Rapid recovery following hip and knee arthroplasty using local infiltration analgesia: length of stay, rehabilitation protocol and cost savings.

BACKGROUND: We implemented local infiltration analgesia (LIA) as a technique of providing post-operative pain management and early mobilization after arthroplasty surgery and have progressively found patients able to go home earlier. This study compares the national data on hip and knee arthroplasty provided by the Royal Australasian College of Surgeons and Medibank Private with our outcomes using LIA and rapid recovery. METHODS: Prospective study of one surgeon including 200 knees, and 165 hips in the two years till June 2016. Variables included in comparison to the two groups were: length of stay, percentage of patients transferred to rehabilitation or intensive care unit (ICU), readmitted within 30 days and average separation cost. RESULTS: Hip replacement median length of stay in our series was two nights versus five nights, inpatient rehabilitation 7% versus 36%, ICU admission zero versus 4%, and readmissions 3.9% versus 6.0%, the average hospital separation cost in our series was $17 813 versus $26 734. Knee replacement median length of stay in our study was one night versus five nights, ICU 0.5% versus 3%, rehabilitation 4.5% versus 43%, and readmission 6% versus 7%, the average hospital separation cost in our group was $16 437 versus $27 505. CONCLUSION: The comprehensive approach of LIA and rapid recovery enables patients to have shorter hospitalization, lower rehabilitation incidence and a resultant reduction in health expenditure.

The Economic and Clinical Impact of an Early Mobility Program in the Trauma Intensive Care Unit: A Quality Improvement Project.

Traumatic injury survivors often face a difficult recovery. Surgical and invasive procedures, prolonged monitoring in the intensive care unit (ICU), and constant preventive vigilance by medical staff guide standards of care to promote positive outcomes. Recently, patients with traumatic injuries have benefited from early mobilization, a multidisciplinary approach to increasing participation in upright activity and walking. The purpose of this project was to determine the impact of an early mobility program in the trauma ICU on length of stay (LOS), ventilator days, cost, functional milestones, and rehabilitation utilization. A quality improvement project compared outcomes and cost before and after the implementation of an early mobility program. The trauma team assigned daily mobility levels to trauma ICU patients. Nursing and rehabilitation staff collaborated to set daily goals and provide mobility-based interventions. Forty-four patients were included in the preintervention group and 43 patients in the early mobility group. Physical therapy and occupational therapy were initiated earlier in the early mobilization group (p = .044 and p = .026, respectively). Improvements in LOS, duration of mechanical ventilation, time to out-of-bed activity and walking, and discharge disposition were not significant. There were no adverse events related to the early mobility initiative. Activity intolerance resulted in termination of 7.1% of mobility sessions. The development and initiation of a trauma-specific early mobility program proved to be safe and reduce patient care costs. In addition, the program facilitated earlier initiation of physician and occupational therapies. Although not statistically significant, retrospective data abstraction provides evidence of fewer ICU and total hospital days, earlier extubations, and greater proactive participation in functional activities.

Economic evaluation of a phase III international randomised controlled trial of very early mobilisation after stroke (AVERT).

OBJECTIVES: While very early mobilisation (VEM) intervention for stroke patients was shown not to be effective at 3 months, 12 month clinical and economical outcomes remain unknown. The aim was to assess cost-effectiveness of a VEM intervention within a phase III randomised controlled trial (RCT). DESIGN: An economic evaluation alongside a RCT, and detailed resource use and cost analysis over 12 months post-acute stroke. SETTING: Multi-country RCT involved 58 stroke centres. PARTICIPANTS: 2104 patients with acute stroke who were admitted to a stroke unit. INTERVENTION: A very early rehabilitation intervention within 24 hours of stroke onset METHODS: Cost-utility analyses were undertaken according to pre-specified protocol measuring VEM against usual care (UC) based on 12 month outcomes. The analysis was conducted using both health sector and societal perspectives. Unit costs were sourced from participating countries. Details on resource use (both health and non-health) were sourced from cost case report form. Dichotomised modified Rankin Scale (mRS) scores (0 to 2 vs 3 to 6) and quality adjusted-life years (QALYs) were used to compare the treatment effect of VEM and UC. The base case analysis was performed on an intention-to-treat basis and 95% CI for cost and QALYs were estimated by bootstrapping. Sensitivity analysis were conducted to examine the robustness of base case results. RESULTS: VEM and UC groups were comparable in the quantity of resource use and cost of each component. There were no differences in the probability of achieving a favourable mRS outcome (0.030, 95% CI -0.022 to 0.082), QALYs (0.013, 95% CI -0.041 to 0.016) and cost (AUD1082, 95% CI -$2520 to $4685 from a health sector perspective or AUD102, 95% CI -$6907 to $7111, from a societal perspective including productivity cost). Sensitivity analysis achieved results with mostly overlapped CIs. CONCLUSIONS: VEM and UC were associated with comparable costs, mRS outcome and QALY gains at 12 months. Compared with to UC, VEM is unlikely to be cost-effective. The long-term data collection during the trial also informed resource use and cost of care post-acute stroke across five participating countries. TRIAL REGISTRATION NUMBER: ACTRN12606000185561; Results.

