A Safe Transitions Pathway for post-craniotomy neurological surgery patients: high-value care that bypasses the intensive care unit.

OBJECTIVE: High-value medical care is described as care that leads to excellent patient outcomes, high patient satisfaction, and efficient costs. Neurosurgical care in particular can be expensive for the hospital, as substantial costs are accrued during the operation and throughout the postoperative stay. The authors developed a "Safe Transitions Pathway" (STP) model in which select patients went to the postanesthesia care unit (PACU) and then the neuro-transitional care unit (NTCU) rather than being directly admitted to the neurosciences intensive care unit (ICU) following a craniotomy. They sought to evaluate the clinical and financial outcomes as well as the impact on the patient experience for patients who participated in the STP and bypassed the ICU level of care. METHODS: Patients were enrolled during the 2018 fiscal year (FY18; July 1, 2017, through June 30, 2018). The electronic medical record was reviewed for clinical information and the hospital cost accounting record was reviewed for financial information. Nurses and patients were given a satisfaction survey to assess their respective impressions of the hospital stay and of the recovery pathway. RESULTS: No patients who proceeded to the NTCU postoperatively were upgraded to the ICU level of care postoperatively. There were no deaths in the STP group, and no patients required a return to the operating room during their hospitalization (95% CI 0%-3.9%). There was a trend toward fewer 30-day readmissions in the STP patients than in the standard pathway patients (1.2% [95% CI 0.0%-6.8%] vs 5.1% [95% CI 2.5%-9.1%], p = 0.058). The mean number of ICU days saved per case was 1.20. The average postprocedure length of stay was reduced by 0.25 days for STP patients. Actual FY18 direct cost savings from 94 patients who went through the STP was $422,128. CONCLUSIONS: Length of stay, direct cost per case, and ICU days were significantly less after the adoption of the STP, and ICU bed utilization was freed for acute admissions and transfers. There were no substantial complications or adverse patient outcomes in the STP group.

Effect of postoperative partial bladder filling after minimally invasive hysterectomy on postanesthesia care unit discharge and cost: a single-blinded, randomized controlled trial.

BACKGROUND: Hysterectomy is one of the most common surgical procedures performed each year with substantial related health care costs. This trial studied the effect of postoperative bladder backfilling to submicturition level in the operating room and its effect on early postoperative patient care and related cost. OBJECTIVE: The objective of the study was to compare the effect of bladder backfilling on early postoperative patient care and related cost. STUDY DESIGN: This was a randomized, single-blinded, controlled trial conducted between April 2016 and February 2017 at a single urban university hospital providing tertiary care for minimally invasive gynecologic surgery. Ninety-one patients undergoing straight-stick laparoscopic and robot-assisted hysterectomy by minimally invasive gynecologic surgeons for benign indications were recruited. The bladder was partially backfilled with 150 mL of normal saline postoperatively in the intervention group and drained in the control group, as per standard of care. Main outcomes studied were time needed to void, time spent in the postanesthesia care unit, and postanesthesia care unit cost after minimally invasive hysterectomy. Our secondary outcomes were postoperative complications. RESULTS: Forty-six patients (50.5%) were randomized to the intervention group, and 45 patients (49.5%) to the control group. Baseline comparative analysis of demographics and preoperative patient-specific variables, surgical history, intraoperative characteristics, and administered medications found the 2 groups to be largely homogenous. After regression analyses for adjustment, we found a significant reduction in the time needed to void, time spent in the postanesthesia care unit, and postanesthesia care unit-associated cost in the intervention group. Patients voided 64.9 minutes earlier than the control group (P = .015) ans spent 64 fewer minutes in the postanesthesia care unit (P = .006), resulting in $401.5 (USD) saving per patient (P = .006). None of the patients encountered any postoperative complications. CONCLUSION: Based on the findings of this randomized clinical trial, postoperative bladder backfilling to submicturition level shortens the time needed for patients to void in the postanesthesia care unit, resulting in shorter postanesthesia care unit stay and resultant cost savings. Conservatively projecting our findings on minimally invasive hysterectomy procedure is estimated to result in $69 million to $139 million (USD) per year in savings. Initiating similar investigations in other ambulatory surgical fields will likely result in a more substantial impact.

Improving the efficiency of the operating room environment with an optimization and machine learning model.

