STANDARDIZED CLINICAL CARE PATHWAYS FOR MAJOR THORACIC CASES REDUCE HOSPITAL COSTS

Background. Standardized clinical care pathways have been developed fo r postoperative management in an attempt to contain costs in an era of rising health care costs and limited resources. The purpose of this s tudy was to assess the effect of these pathways on length of stay, hos pital charges, and outcome for major thoracic surgical procedures. Met hods. All anatomic lung (segmentectomy, lobectomy, and pneumonectomy) and partial and complete esophageal resections performed from July 199 1 to July 1997 were retrospectively analyzed for length of stay, hospi tal charges, and outcome. A prospectively developed database was used. Clinical care pathways were introduced in March 1994. Comparisons wer e made between the procedures performed before (group I) and after (gr oup II) pathway implementation. Common to both pathways are early mobi lization and prudent x-ray and laboratory analysis. In addition, the p athway for esophagectomies emphasizes overnight intubation with 24-hou r intensive care unit care, and staged diet advancement. The discharge goal was postoperative day 10. For lung resection the emphasis is ear ly postoperative extubation with overnight intensive care unit managem ent. The discharge goal was postoperative day 7. Results. Group I esop hagectomies (n = 56) had significantly greater hospital charges compar ed with group II (n = 96) ($21,977 +/- $13,555 versus $17,919 +/- $5,3 21; p < 0.04, in actual dollars) and ($29,097 +/- $18,556 versus $19,2 60 +/- $6,000; p < 0.001, in dollars adjusted for inflation) and great er length of stay (13.6 +/- 6.9 versus 9.5 +/- 2.8 days; p < 0.001). G roup I lung resections (n = 185) had a significantly greater length of stay compared with group II (n = 241) (8.0 +/- 6.2 versus 6.4 +/- 3.8 days; p < 0.002); although charges trended downward ($13,113 +/- $10, 711 versus $12,404 +/- $7,189; not significant) in actual dollars, cha rges were significantly less in dollars adjusted for inflation ($17,10 3 +/- $13,211 versus $13,432 +/- $8,056; p < 0.01). The most significa nt decreases in charges for esophagectomies were in miscellaneous char ges (61% in dollars adjusted for inflation), pharmaceuticals (60%), la boratory (42%) and radiologic (39%) tests, physical therapy charges (3 5%), and routine charges (34%). For lung resections the greatest savin gs occurred for pharmaceuticals (38%), supplies (34%), miscellaneous c harges (25%), and routine charges (22%). Mortality was similar (esopha gectomies: I, 3.6%; II, 0%; lung resections: I, 0.5%; II, 0.8%; not si gnificant). Conclusions. Introduction of standardized clinical pathway s has resulted in a marked reduction of length of stay for all major t horacic surgical procedures. Total charges were reduced for both esoph agectomies (34%) and lung resections (21%) with continued quality of o utcome. (Ann Thorac Surg 1998;66:914-9) (C) 1998 by The Society of Tho racic Surgeons.