Bias-corrected estimates of reduction of post-surgery length of stay and corresponding cost savings through the widespread national implementation of fast-tracking after liver transplantation: a quasi-experimental study.

Background: Fast-tracking is an approach adopted by Mayo Clinic in Florida's (MCF) liver transplant (LT) program, which consists of early tracheal extubation and transfer of patients to surgical ward, eliminating a stay in the intensive care unit in select patients. Since adopting this approach in 2002, MCF has successfully fast-tracked 54.3% of patients undergoing LT. Objectives: This study evaluated the reduction in post-operative length of stay (LOS) that resulted from the fast-tracking protocol and assessed the potential cost saving in the case of nationwide implementation. Methods: A propensity score for fast-tracking was generated based on MCF liver transplant databases during 2011-2013. Various propensity score matching algorithms were used to form control groups from the United Network of Organ Sharing Standard Analysis and Research (STAR) file that had comparable demographic characteristics and health status to the treatment group identified in MCF. Multiple regression and matching estimators were employed for evaluation of the post-surgery LOS. The algorithm generated from the analysis was also applied to the STAR data to determine the proportion of patients in the US who could potentially be candidates for fast-tracking, and the potential savings. Results: The effect of the fast-tracking on the post-transplant LOS was estimated at approximately from 2.5 (p-value = 0.001) to 3.2 (p-value < 0.001) days based on various matching algorithms. The cost saving from a nationwide implementation of fast-tracking of liver transplant patients was estimated to be at least $78 million during the 2-year period. Conclusion: The fast-track program was found to be effective in reducing post-transplant LOS, although the reduction appeared to be less than previously reported. Nationwide implementation of fast-tracking could result in substantial cost savings without compromising the patient outcome.

Beyond surgery: clinical and economic impact of Enhanced Recovery After Surgery programs.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a perioperative management based on multimodality and multidisciplinary work. ERAS has been shown to have important clinical and economic benefits, but its spread remains slow worldwide. DISCUSSION: This manuscript reviews the overall program benefits and focuses on important aspects for implementation well beyond surgery. Implementation of ERAS pathways improves clinical outcomes and induces substantial economic gains. ERAS is the current surgical revolution.

Time-driven Activity-based Cost of Fast-Track Total Hip and Knee Arthroplasty.

BACKGROUND: Fast-track total hip and knee arthroplasty (THA and TKA) has been shown to reduce the perioperative convalescence resulting in less postoperative morbidity, earlier fulfillment of functional milestones, and shorter hospital stay. As organizational optimization is also part of the fast-track methodology, the result could be a more cost-effective pathway altogether. As THA and TKA are potentially costly procedures and the numbers are increasing in an economical limited environment, the aim of this study is to present baseline detailed economical calculations of fast-track THA and TKA and compare this between 2 departments with different logistical set-ups. METHODS: Prospective data collection was analyzed using the time-driven activity-based costing method (TDABC) on time consumed by different staff members involved in patient treatment in the perioperative period of fast-track THA and TKA in 2 Danish orthopedic departments with standardized fast-track settings, but different logistical set-ups. RESULTS: Length of stay was median 2 days in both departments. TDABC revealed minor differences in the perioperative settings between departments, but the total cost excluding the prosthesis was similar at USD 2511 and USD 2551, respectively. CONCLUSION: Fast-track THA and TKA results in similar cost despite differences in the organizational set-up. Compared to cost associated with longer more conventional published pathways, fast-track is cheaper, which on top of the favorable published clinical outcome adds to cost efficiency and the potential for economic savings. Detailed baseline TDABC calculations are provided for comparison and further optimization of cost-benefit effectiveness.

Early Rehabilitation in the Medical and Surgical Intensive Care Units for Patients With and Without Mechanical Ventilation: An Interprofessional Performance Improvement Project.

