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 critical pathways, substantial reduction in overall costs can be achieved while maintaining the quality of care and patient satisfaction. METHODS: Our series consists of 856 consecutive patients treated with radical retropubic prostatectomy by 24 surgeons in a single hospital between January 1, 1994, and January 31, 1997. A clinical pathway for radical retropubic prostatectomy was implemented July 1, 1994. The patients were subdivided into three groups: (1) baseline: patients who underwent surgery in the 6 months immediately before the pathway onset (n = 113); (2) nonpathway: 75 patients treated off the clinical pathway; and (3) pathway: 668 men placed on the clinical pathway. We compare average 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; low volume physicians performed less than 12 operations per year. Charges were further broken down by department. Patient satisfaction was recorded by an outside source after discharge. Postoperative complications 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 patients, and $10,042 and 4.0 days for pathway patients, respectively. Implementation of the clinical pathway was associated with lower charges and length of stay in the pathway group as well as the nonpathway group, with larger reductions in pathway patients. With continuous reassessment and modification of the clinical pathway, both average hospital charges and average length of stay have progressively decreased from $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, operating room, anesthesia, and nursing or routine care. Patient satisfaction was similar in the pathway group and the nonpathway group. Incidence of postoperative complications did not differ significantly between the pathway and nonpathway groups. Length of stay and hospital charges were significantly lower for high than low volume surgeons, irrespective of the declines observed over time (P = 0.0001 and 0.0001, respectively). CONCLUSIONS: Average hospital charges and average length of stay for all surgeons were lowered significantly with the implementation of a clinical pathway and continue to decrease with continuous reassessment. The pathway was not associated with any increase in postoperative complications or patient dissatisfaction. Surgeons who operate frequently have lower average lengths of stay and hospital charges than those who operate infrequently.

The effects of a practice guideline on endoscopic sinus surgery at an academic center.

Practice guidelines (PG) (or clinical pathways) are increasingly important tools for standardizing health care delivery, improving efficiency, monitoring quality, and controlling costs. Health services researchers divide the delivery of health care into three stages: structure, process, and outcome. PGs are a technique to standardize the process of health care delivery, which may result in improved clinical outcomes or may maintain clinical outcomes while increasing process efficiency and decreasing costs. We describe the development and implementation of a PG for endoscopic sinus surgery at an academic center, and report preliminary results on the effects of the PG on the health care process. The PG was developed using a multidisciplinary combination of consensus-building and evidence-based techniques. Initially, participation in the PG was voluntary and at the attending physician's discretion. One year after implementation of the PG, 41 patients had been enrolled by members of the medical school's full-time faculty. Process and short-term outcome variables on those patients were compared to a random sample of 50 patients treated by the same physicians, but not using the PG. There was no evidence of selection bias into the PG based on demographics, severity of sinusitis, or the presence of comorbid factors. There were no differences in time spent in the operating room, postanesthesia care unit, or day surgery observation unit, between patients using the PG and not using the PG. However, patients not using the PG had a significantly higher rate of unplanned admission. Patients using the PG had significantly lower median hospital costs and charges than did patients not using the PG. In addition, median hospital costs and charges decreased steadily for all patients (not just those using the PG), simultaneous with the development and implementation of the PG. There were no differences in short-term clinical outcomes between PG and non-PG patients. In summary, the development and implementation of a PG for endoscopic sinus surgery resulted in lower hospital costs and charges while maintaining acceptable short-term clinical outcomes. PGs have important implications for improving the efficiency of the health care process.

Favorable neurological outcome in 7 cases of perinatal intracranial hemorrhage due to immune thrombocytopenia.

Neonatal intracranial hemorrhage secondary to immune thrombocytopenia has been uniformly associated with neurological sequelae in survivors. These sequelae are seizures, hydrocephalus, mental retardation, and developmental delay. We report 7 survivors of intracranial hemorrhage who were prospectively evaluated regarding their long-term outcome at a mean of approximately 5 years of age. Five children were completely normal. One was delayed in speech, and one had a ventriculoperitoneal (VP) shunt in place and a residual hemiparesis. Four children had had seizures including the two with sequelae (speech delay and hemiparesis); only the patient with the VP shunt was still taking anticonvulsant medication. This latter patient was also the only one who required special education classes in which she was maintaining her grade level. In summary, a good long-term outcome can be expected in at least some patients with neonatal intracranial hemorrhage in cases of severe neonatal thrombocytopenia caused by maternal antiplatelet antibodies. This good outcome may be a result of, and should encourage, early diagnosis and vigorous supportive care in the neonatal intensive care unit.