The operating room is a major cost and revenue center for most hospitals. Thus, more effective operating room management and scheduling can provide significant benefits. In many hospitals, the post-anesthesia care unit (PACU), where patients recover after their surgical procedures, is a bottleneck. If the PACU reaches capacity, patients must wait in the operating room until the PACU has available space, leading to delays and possible cancellations for subsequent operating room procedures. We develop a generalizable optimization and machine learning approach to sequence operating room procedures to minimize delays caused by PACU unavailability. Specifically, we use machine learning to estimate the required PACU time for each type of surgical procedure, we develop and solve two integer programming models to schedule procedures in the operating rooms to minimize maximum PACU occupancy, and we use discrete event simulation to compare our optimized schedule to the existing schedule. Using data from Lucile Packard Children's Hospital Stanford, we show that the scheduling system can significantly reduce operating room delays caused by PACU congestion while still keeping operating room utilization high: simulation of the second half of 2016 shows that our model could have reduced total PACU holds by 76% without decreasing operating room utilization. We are currently working on implementing the scheduling system at the hospital.

Preoperative and Intraoperative Predictive Factors of Immediate Extubation After Neonatal Cardiac Surgery.

BACKGROUND: We sought to identify preoperative and intraoperative predictors of immediate extubation (IE) after open heart surgery in neonates. The effect of IE on the postoperative intensive care unit (ICU) length of stay (LOS), cost of postoperative ICU care, operating room turnover, and reintubation rates was assessed. METHODS: Patients younger than 31 days who underwent cardiac surgery with cardiopulmonary bypass (January 2010 to December 2013) at a tertiary-care children's hospital were studied. Immediate extubation was defined as successful extubation before termination of anesthetic care. Data on preoperative and intraoperative variables were compared using descriptive, bivariate, and multivariate statistics to identify the predictors of IE. Propensity scores were used to assess effects of IE on ICU LOS, the cost of ICU care, reintubation rates, and operating room turnover time. RESULTS: One hundred forty-eight procedures done at a median age of 7 days resulted in 45 IEs (30.4%). The IE rate was 22.2% with single-ventricle heart disease. Independent predictors of IE were the absence of the need for preoperative ventilatory assistance, higher gestational age, anesthesiologist, and shorter cardiopulmonary bypass. Immediate extubation was associated with shorter ICU LOS (8.3 versus 12.7 days; p < 0.0001) and lower cost of ICU care (mean postoperative ICU charges, $157,449 versus $198,197; p < 0.0001) with no significant difference in the probability of reintubation (p = 0.7). Immediate extubation was associated with longer operating room turnover time (38.4 versus 46.7 minutes; p = 0.009). CONCLUSIONS: Immediate extubation was accomplished in 30.4% of neonates undergoing open heart surgery involving cardiopulmonary bypass. Immediate extubation was associated with lesser ICU LOS, postoperative ICU costs, and minimal increase in operating room turnover time, but without an increase in reintubation rates. Low gestational age, preoperative ventilatory support requirement, and prolonged cardiopulmonary bypass time were inversely associated with the ability to accomplish IE.

Cost-analysis of robotic-assisted laparoscopic hysterectomy versus total abdominal hysterectomy for women with endometrial cancer and atypical complex hyperplasia.

INTRODUCTION: The aim of this study was to analyse the hospital cost of treatment with robotic-assisted laparoscopic hysterectomy and total abdominal hysterectomy for women with endometrial cancer or atypical complex hyperplasia and to identify differences in resource use and cost. MATERIAL AND METHODS: This cost analysis was based on two cohorts: women treated with robotic-assisted laparoscopic hysterectomy (n = 202) or with total abdominal hysterectomy (n = 158) at Copenhagen University Hospital, Herlev, Denmark. We conducted an activity-based cost analysis including consumables and healthcare professionals' salaries. As cost-drivers we included severe complications, duration of surgery, anesthesia and stay at the post-anesthetic care unit, as well as number of hospital bed-days. Ordinary least-squares regression was used to explore the cost variation. The primary outcome was cost difference in Danish kroner between total abdominal hysterectomy and robotic-assisted laparoscopic hysterectomy. RESULTS: The average cost of consumables was 12,642 Danish kroner more expensive per patient for robotic-assisted laparoscopic hysterectomy than for total abdominal hysterectomy (2014 price level: 1€ = 7.50 Danish kroner). When including all cost-drivers, the analysis showed that the robotic-assisted laparoscopic hysterectomy procedure was 9386 Danish kroner (17%) cheaper than the total abdominal hysterectomy (p = 0.003). When the robot investment was included, the cost difference reduced to 4053 Danish kroner (robotic-assisted laparoscopic hysterectomy was 7% cheaper than total abdominal hysterectomy) (p = 0.20). Increasing age and Type 2 diabetes appeared to influence the overall costs. CONCLUSION: For women with endometrial cancer or atypical complex hyperplasia, robotic-assisted laparoscopic hysterectomy was cheaper than total abdominal hysterectomy, mostly due to fewer complications and shorter length of hospital stay.

