REDUCTION OF HOSPITAL RESOURCES UTILIZATION IN VASCULAR-SURGERY - A 4-YEAR EXPERIENCE

Purpose: Managed care whether through risk or through capitated contra cts results in reduction in resources, reduced length of hospital stay , and reduced utilization of hospital resources (collectively referred to as resource reductions). These resource reductions will become eve n more noticeable as a greater proportion of Medicare patients who nee d vascular operations select a managed-care senior product. We examine d the results of a 4-year experience with resource management in an ac ademic vascular surgery practice during which best practice plans were developed and implemented. Methods: We analyzed hospital cost data, w hich included both total hospital and intensive care unit length of st ay, average units per operation for laboratory, pharmacy, and radiolog y services and operating room and direct hospital costs for 257 caroti d endarterectomies performed over fiscal years (FY) 1994, 1995, 1996, and 1997 (6 month data) and 175 infrainguinal bypass procedures perfor med during the same period. Results: For carotid endarterectomy, lengt h of stay decreased 66% over the 4-year period to an average of 2.07 d ays in FY97. Both radiology and pharmacy utilization were reduced afte r the first year of institution of best practice plans (56% and 32% re spectively) with 4-year total reductions of 86% and 55% by FY97. The m ost notable changes included elimination of routine postoperative labo ratory testing, use of aspirin rather than low-molecular-weight dextra n, emphasis on oral rather than intravenous vasoactive drugs, and rout ine use of duplex scanning alone rather than angiography for diagnosis after FY94-95. The length of operating room time for carotid endarter ectomy remained relatively constant from FY94 to FY97. As a result of these multiple factors, our study showed a 30% decrease in total avera ge direct hospital costs for carotid endarterectomy from $9974 to $700 2 in this 4-year period. Infrainguinal bypass graft procedures showed a progressive decrease in total cost of 28% for patients without compl ications to $15,186 but remained unchanged for those with complication s. Laboratory use, pharmacy use, and radiology use were not significan tly different. Conclusions: Case management for patients undergoing ca rotid endarterectomy and infrainguinal bypass grafting involving an in tegrated team of vascular surgeons, surgical house staff, a dedicated vascular nurse, and a social work case manager resulted in dramatic re ductions both in length of stay and hospital resource utilization. As these costs decreased, operating room expenses assumed increasing impo rtance. Operating room costs account for 60% of the direct costs of ca rotid endarterectomy and a comparable percentage for uncomplicated inf rainguinal bypass grafting. Further substantial reductions in direct h ospital costs will depend primarily on reductions in operating room co sts, particularly those related to length of time in the operating roo m.