Cost and utilization impact of a clinical pathway for patients undergoing pancreaticoduodenectomy

Background:When implemented in several common surgical procedures, clinical pathways have been reported to reduce costs and resource utilization, whil e maintaining or improving patient care. However, then is little data to su pport their use in more complex surgery. The objective of this study was to determine the effects of clinical pathway implementation in patients under going elective pancreaticoduodenectomy (PD) on cost and resource utilizatio n. Methods: Outcome data from before and after the development of a clinical p athway were analyzed. The clinical pathway standardized the preoperative ou tpatient care, critical care, and postoperative floor care of patients who underwent PD. An independent department determined total costs for each pat ient, which included all hospital and physician costs, in a blinded review. Outcomes that were examined included perioperative mortality, postoperativ e morbidity, length of stay, readmissions, and postoperative clinic visits. Results: From January, 1996 to December, 1998, 148 consecutive patients und erwent PD or total pancreatectomy; 68 before pathway development (PrePath) and 80 after pathway implementation (PostPath). There were no significant d ifferences in patient demographics, comorbid conditions, underlying diagnos is, or use of neoadjuvant therapy between the two groups. Mean total costs were significantly reduced in PostPath patients compared with PrePath patie nts ($36,627 vs. $47,515; P = .003). Similarly, mean length of hospital sta y was also significantly reduced in PostPath patients (13.5 vs. 16.4 days; P = .001). The total cost differences could not be attributed solely to dif ferences in room and board costs. Cost and length-of-stay differences remai ned when outliers were excluded from the analysis. Despite these findings, there were no significant differences between PrePath and PostPath patients in terms of perioperative mortality (3% vs, 1%), readmissions within 1 mon th of discharge (15% vs. 11%), or mean number of clinic visits within 90 da ys of discharge (3.3 vs. 3.3 visits). Conclusions: The establishment of a clinical pathway for PD patients dramat ically reduced costs and resource utilization without any apparent detrimen tal effect on quality of patient care. These findings support the implement ation of clinical pathways for PD patients, as well as investigation into p athway care for other complex surgical procedures.