Example of cost calculations for an operating room and a post-anaesthesia care unit.

OBJECTIVE: The aim of this study was to evaluate the cost of an operating room using data from our hospital. Using an accounting-based method helped us. METHODS: Over the year 2012, the sum of direct and indirect expenses with cost sharing expenses allowed us to calculate the cost of the operating room (OR) and of the post-anaesthesia care unit (PACU). RESULTS: The cost of the OR and PACU was €10.8 per minute of time offered. Two thirds of the direct expenses were allocated to surgery and one third to anaesthesia. Indirect expenses were 25% of the direct expenses. The cost of medications and single use medical devises was €111.45 per anaesthesia. The total cost of anaesthesia (taking into account wages and indirect expenses) was €753.14 per anaesthesia as compared to the total cost of the anaesthesia. The part of medications and single use devices for anaesthesia was 14.8% of the total cost. CONCLUSION: Despite the difficulties facing cost evaluation, this model of calculation, assisted by the cost accounting controller, helped us to have a concrete financial vision. It also shows that a global reflexion is necessary during financial decision-making.

A clinical and economic evaluation of fast-track recovery after cardiac surgery.

BACKGROUND: In the last 5 decades, the care of cardiac surgical patients has improved with the aid of strategies aimed at facilitating patient recovery. One of the innovations in this context is "fast-tracking" or "rapid recovery." This process refers to all interventions that aim to shorten a patient's stay in the intensive care unit (ICU) through accelerating the patient's transfer to a step-down or telemetry unit and to the general ward. METHODS: Patients were allocated to 2 groups. The fast-track group (n = 84) went through an independent theatre recovery unit (TRU). The patients were then transferred on the same day to an intermediate care unit and transferred on the following day to the ward. The intensive care group (52 patients) went to the ICU for at least 1 day, after which they were transferred to the ward. RESULTS AND DISCUSSION: The fast-track pathway significantly reduced the length of stay (LOS) in an intensive care facility (P < .001). The duration of intubation was reduced from a median of 4.08 hours (range, 1.17-13.17 hours) in the intensive care group to 2.75 hours (range, 0.25-18.57 hours) in the fast-track group (P < .001). However, the median values for total hospital LOS, incidences of complications, reintubation, and readmission were similar for the 2 groups. The incidence of failure in the fast-track group was 10%. The mean (SD) cost of the perioperative care was £4182 ± £2284 ($6683 ± 3650) for the fast-track patients, compared with £4553 ± £1355 ($7277 ± $2165) for the intensive care group. CONCLUSION: Fast-track recovery after cardiac surgery decreases the intensive care LOS and the total duration of intubation. It is a cost-effective strategy compared with conventional recovery protocols; however, it does not reduce the total hospital LOS or the incidence of complications.

Cost-effectiveness of the radial versus femoral artery approach to diagnostic cardiac catheterization.