BACKGROUND: Most early mobility studies focus on patients on mechanical ventilation and the role of physical and occupational therapy. This Performance Improvement Project (PIP) project examined early mobility and increased intensity of therapy services on patients in the intensive care unit (ICU) with and without mechanical ventilation. In addition, speech-language pathology rehabilitation was added to the early mobilization program. OBJECTIVE: We sought to assess the efficacy of early mobilization of patients with and without mechanical ventilation in the ICU on length of stay (LOS) and patient outcomes and to determine the financial viability of the program. DESIGN: PIP. Prospective data collection in 2014 (PIP) compared with a historical patient population in 2012 (pre-PIP). SETTING: Medical and surgical ICUs of a Level 2 trauma hospital. PATIENTS: There were 160 patients in the PIP and 123 in the pre-PIP. INTERVENTIONS: Interprofessional training to improve collaboration and increase intensity of rehabilitation therapy services in the medical and surgical intensive care units for medically appropriate patients. MEASUREMENTS: Demographics; intensity of service; ICU and hospital LOS; medications; pain; discharge disposition; functional mobility; and average cost per day were examined. MAIN RESULTS: Rehabilitation therapy services increased from 2012 to 2014 by approximately 60 minutes per patient. The average ICU LOS decreased by almost 20% from 4.6 days (pre-PIP) to 3.7 days (PIP) (P = .05). A decrease of over 40% was observed in the floor bed average LOS from 6.0 days (pre-PIP) to 3.4 days (PIP) (P < .01). An increased percentage of PIP patients, 40.5%, were discharged home without services compared with 18.2% in the pre-PIP phase (P < .01). Average cost per day in the ICU and floor bed decreased in the PIP group, resulting in an annualized net cost savings of $1.5 million. CONCLUSIONS: The results of the PIP indicate that enhanced rehabilitation services in the ICU is clinically feasible, results in improved patient outcomes, and is fiscally sound. Most early mobility studies focus on patients on mechanical ventilation. The results of this PIP project demonstrate that there are significant benefits to early mobility and increased intensity of therapy services on ICU patients with and without mechanical ventilation. Benefits include reduced hospitalization LOS, decreased health care costs, and decreased need for postacute care services. LEVEL OF EVIDENCE: III.

Economic Evaluation Plan (EEP) for A Very Early Rehabilitation Trial (AVERT): An international trial to compare the costs and cost-effectiveness of commencing out of bed standing and walking training (very early mobilization) within 24 h of stroke onset with usual stroke unit care.

RATIONALE: A key objective of A Very Early Rehabilitation Trial is to determine if the intervention, very early mobilisation following stroke, is cost-effective. Resource use data were collected to enable an economic evaluation to be undertaken and a plan for the main economic analyses was written prior to the completion of follow up data collection. AIM AND HYPOTHESIS: To report methods used to collect resource use data, pre-specify the main economic evaluation analyses and report other intended exploratory analyses of resource use data. SAMPLE SIZE ESTIMATES: Recruitment to the trial has been completed. A total of 2,104 participants from 56 stroke units across three geographic regions participated in the trial. METHODS AND DESIGN: Resource use data were collected prospectively alongside the trial using standardised tools. The primary economic evaluation method is a cost-effectiveness analysis to compare resource use over 12 months with health outcomes of the intervention measured against a usual care comparator. A cost-utility analysis is also intended. STUDY OUTCOME: The primary outcome in the cost-effectiveness analysis will be favourable outcome (modified Rankin Scale score 0-2) at 12 months. Cost-utility analysis will use health-related quality of life, reported as quality-adjusted life years gained over a 12 month period, as measured by the modified Rankin Scale and the Assessment of Quality of Life. DISCUSSION: Outcomes of the economic evaluation analysis will inform the cost-effectiveness of very early mobilisation following stroke when compared to usual care. The exploratory analysis will report patterns of resource use in the first year following stroke.

Original Research: Implementation of an Early Mobility Program in an ICU.

