IMPACT OF A CLINICAL PATHWAY FOR RADICAL RETROPUBIC PROSTATECTOMY

Objectives. Cost containment has become an important issue in medical practice. With the implementation of collaborative care programs and c ritical pathways, substantial reduction in overall costs can be achiev ed while maintaining the duality of care and patient satisfaction. Met hods. Our series consists of 856 consecutive patients treated with rad ical retropubic prostatectomy by 24 surgeons in a single hospital betw een January 1, 1994, and January 31, 1997. A clinical pathway for radi cal retropubic prostatectomy was implemented July 1, 1994. The patient s were subdivided into three groups: (1) baseline: patients who underw ent surgery in the 6 months immediately before the pathway onset (n = 113); (2) nonpathway: 75 patients treated off the clinical pathway; an d (3) pathway: 668 men placed on the clinical pathway. We compare aver age length of stay and average hospital charges among the three groups . We also compare average length of stay among physician volume groups : high volume physicians performed at least 12 operations per year; lo w volume physicians performed less than 12 operations per year. Charge s were further broken down by department. Patient satisfaction was rec orded by an outside source after discharge. Postoperative complication s were assessed in the clinical pathway and nonpathway groups. Results . Average hospital charges and average length of stay were $12,926 and 5.8 days for baseline patients, $11,795 and 5.0 days for nonpathway p atients, and $10,042 and 4.0 days for pathway patients, respectively. Implementation of the clinical pathway was associated with lower charg es and length of stay in the pathway group as well as the nonpathway g roup, with larger reductions in pathway patients. With continuous reas sessment and modification of the clinical pathway, both average hospit al charges and average length of stay have progressively decreased fro m $10,540 and 4.9 days in 1994 to $8766 and 2.7 days in January 1997. Charges were uniformly reduced in radiology, laboratory, pharmacy, ope rating room, anesthesia, and nursing or routine care. Patient satisfac tion was similar in the pathway group and the nonpathway group. Incide nce of postoperative complications did not differ significantly betwee n the pathway and nonpathway groups. Length of stay and hospital charg es were significantly lower for high than low volume surgeons, irrespe ctive of the declines observed over time (P = 0.0001 and 0.0001, respe ctively). Conclusions. Average hospital charges and average length of stay for all surgeons were lowered significantly with the implementati on of a clinical pathway and continue to decrease with continuous reas sessment. The pathway was not associated with any increase in postoper ative complications or patient dissatisfaction. Surgeons who operate f requently have lower average lengths of stay and hospital charges than those who operate infrequently. (C) 1998, Elsevier Science Inc. All r ights reserved.