BACKGROUND: The radial approach to cardiac catheterization is increasingly popular due to shorter procedural and recovery times and greater patient comfort. METHODS: Comparative cost analysis between radial or femoral (with or without closure device) approaches were performed. RESULTS: Radial (R), femoral (F), and femoral with a closure device (F +/- C) approaches were used in 70, 62 and 49 consecutive cases, respectively. Group R had higher access equipment cost (93.0 dollars +/- 9.5 vs. 40.5 dollars) in group F (p < 0.001), but lower catheter cost (19.7 dollars +/- 12.7 vs. 31.1 dollars +/- 9.3; p < 0.001) than Group F, and lower contrast cost (26.9 dollars +/- 17.0 vs. 42.9 dollars +/- 25.0) in Group F +/- C (p < 0.001). There was a lower postprocedure recovery cost (185.2 dollars +/- 52.7) in Group R compared to 337.5 dollars +/- 59.0 in Group F (p < 0.001) and 208 dollars +/- 70.4 in Group F +/- C (p < 0.001), with a median recovery time of 126.0 +/- 36.0 minutes in group R vs. 240.0 +/- 42.0 minutes, and 150.0 +/- 48.0 minutes in groups F and F +/- C, respectively (both p < 0.05). The total variable procedural cost, which includes approach-dependent equipment and recovery room stay, was significantly lower in the Radial group than in the Femoral group (369.5 dollars +/- 74.6 vs. 446.9 dollars +/- 60.2 and 553.4 dollars +/- 81.0; p < 0.001). CONCLUSION: The radial artery approach to diagnostic cardiac catheterization is clearly more cost effective than the femoral approach, with or without the use of a femoral closure device.

Financial and operational impact of a direct-from-PACU discharge pathway for laparoscopic cholecystectomy patients.

BACKGROUND: We assessed the operational and financial impact of discharging laparoscopic cholecystectomy (LC) patients directly from the postanesthetic care unit (PACU) in comparison with post-transfer discharge from a hospital bed in a busy academic hospital. METHODS: We retrospectively compared 6 months of performance (bed utilization; recovery room and hospital length of stay; complications; readmissions; hospital costs, revenue, and margin) after implementation of PACU discharges (case patients) to the corresponding 6 months in the prior year (control patients). RESULTS: After implementation, 66% of LC case patients were discharged on the day of surgery, compared with 29% in the control group (P < .05). Eighty percent of the day-of-surgery discharges were directly from the PACU. Shifting to PACU discharge saved 1 in-hospital bed transfer and 1 bed-day for each PACU discharge. Recovery room length of stay for PACU discharge patients was 26% longer than for hospital discharge patients (P = NS). Average hospital length of stay for all patients discharged on the day of surgery was 3.2 hours shorter (P < .05) for case patients (80% PACU discharge) than for control patients. There were no readmissions in the PACU discharge group and no difference in complications. While costs, revenue, and net margin for PACU discharge patients were reduced by 40% to 50% (P < .02) relative to floor discharge patients, the hospital's net margin for the combined case patient group was preserved relative to the control group. CONCLUSIONS: PACU discharge of LC patients significantly reduces bed utilization, decreases in-hospital transfers, and allows congested hospitals to better accommodate patient care needs and generate additional revenue.

Use of a remifentanil and propofol combination in outpatients to facilitate rapid discharge home.

The goal of our study was to evaluate whether the combination of remifentanil and propofol facilitated shorter recovery time and decreased charges compared with conventional balanced anesthesia. We studied 49 patients, aged 13 to 75 years, who underwent elective outpatient surgery. All data were analyzed using the Pearson chi2 and the Student t test; results were considered statistically significant at a P value of.05 or less. Group 1 received a remifentanil-propofol combination and group 2, a conventional balanced anesthetic. Group 1 had decreased mean operating room (dollar 280.83 vs dollar 337.42; P = .05) and operating room plus postanesthesia care unit (PACU) (dollar 442.67 vs dollar 544.62) charges (P = .02). Group 1 had less PACU time (48.26 vs 59.62 minutes) and 2 group 1 patients bypassed the PACU. We conclude that a remifentanil-propofol combination is more cost effective than conventional balanced anesthetics and enables some patients to bypass the PACU, resulting in quicker discharge. Our findings have important implications for ambulatory surgery centers and office-based practices.

Reduction of anesthesia process times after the introduction of an internal transfer pricing system for anesthesia services.

To improve operating room workflow, an internal transfer pricing system (ITPS) for anesthesia services was introduced in our hospital in 2001. The basic principle of the ITPS is that the department of anesthesia receives reimbursement only for the surgically controlled time, not for anesthesia-controlled time (ACT). A reduction in anesthesia process times is therefore beneficial for the anesthesia department. In this study, we analyzed the ACT (with its parts: preparation before induction, induction, extubation, and recovery room transfer) for 3 yr before and 3 yr after the introduction of the ITPS in 55,776 cases. Furthermore, the anesthesia cases were subsegmented into 10 different anesthesia techniques, and the process times were studied. The average total ACT was reduced from 40.4 +/- 23.5 min in 1998 to 34.3 +/- 21.7 min in 2003. The main effect came from reductions in anesthesia preparation time and recovery room transfer time, whereas induction and extubation time changed little. A significant reduction in average ACT was seen in 7 of 10 analyzed anesthesia techniques, ranging from 4 to 18 min. We conclude that transfer pricing of anesthesia services based on the surgically controlled time can be a successful approach to reduce anesthesia process times.

