In this cost-effectiveness study, we employed a decision tree model with Monte Carlo probability sensitivity analysis to determine the incremental cost (in US$) per quality-adjusted life year (QALY) and life year (LY) of performing the TAVR procedure using the resource-intensive approach versus the minimally invasive strategy in high-risk surgical patients.

Using Time-Driven Activity-Based Costing as a Key Component of the Value Platform: A Pilot Analysis of Colonoscopy, Aortic Valve Replacement and Carpal Tunnel Release Procedures.

BACKGROUND: Time-driven activity-based costing (TDABC) is a methodology that calculates the costs of healthcare resources consumed as a patient moves along a care process. Limited data exist on the application of TDABC from the perspective of an anesthesia provider. We describe the use of TDABC, a bottom-up costing strategy and financial outcomes for three different medical-surgical procedures. METHODS: In each case, a multi-disciplinary team created process maps describing the care delivery cycle for a patient encounter using the TDABC methodology. Each step in a process map delineated an activity required for delivery of patient care. The resources (personnel, equipment and supplies) associated with each step were identified. A per minute cost for each resource expended was generated, known as the capacity cost rate, and multiplied by its time requirement. The total cost for an episode of care was obtained by adding the cost of each individual resource consumed as the patient moved along a clinical pathway. RESULTS: We built process maps for colonoscopy in the gastroenterology suite, calculated costs of an aortic valve replacement by comparing surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) techniques, and determined the cost of carpal tunnel release in an operating room versus an ambulatory procedure room. CONCLUSIONS: TDABC is central to the value-based healthcare platform. Application of TDABC provides a framework to identify process improvements for health care delivery. The first case demonstrates cost-savings and improved wait times by shifting some of the colonoscopies scheduled with an anesthesiologist from the main hospital to the ambulatory facility. In the second case, we show that the deployment of an aortic valve via the transcatheter route front loads the costs compared to traditional, surgical replacement. The last case demonstrates significant cost savings to the healthcare system associated with re-organization of staff required to execute a carpal tunnel release.

The July Spike in Operating Room Management: Reality or Perception?

Background Some research has found increased incidence of medical errors in teaching hospitals at the beginning of the academic year and have termed this the "July Phenomenon." Objective Our primary hypothesis was that the "July Phenomenon" for anesthesiology and surgical residents might manifest itself as operational inefficiency, measured by monthly total operating room (OR) minutes. Secondary measures were monthly elective overutilized minutes (OR workload minus OR allocated time, after 5:30 pm at our institution), 80th percentile number of ORs running at 7:00 pm, and mean last room end time. Methods Data were collected retrospectively from a 525-bed academic tertiary care hospital from January 2010 to September 2014 and were deconstructed to assess for a seasonal component using local regression (Loess). Variable month length was addressed by transforming the monthly totals to average daily minutes and overutilized minutes. Linear regression quantified significance for all primary and secondary analyses. Results In the regressions, monthly average minutes showed no significant difference in July (P = .65) compared to the baseline month of April. There were no significant differences for any month for overutilized minutes or 80th percentile number ORs working at 7:00 pm. Only August was significant (P = .005) for mean last room end time. Conclusions Data from a single institution study did not show a "July Phenomenon" in the number of operating minutes, overutilized minutes, or the number of ORs working late in July.