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60% of ACDF Costs Are Disposables; Change PT Staffing, Shorten LOS; Blood Transfusions Triple Readmissions!

Elizabeth Hofheinz, M.P.H., M.Ed. • Wed, May 24th, 2017

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Nearly 60% of the Cost of an ACDF Are Disposables

Healthcare in the U.S. is not only labyrinthine for patients…some aspects of it can even leave doctors scratching their heads. Seeking to put a fine point on the reality of surgical costs, Alexander R. Vaccaro, M.D., Ph.D., M.B.A., president of Rothman Institute in Philadelphia, along with Greg Schroeder, M.D., his spine partner, worked with colleagues to determine the minute-by-minute and ultimately, the total, true cost of a one or two level anterior cervical discectomy and fusion (ACDF).

Dr. Vaccaro told OTW, “The future is value-based reimbursement, so knowing where we stand with true cost is fundamental in order for surgeons and hospitals to function well in this system.”

Dr. Vaccaro and colleagues examined the minutiae of the ACDF care cycle using a tool known as Time Driven Activity Based Costing (TDABC). “Using this method means that each step in the care process is accounted for in terms of resources used. We had a research assistant by the side of each patient as he or she moved through each step of the care cycle. So the patient would arrive at the hospital at 5:15, was met by the assistant, and every person that patient interacts with was taken into account.”

“For example, when the patient signed in at the desk then the salary of the person at the desk was accounted for. It was same all the way through: supplies, personnel, pre-admission testing, the surgery and the postoperative visits for the first 90 days. This is only way to differentiate the insurance claim cost from the actual cost to the hospital.”

“We identified the salary for every member of the care team and the cost per minute was determined. All salaries were based on the total compensation paid to each employee. The charges for all disposables were the actual cost that the facility paid for the item. The overnight cost was estimated to be the time and resources utilized for the overnight portion of the patient’s hospital stay.”

And their findings gave even Alex Vaccaro a jolt. “Eleven patients had a single level ACDF and 16 had a two-level fusion. The total cost for the episode of care was roughly $37,000. The most expensive aspect of the care cycle was the hospital disposable costs—approximately $21,000. The second largest was intraoperative personnel costs—roughly $6,000.”

Dr. Vaccaro told OTW, “This was a real eye-opener. I am utterly amazed at the cost of healthcare in America. We as doctors can effect change and help to bring down the cost of care by eliminating wasteful, unnecessary steps in the supply chain. We need to collaborate, and work from the fundamental standpoint that our current system is unsustainable and unrealistic. An average day in a hospital should not be so expensive.”

Change PT Staffing, Shorten Hospital Length of Stay (LOS)!

You could say that these researchers are thinking “outside the surgical episode” box.

A team from the University of Utah recently took on the challenge of shifting physical therapist hours to see if they could get patients up and moving earlier during their hospital stay. Their work, “Improving value in primary total joint arthroplasty care pathways: changes in inpatient physical therapy staffing,” was published in the March 2017 edition of Arthroplasty Today.

Christopher Pelt, M.D., an assistant professor in the Department of Orthopaedic Surgery at the University of Utah and a co-author on the study, told OTW, “The importance of improving value in total joint replacement surgery and postoperative care is obvious. Value based healthcare initiatives continue to push surgeons and providers to lowering costs and improving outcomes.”

“Recently, value based payments, such as Model 2 of the voluntary BPCI [Bundled Payments for Care Improvement] program from CMS [Centers for Medicare & Medicaid Services] helped to shed some light on the importance of controlling costs outside of the immediate inpatient stay by extending our view of the total episode costs out to 90 days beyond surgery. However, prior to our involvement in that, our focus was on looking internally at ways to improve the value of care we provide during the inpatient stay.”

“Approximately five years ago, University of Utah Health worked hard to create an internal cost and quality program, known as Value Directed Outcomes (VDO). With VDO as a tool to help us track cost, quality, and other important data, we were able to come up with several projects that could be developed, implemented, and monitored. The importance of early ambulation was well established in the literature. It seems intuitive to think that getting patients up earlier in their inpatient stay could help them to get out of the hospital sooner.”