A retrospective comparison of costs for regional and general anesthesia techniques.

In this retrospective study, we compared the costs for three different regional anesthesia techniques with the costs of general anesthesia (GA). A total of 1587 anesthesia cases which were performed for orthopedic and trauma patients over a 1-yr period in a tertiary level, university hospital setting were analyzed. The anesthesia technique-related costs were determined calculating case-specific costs for personnel, supplies, and drugs. The techniques were compared on the basis of anesthesia costs and surgical procedure duration. As a result, we found that the costs per surgical minute largely depend on the surgical procedure duration. Based on the regression function, the cost advantage of spinal anesthesia over GA can be estimated to be 13% for a 50-min case, 9% for a 100-min case, and 5% for a 200-min case. The cost disadvantage of brachial plexus anesthesia over GA can be estimated to be 19% for a 50-min case, 8% in a 100-min case, and 1% for a 200-min case. We found no difference in costs between epidural and GA. We concluded that cost comparisons of anesthesia techniques largely depend on the surgical duration of the cases studied. Even in a teaching hospital setting, spinal anesthesia has economic advantages over GA. Especially for short cases, brachial plexus block is more expensive in this setting.

The reduction in hospital stay and costs in the care of patients with congenital heart diseases undergoing fast-track cardiac surgery.

OBJECTIVE: To assess the care provided to patients with congenital heart diseases and ischemic heart diseases undergoing cardiac surgery according to the fast-track recovery protocol compared with those undergoing the conventional procedure. METHODS: The transfer of patients from one hospital unit to another was assessed for 175 patients, 107 (61%) men and 68 (39%) women, with ages ranging from 0.3 to 81 years. RESULTS: The discharge rate from the different hospital units per unit of time of the patients with congenital heart diseases treated according to the fast-track recovery protocol compared with that of patients conventionally treated was as follows: a) 11.3 times faster than the discharge rate of patients treated according to the conventional protocol, in regard to the time spent in the operating room; b) 6.3 times faster in regard to the duration of the surgical intervention; c) 6.8 times faster in regard to the duration of anesthesia; d) 1.5 times faster in regard to the duration of perfusion; e) 2.8 times faster in regard to the stay in the postoperative recovery I unit; f) 6.7 times faster in regard to hospital stay (time period between hospital admission and hospital discharge); g) 2.8 times faster in regard to the stay in the preoperative unit; h) 2.1 times faster in regard to the stay in the admission unit after discharge from postoperative recovery; i) associated with reduced costs. The difference was not significant for patients with ischemic heart disease. CONCLUSION: A reduction in the length of hospital stay and costs for the care of patients undergoing cardiac surgery according to the fast-track protocol was observed.

Redução do período de internação e de despesas no atendimento de portadores de cardiopatias congênitas submetidos à intervenção cirúrgica cardíaca no protocolo da via rápida / The reduction in hospital stay and costs in the care of patients with congenital heart diseases undergoing fast-track cardiac surgery

OBJETIVO: Avaliar o atendimento de cardiopatas congênitos e cardiopatas isquêmicos submetidos à cirurgia cardíaca no protocolo de atendimento na via rápida (fast-track recovery) em relação ao convencional. MÉTODOS: Avaliada a movimentação de 175 pacientes, 107 (61 por cento) homens e 68 (39 por cento) mulheres, idades entre 0,3-81 anos nas diferentes unidades hospitalares. RESULTADOS: A taxa de alta das diferentes unidades hospitalares por unidade de tempo, dos cardiopatas congênitos atendidos no protocolo da via rápida em relação ao convencional foi: a) 11,3 vezes a taxa de alta quando assistidos no protocolo da via convencional, quanto ao tempo de permanência no centro cirúrgico; b) 6,3 vezes quanto à duração da intervenção cirúrgica; c) 6,8 vezes quanto à duração da anestesia; d) 1,5 vezes quanto à duração da perfusão; e) 2,8 vezes quanto à permanência na unidade de recuperação pós-operatória I; f) 6,7 vezes quanto à permanência no hospital (período de tempo entre a data da internação e a data da alta); g) 2,8 vezes quanto à permanência na unidade de internação pré-operatória; h) 2,1 vezes quanto à permanência na unidade de internação após a alta da recuperação pós-operatória; i) associada com redução de despesas pré e pós-operatórias. A diferença não foi significativa nos portadores de cardiopatia isquêmica. CONCLUSAO: Verificou-se redução do período de internação e de despesas no atendimento dos pacientes submetidos à intervenção cirúrgica cardíaca no protocolo da via rápida.

