Understanding and Managing Direct Operating Room Supply Costs in Cardiac Surgery.

BACKGROUND: Value-based bundles require surgeons to understand their costs. Current approaches to cost reporting are confusing and difficult to reproduce. Using the Epic surgical receipt function, we describe an intuitive and systematic approach for evaluating financial data within the operating room. METHODS: We conducted a retrospective review of all congenital cardiac procedures performed at a single academic medical center between January 1, 2020, and January 1, 2021. Direct operating room supply costs were obtained using the Epic surgical receipt function. Costs were analyzed on the basis of contribution to total annual cost and variability in case cost. Implications for strategies identified within congenital cardiac surgery were then evaluated in adult cardiac surgery. RESULTS: Five procedures representing 71 patients accounted for more than 50% of the total direct operating room supply costs (left ventricular assist device, Norwood procedure, pulmonary valve replacement, right ventricle-to-pulmonary artery shunt, and aortic arch augmentation). Disposable vascular clips, suture brand preference, and surgical patch materials accounted for 3.7%, 6.6%, and 26.5% of annual direct operating room supply costs, respectively. Improvements to these categories would represent 12% to 14% ($250 000) in annual savings without an anticipated effect on outcomes. Across adult and congenital cardiac surgery, 95% of all name-brand suture use was tied to preference cards. An opt-in vs default approach to name-brand polypropylene suture could save more than $250 000 annually. CONCLUSIONS: The surgical receipt represents a reliable and intuitive way for reporting surgical costs. Systematically analyzing costs and their impact on outcomes will help surgeons improve the value of care they provide.

Insurance status predicts acuity of thoracic aortic operations.

OBJECTIVE: Nonelective case status is the strongest predictor of mortality for thoracic aortic operations. We hypothesized that underinsured patients were more likely to require nonelective thoracic aortic surgery because of reduced access to preventative cardiovascular care and elective surgical services. METHODS: Between June 2005 and August 2011, 826 patients were admitted to a single aortic referral center and underwent 1 or more thoracic aortic operations. Patients with private insurance or Medicare (insured group, n=736; 89%) were compared with those with Medicaid or no insurance (underinsured group, n=90; 11%). RESULTS: The proportion of patients requiring nonelective surgery was higher for underinsured than insured patients (56% vs 26%, P<.0001). Multivariable analysis revealed underinsurance to be the strongest independent predictor of nonelective case status (odds ratio [OR], 2.67; P<.0001). Preoperative use of lipid-lowering medications (OR, 0.63; P<.009) or a history of aortic surgery (OR, 0.48; P<.001) was associated with a decreased risk of nonelective operation. However, after adjustment for differences in preoperative characteristics and case status, underinsurance did not confer an increased risk of procedural morbidity or mortality (adjusted OR, 0.94; P=.83) or late death (adjusted hazard ratio, 0.83, P=.58) when compared with insured patients. CONCLUSIONS: Underinsured patients were at the greatest risk of requiring nonelective thoracic aortic operation, possibly because of decreased use of lipid-lowering therapies and aortic surveillance. These data imply that greater access to preventative cardiovascular care may reduce the need for nonelective thoracic aortic surgery and lead to improved survival from thoracic aortic disease.

Insurance status is associated with acuity of presentation and outcomes for thoracic aortic operations.

BACKGROUND: Nonelective procedure status is the greatest risk factor for postoperative morbidity and mortality in patients undergoing thoracic aortic operations. We hypothesized that uninsured patients were more likely to require nonelective thoracic aortic operation due to decreased access to preventative care and elective surgical services. METHODS AND RESULTS: An observational study of the Society of Thoracic Surgeons Database identified 51 282 patients who underwent thoracic aortic surgery between 2007 and 2011 at 940 North American centers. Patients were stratified by insurance status (private insurance, Medicare, Medicaid, other insurance, or uninsured) as well as age <65 or ≥65 years to account for differences in Medicare eligibility. The need for nonelective thoracic aortic operation was highest for uninsured patients (71.7%) and lowest for privately insured patients (36.6%). The adjusted risks of nonelective operation were increased for uninsured patients (adjusted risk ratio, 1.77; 95% confidence interval, 1.70-1.83 for age <65 years; adjusted risk ratio, 1.46; 95% confidence interval, 1.29-1.62 for age ≥65 years) as well as Medicaid patients aged <65 years (adjusted risk ratio, 1.18; 95% confidence interval, 1.10-1.26) when compared with patients with private insurance. The adjusted risks of major morbidity or mortality were further increased for all patients aged <65 years without private insurance (adjusted risk ratios between 1.13 and 1.27). CONCLUSIONS: Insurance status was associated with acuity of presentation and major morbidity and mortality for thoracic aortic operations. Efforts to reduce insurance-based disparities in the care of patients with thoracic aortic disease seem warranted and may reduce the incidence of aortic emergencies and improve outcomes after thoracic aortic surgery.

Intraoperative use of low-dose recombinant activated factor VII during thoracic aortic operations.

BACKGROUND: Numerous studies have supported the effectiveness of recombinant activated factor VII (rFVIIa) for the control of bleeding after cardiac procedures; however safety concerns persist. Here we report the novel use of intraoperative low-dose rFVIIa in thoracic aortic operations, a strategy intended to improve safety by minimizing rFVIIa exposure. METHODS: Between July 2005 and December 2010, 425 consecutive patients at a single referral center underwent thoracic aortic operations with cardiopulmonary bypass (CPB); 77 of these patients received intraoperative low-dose rFVIIa (≤60 µg/kg) for severe coagulopathy after CPB. Propensity matching produced a cohort of 88 patients (44 received intraoperative low-dose rFVIIa and 44 controls) for comparison. RESULTS: Matched patients receiving intraoperative low-dose rFVIIa got an initial median dose of 32 µg/kg (interquartile range [IQR], 16-43 µg/kg) rFVIIa given 51 minutes (42-67 minutes) after separation from CPB. Patients receiving intraoperative low-dose rFVIIa demonstrated improved postoperative coagulation measurements (partial thromboplastin time 28.6 versus 31.5 seconds; p=0.05; international normalized ratio, 0.8 versus 1.2; p<0.0001) and received 50% fewer postoperative blood product transfusions (2.5 versus 5.0 units; p=0.05) compared with control patients. No patient receiving intraoperative low-dose rFVIIa required postoperative rFVIIa administration or reexploration for bleeding. Rates of stroke, thromboembolism, myocardial infarction, and other adverse events were equivalent between groups. CONCLUSIONS: Intraoperative low-dose rFVIIa led to improved postoperative hemostasis with no apparent increase in adverse events. Intraoperative rFVIIa administration in appropriately selected patients may correct coagulopathy early in the course of refractory blood loss and lead to improved safety through the use of smaller rFVIIa doses. Appropriately powered randomized studies are necessary to confirm the safety and efficacy of this approach.