OBJECTIVE: Research is needed to determine the feasibility of implementing a dedicated ICU mobility team in community hospital settings. The purpose of this study was to assess, in one such hospital, four nurse-sensitive quality-of-care outcomes (falls, ventilator-associated events, pressure ulcers, and catheter-associated urinary tract infections [CAUTIs]), as well as hospital costs, sedation and delirium measures, and functional outcomes by comparing ICU patients who received physical therapy from a dedicated mobility team with ICU patients who received routine care. METHODS: We conducted a retrospective longitudinal study at a community acute care hospital; patients were randomly assigned to intervention or routine care groups. The mobility team screened patients Monday through Friday using a mobility algorithm to determine eligibility for participation in each early mobility session. Based on their strength, balance, hemodynamic stability, and ability to participate in early mobility activities, patients advanced through four progressively difficult phases of mobility. Data were collected and analyzed after patients were discharged from the hospital. RESULTS: The 66 patients who received the mobility intervention had significantly fewer falls, ventilator-associated events, pressure ulcers, and CAUTIs than the 66 patients in the routine care group. The mobility group also had lower hospital costs, fewer delirium days, lower sedation levels, and improved functional independence compared with the routine care group. Patients in the mobility group got out of bed on 2.5 more days than patients in the routine care group. There were also no adverse events in the mobility group. CONCLUSIONS: It is feasible for a community hospital to create and implement a dedicated ICU mobility team. Early mobilization of ICU patients contributed to fewer delirium days and improved patient outcomes, sedation levels, and functional status.

Association of early ambulation with length of stay and costs in total knee arthroplasty: retrospective cohort study.

OBJECTIVE: The objective of this study was to evaluate the association of early ambulation with length of stay, costs, and outcomes in inpatients undergoing total knee arthroplasty. DESIGN: This is a retrospective study of 1504 patients who underwent total knee arthroplasty between August 2009 and January 2011 in a tertiary teaching hospital. All patients commenced physiotherapy interventions on postoperative day 1. The patients were categorized into an early ambulation group (began ambulating on postoperative day 1; n = 803) or a late ambulation group (began ambulating on postoperative day 2; n = 701). Multivariable regression and propensity score analyses were used to reduce selection biases. RESULTS: Early ambulation was associated with a statistically significant reduction in the adjusted average length of stay (-0.44 day; P < 0.001) and adjusted average total hospitalization costs (Singapore, -$385; United States, -$315; P < 0.001). Both groups did not differ significantly in the 90-day readmission rate; however, early ambulation was associated with higher odds of achieving at least 90 degrees of knee flexion (adjusted odds ratio, 1.33; P < 0.01) and requiring a walking aid with a smaller base of support (adjusted proportional odds ratio, 1.36; P < 0.001). CONCLUSIONS: As little as a 1-day difference in the day of first ambulation was associated with a shorter length of stay, lower hospitalization costs, and improved knee function. The results of this study provide the first empirical support for the usefulness of early ambulation after total knee arthroplasty.

ICU early physical rehabilitation programs: financial modeling of cost savings.

OBJECTIVE: To evaluate the potential annual net cost savings of implementing an ICU early rehabilitation program. DESIGN: Using data from existing publications and actual experience with an early rehabilitation program in the Johns Hopkins Hospital Medical ICU, we developed a model of net financial savings/costs and presented results for ICUs with 200, 600, 900, and 2,000 annual admissions, accounting for both conservative- and best-case scenarios. Our example scenario provided a projected financial analysis of the Johns Hopkins Medical ICU early rehabilitation program, with 900 admissions per year, using actual reductions in length of stay achieved by this program. SETTING: U.S.-based adult ICUs. INTERVENTIONS: Financial modeling of the introduction of an ICU early rehabilitation program. MEASUREMENTS AND MAIN RESULTS: Net cost savings generated in our example scenario, with 900 annual admissions and actual length of stay reductions of 22% and 19% for the ICU and floor, respectively, were $817,836. Sensitivity analyses, which used conservative- and best-case scenarios for length of stay reductions and varied the per-day ICU and floor costs, across ICUs with 200-2,000 annual admissions, yielded financial projections ranging from -$87,611 (net cost) to $3,763,149 (net savings). Of the 24 scenarios included in these sensitivity analyses, 20 (83%) demonstrated net savings, with a relatively small net cost occurring in the remaining four scenarios, mostly when simultaneously combining the most conservative assumptions. CONCLUSIONS: A financial model, based on actual experience and published data, projects that investment in an ICU early rehabilitation program can generate net financial savings for U.S. hospitals. Even under the most conservative assumptions, the projected net cost of implementing such a program is modest relative to the substantial improvements in patient outcomes demonstrated by ICU early rehabilitation programs.

Financial implications of starting a mobility protocol in a surgical intensive care unit.

A review of the literature revealed that there was a dearth of information regarding the financial impact of implementing a mobility program in an intensive care unit. The purpose of this article was to identify and quantify costs and cost-benefit from implementing a mobility protocol. Factors to be considered when implementing a mobility program in an intensive care unit are identified and discussed. The increased acuity and lengths of stay associated with this population and the unavoidable increase in the incidence of hospital-acquired pressure ulcers make it difficult to extrapolate the economic benefits of the mobility program at this time.