Economics of nerve block pain management after anterior cruciate ligament reconstruction: potential hospital cost savings via associated postanesthesia care unit bypass and same-day discharge.

BACKGROUND: Anterior cruciate ligament reconstruction is a complex outpatient surgical procedure often associated with pain. Traditionally, the procedure is performed under general anesthesia and often requires the use of the PACU. Refractory pain and/or nausea/vomiting occasionally leads to an unplanned hospital admission. In this study, the authors examine the associations of nerve block analgesia for these patients and its associated reductions in PACU use, hospital admission, and hospital costs. METHODS: This was an observational, nonrandomized study in which existing data regarding patients' day-of-surgery outcomes were merged with hospital cost data. We reviewed a consecutive sample of 948 men and women who were in good health and underwent anterior cruciate ligament reconstruction in an outpatient surgery unit between July 1995 and June 1999. RESULTS: The use of nerve block analgesia was associated with reduced PACU admissions to 18% and decreased unplanned hospital admission rates from 17% to 4%. Multivariate linear regression analysis showed that patients bypassing the PACU had an associated hospital cost reduction of 12% (P = 0.0001), whereas patients who needed hospital admission had an associated hospital cost increase of 11% (P = 0.0003). CONCLUSIONS: The use of nerve blocks for acute pain management in patients undergoing anterior cruciate ligament reconstruction is associated with PACU bypass and reliable same-day discharge. Although the cost savings for this one procedure are unlikely to generate sufficient cost savings via staffing reductions, extrapolating these results to a large volume of all types of invasive outpatient orthopedic procedures may have the potential to create significant hospital cost savings.

Fast-track eligibility, costs and quality of recovery after intravenous anaesthesia with propofol-remifentanil versus balanced anaesthesia with isoflurane-alfentanil.

BACKGROUND AND OBJECTIVE: The randomized, patient- and observer-blinded study was performed in 120 patients undergoing ear, nose and throat surgery to test the hypothesis that intravenous anaesthesia with propofol-remifentanil when compared with a balanced anaesthesia technique using isoflurane-alfentanil improves the speed of recovery, minimizes postoperative side-effects and, thus, leads to an improved quality of recovery without increasing total costs. METHODS: The total costs for each anaesthesia technique were calculated considering drug acquisition costs, personnel costs for the additional time spent in the operating room and the postanaesthesia care unit until fast-tracking eligibility, and the costs to treat the side-effects during and after operation. RESULTS: The times from the end of surgery to tracheal extubation and the time until leaving the operating room were not different between the two groups. However, more patients receiving intravenous anaesthesia (80 versus 49%) were eligible for fast tracking and thus could bypass the recovery room. This was associated with an average cost saving of 6.00 euros per patient. However, intravenous anaesthesia was associated with higher total costs (89 euros versus 78 euros) mainly because of higher acquisition costs of the anaesthetics (34.60 euros versus 16.50 euros). There was no difference in the quality of recovery as measured by a Quality of Recovery score and patient satisfaction between the two groups. CONCLUSIONS: The higher acquisition costs of the intravenous anaesthetics propofol and remifentanil cannot be compensated for by improved speed of recovery. This anaesthesia technique is more cost intensive than balanced anaesthesia using isoflurane and alfentanil.

[Relative anesthesia-cost for laparoscopic cholecystectomy: fairly low]. / Le coût relatif de l'anesthésie pour la cholécystectomie laparoscopique est peu élevé.

