Reduction of hospital resources utilization in vascular surgery: a four-year experience.

PURPOSE: Managed care whether through risk or through capitated contracts 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 even more noticeable as a greater proportion of Medicare patients who need vascular operations select a managed-care senior product. We examined the results of a 4-year experience with resource management in an academic vascular surgery practice during which best practice plans were developed and implemented. METHODS: We analyzed hospital cost data, which included both total hospital and intensive care unit length of stay, average units per operation for laboratory, pharmacy, and radiology services and operating room and direct hospital costs for 257 carotid endarterectomies performed over fiscal years (FY) 1994, 1995, 1996, and 1997 (6 month data) and 175 infrainguinal bypass procedures performed during the same period. RESULTS: For carotid endarterectomy, length of stay decreased 66% over the 4-year period to an average of 2.07 days in FY97. Both radiology and pharmacy utilization were reduced after the first year of institution of best practice plans (56% and 32% respectively) with 4-year total reductions of 86% and 55% by FY97. The most notable changes included elimination of routine postoperative laboratory testing, use of aspirin rather than low-molecular-weight dextran, emphasis on oral rather than intravenous vasoactive drugs, and routine use of duplex scanning alone rather than angiography for diagnosis after FY94-95. The length of operating room time for carotid endarterectomy remained relatively constant from FY94 to FY97. As a result of these multiple factors, our study showed a 30% decrease in total average direct hospital costs for carotid endarterectomy from $9974 to $7002 in this 4-year period. Infrainguinal bypass graft procedures showed a progressive decrease in total cost of 28% for patients without complications to $15,186 but remained unchanged for those with complications. Laboratory use, pharmacy use, and radiology use were not significantly different. CONCLUSIONS: Case management for patients undergoing carotid endarterectomy and infrainguinal bypass grafting involving an integrated team of vascular surgeons, surgical house staff, a dedicated vascular nurse, and a social work case manager resulted in dramatic reductions both in length of stay and hospital resource utilization. As these costs decreased, operating room expenses assumed increasing importance. Operating room costs account for 60% of the direct costs of carotid endarterectomy and a comparable percentage for uncomplicated infrainguinal bypass grafting. Further substantial reductions in direct hospital costs will depend primarily on reductions in operating room costs, particularly those related to length of time in the operating room.

The clinical and hemodynamic results after axillary-to-popliteal vein valve transplantation.

PURPOSE: To evaluate the results of axillary vein to popliteal vein valve transplantation (VVTX), we reviewed the clinical, phlebographic, and noninvasive hemodynamic results in 15 patients. METHODS: All patients had postthrombotic destruction of deep venous valves as determined by ascending phlebography, whereas descending phlebography demonstrated grade III or IV reflux in all patients. A segment of valve-bearing axillary vein was transplanted to the popliteal vein in the affected limb. Postoperative evaluation was by clinical, noninvasive, and phlebographic means. RESULTS: Over a mean follow-up period of 5.3 years (1.25 to 11 years), 13 of 14 patients (93%) had symptomatic improvement with relief of swelling, whereas all 14 patients who were admitted with pain had relief after operation. Thirteen of 15 patients (87%) returned to work or household duties. Physical findings of edema, skin pigmentation, and lipodermatosclerosis improved in most patients. Only three patients (21%) had development of recurrent ulcers, with an average postoperative ulcer-free interval of 4 years by life-table analysis. The cumulative ulcer-free survival rate for the group averaged 62% at late follow-up. All three patients with ulcer recurrence had a functioning valve by descending phlebography, but recurrent perforating veins were found in two patients, and deep venous thrombosis above a patent VVTX was observed in the third. Late assessment of reflux by venous filling index and valve closure times for the entire sample demonstrated mean values of 4.9 seconds in the latter and 6.8 ml/sec in the former. Residual volume fraction, which correlates with invasive ambulatory venous pressures, was reduced to a mean of 31%. No deterioration in late sequential noninvasive values could be detected. CONCLUSION: VVTX is a durable procedure for preventing recurrent venous ulcers.