Usefulness of an enhanced recovery after surgery protocol for perioperative management following open repair of an abdominal aortic aneurysm.

PURPOSE: To achieve early recovery and early discharge from the hospital by applying an enhanced recovery after surgery (ERAS) protocol, which is mainly used with colonic surgery, for the perioperative management of open AAA surgery. METHOD: One hundred twenty-seven open AAA surgery cases successfully carried out between 2003 and 2011 were included in this study. The ERAS protocol was used for the cases from April 2008 onward, and we performed a comparison of the conventionally treated cases with ERAS cases regarding the start of postoperative oral consumption, the postoperative hospital stay, and hospitalization medical costs. RESULTS: The time to restarting oral consumption and the postoperative hospital stay were significantly shorter for the ERAS group (n = 52) compared to the conventionally managed group (n = 75); with values of 59 ± 15 and 93 ± 25 h (p = 0.021), 9 ± 3 and 16 ± 5 days (p = 0.001), respectively. The medical costs for the ERAS group were 92 % of the costs of the conventionally managed group. CONCLUSION: Use of the ERAS protocol for the perioperative management of open AAA surgery shortened the time before recommencing oral consumption, the postoperative hospital stay, and reduced the medical costs compared to the conventional approach.

[Fast-track paediatric surgery]. / Fast-track-Kinderchirurgie.

Fast-track surgery is a comprehensive perioperative treatment concept that has been successfully performed and widely accepted in adult surgery since the 1990s. The crucial aim is to speed up convalescence and to avoid perioperative complications as pneumonia and thrombosis. Compared to conventional treatment strategies, hospital stays are substantially reduced. In the paediatric field fast-track surgery is not generally established. However, in recent studies a high efficiency of paediatric surgical fast-track procedures with respect to medical, psychological, economical and ethical parameters has been shown. It has been confirmed that early convalescence leads to an increase of satisfaction of the patients and their parents without higher complication rates. Shorter hospital stays lead to reduced expenses for the health insurances and parents. Fast-track concepts are not implemented in the German reimbursement system G-DRG. Thus, problems with intensified nursing and reimbursement remain to be solved.

[Economic consequences of accelerated care pathways in total knee-arthroplasty]. / Økonomiske konsekvenser ved accelererede knaealloplastikforløb.

INTRODUCTION: The aim of this study was to compare economic costs, readmissions and the use of services in the primary health care sector associated with total knee-arthroplasty (TKA) between a department with accelerated care pathways and two departments with more conventional pathways. MATERIAL AND METHODS: The cost data were collected retrospectively for 2006 for one department with accelerated pathways in TKA with a separate arthroplastic section, one department with more conventional pathways where the TKA patients were admitted together with acute patients and one department with conventional pathways with only elective orthopaedic surgery. We compared readmissions and the use of secondary services in the primary health sector within three months after discharge. RESULTS: Patient characteristics were comparable in the three departments, but the length of stay was significantly different (4.4 days; 7.2 days and 6.5 days). Savings of DKK 6,248 and DKK 5,229 per patient, respectively, were generated from the accelerated pathway compared with the two more conventional pathways. There was no difference regarding readmissions or use of services from the patients' general practitioner, but fewer visits at a private physiotherapist were used by patients in the accelerated pathway than by patients in the two more conventional pathways. CONCLUSION: The study shows that accelerated pathways are cost-saving compared with more conventional pathways.

[Fast track in casualty surgery]. / Fast Track in der Unfallchirurgie.

The concept of "fast track" has not yet been established in orthopaedic trauma surgery. Principles such as those used in the "fast track" procedure for abdominal surgery have been employed in orthopaedic surgery for a long time. The best results can be achieved by early operative treatment, stable osteosynthesis and, if the soft tissues allow, an early initiation of mobilization under optimal pain management. Based on new techniques in osteosynthesis, in particular locked-screw techniques, "fast track" is also applicable for fragility fractures (osteoporosis), complex shattered bone and bone defect situations.

[Fast track in vascular surgery]. / Fast Track in der Gefässchirurgie.

Vascular comorbidities are common in vascular surgery, being associated with perioperative complications. Since it was demonstrated that the postoperative course could be optimized by introduction of the fast track concept in general surgery, application to vascular surgery may also be of benefit. The fast track concept was introduced in our institution on May 1st 2008 with special adjustments for vascular surgery. The authors describe the development and implementation of a clinical pathway, which proved to be of value in vascular surgery.