PURPOSE: The relative contribution of anesthesia costs to total perioperative costs is not known precisely. The goal of this prospective study was to measure the proportion of anesthesia costs relative to total hospital costs of elective laparoscopic cholecystectomy (LC) for in-patients. METHODS: With Institutional approval, the total hospital costs of elective LC for 62 ASA I-III patients were analyzed. All direct and indirect variable costs, including salaries of anesthesia and surgery teams, were obtained for each patient. Data are expressed as mean +/- SEM. RESULTS: Intraoperative anesthesia costs as a percentage of the total hospital costs equaled 10.5 +/- 0.3%. Postanesthesia care unit (PACU) cost was 3.1 +/- 0.2%. The largest hospital cost category was the operating room with 37.4 +/- 0.6%. The costs attributed to the ward equaled 31.3 +/- 3%. Other costs were generated by radiology (6.2 +/- 1.1%), laboratory (5.4 +/- 0.7%), admission unit (3.4 +/- 0.2%), pharmacy (2.0 +/- 0.4%) and administration (0.7 +/- 0.1%). CONCLUSION: Even if salaries are included, anesthesia and PACU costs (13.6%) represent a small portion only of total hospital costs. Cost savings thus may result from improving operating room efficiency and shortening of hospitalisation rather than programs aiming at lowering anesthesia costs.

Nasoalveolar molding and gingivoperiosteoplasty versus alveolar bone graft: an outcome analysis of costs in the treatment of unilateral cleft alveolus.

OBJECTIVE: The purpose of this study was to compare the financial impact of two treatment approaches to the unilateral cleft alveolus. The recently advocated nasoalveolar molding (NAM; and gingivoperiosteoplasty (GPP; at the time of lip repair were compared with the traditional approach of secondary alveolar bone graft. DESIGN: The records of all patients (n = 30) with unilateral cleft lip and alveolus treated by a single surgeon during 1985 through 1988 were examined retrospectively. The patients were divided into two groups: group 1 patients (n = 14) were treated by lip repair, primary nasal repair, and secondary alveolar bone graft prior to eruption of permanent dentition; group 2 patients (n = 16) were treated by NAM, GPP, lip repair, and primary nasal repair. Patients who required secondary alveolar bone graft after GPP were noted. The cost of treatment by each protocol was calculated in 1998 dollars. RESULTS: The average cost of treatment for a patient treated by lip repair, primary nasal repair, and secondary alveolar bone graft prior to eruption of permanent dentition was $22,744. Of the 16 patients treated by NAM, GPP, lip repair, and primary nasal repair, 10 required no further treatment of the unilateral cleft alveolus; six patients required secondary alveolar bone graft. The average per-patient treatment cost in this group was $19,745. The average cost savings of NAM and GPP, compared with alveolar bone graft is $2999. CONCLUSIONS: The treatment of unilateral cleft alveolus by nasoalveolar molding and gingivoperiosteoplasty results in substantial cost savings, compared with treatment by secondary alveolar bone graft.

A pilot study of recovery room bypass ("fast-track protocol") in a community hospital.

PURPOSE: To evaluate the effectiveness of short-acting anesthetic drugs and techniques to achieve recovery room bypass criteria after minor surgery in a community hospital environment. METHODS: After agreement by a multidisciplinary committee, a pilot project was undertaken to assess the usefulness of ultra- short acting anesthetic drugs and pre-emptive analgesia to facilitate rapid recovery from general anesthesia. A cohort of 100 ASA I-II patients aged 18-65 yr undergoing simple knee arthroscopy or minor peripheral orthopedic procedures was compared to a similar cohort treated in the three months prior to the study period. Outcomes of interest included patient morbidity, success in achieving post-anesthesia care unit (PACU) bypass criteria, impact upon nursing resources, duration of operating room (OR) and hospital stay, and pharmaceutical costs before and after implementation. RESULTS: No patient morbidity was demonstrated prior to discharge home, and successful PACU bypass occurred in 83% of cases. Achievement of PACU discharge criteria while in the OR did not prolong the OR time, and discharge from hospital occurred earlier in the patients who did not require PACU care (P=0.0006 all "fast-track cases" vs all "controls"). Nursing complaints were more numerous when the day surgery personnel did not normally participate in PACU care. The cost of anesthetic care was significantly more using ultra-short acting drugs (CDN $14.17 vs CDN $20.57), but closer adherence to protocol could reduce this differential (CDN $18.84). CONCLUSION: Not all patients who receive a general anesthetic require admission to a phase I recovery facility. However, the justification for use of more expensive pharmaceuticals to achieve PACU bypass requires extensive changes in operating systems and voluntary professional behaviours.