“However, this was against tradition and dogma, where the prior model of healthcare around the postoperative patient was that of the ‘sick patient.’”

“Shifting the thinking of the health care team to model the care around the patient to that of a ‘well patient’ helped to drive toward interventions that could engage earlier functional recovery opportunities.

“Early ambulation is one such intervention.”

“The problem, however, was how to implement this intervention. Patients get out of surgery at all hours of the day, and often the therapists were gone or leaving prior to the patients reaching the inpatient ward. Further, nurses would refuse to mobilize the patient until therapy had ‘cleared’ them as safe to get out of bed.”

“The development of this intervention and setup process is actually one of the most important features of this study.”

“We met as a large multidisciplinary group of surgeons, nurses, therapists, case managers, and value engineers with a goal of identifying opportunities for improvement in our joint replacement care pathways using currently available resources. It was that team approach that helped lead to the changes. By including the key team members in the care of the postoperative joint patient, the whole group had input and then ultimately buy-in to the process improvements.”

“The therapists were actually more than happy to find alternative staffing hours in order to help mobilize more patients on the day of surgery. Without having included them in the early brainstorming and care pathway design process, it may have been challenging to ask a group of professionals to change their work hours to include an evening swing shift.”

“By making a relatively simple change to staffing hours of our physical therapists, and by using resources currently available to us with little additional financial or institutional investment, we made a significant improvement in the number of patients ambulating on POD [postoperative day] 0, with a modest reduction in both length of stay (LOS) and inpatient costs.”

“Engaging the entire care team can help make small but meaningful improvements in the care of our patients. As we continue to feel the pressures of improving value by decreasing costs and improving outcomes, perhaps we can use the resources around us to aid in this transformation. While the issue of early ambulation, early discharge with decreased LOS and inpatient hospital costs are clearly multifactorial, the small intervention of making an effort to mobilize more patients on the day of surgery helped to decrease LOS and lower inpatient costs at our institution.”

Blood Transfusions Triple Risk of Readmissions

It’s time for a reliable transfusion protocol, says new research appearing in the April 15, 2017 edition of Spine.

To that end, researchers from Rush University Medical Center, Duke University Medical Center, the University of Illinois at Chicago, the University of Kentucky, Yale University, and the University of Texas Southwestern conducted a retrospective study comparing outcomes and readmission rates in patients who received blood transfusions to those who did not. What they found shocked them.

The study was entitled, “Association of Intraoperative Blood Transfusions on Postoperative Complications, 30-Day Readmission Rates, and 1-Year Patient-Reported Outcomes.”

Owoicho Adogwa, M.D., M.P.H., co-author on the study and a member of the Department of Neurosurgery at Rush told OTW, “Correctly or incorrectly, 30-day admission is being used by third party payers as a proxy for quality. There are several reasons why a patient may be readmitted within 30 days, which include postoperative complications and infection.”

“Numerous studies in other journals have demonstrated that blood transfusions can be associated with complications. The goal of this study was to assess whether transfusions after elective spine surgery contribute to an inferior postoperative complications profile and a higher 30-day-admission rate.”

“There were several noticeable findings. There was a twofold increase in the incidence of postoperative complications in patients receiving blood transfusions compared with those who did not receive any transfusions. Also, there was an almost threefold increase in the 30-day readmission rate in patients who received blood transfusions. Lastly, receiving a blood transfusion was independently predictive of the likelihood of readmission within 30 days of discharge.”

“While I expected the use of blood transfusion to be moderately associated with increased postoperative complications, I was astounded by the degree to which this proved to be the case. I certainly did not expect a twofold increase in postoperative complications and an almost threefold increase in 30-day readmission rates. These are impressive numbers that we cannot ignore.”

“Most surgeons do not associate blood transfusions with a prolonged hospital stay, inferior complications profile and higher 30-day readmission rates. Accordingly, most spine surgeons have no existing protocol in place to guide the optimal use of these blood products. My hope is that we have demonstrated that the use of these products is not trivial.”

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