Total joint Perioperative Surgical Home: an observational financial review

Perioperative Medicine

Zeev N Kain¹  Ranjan Gupta²  Shermeen B Vakharia¹  Leslie M Garson¹  Ran Schwarzkopf²  Maxime Cannesson¹  Darren R Raphael¹ 

[1] Department of Anesthesiology and Perioperative Care, University of California, 333 The City Boulevard West, Suite 2150, Orange, Irvine, California 92868, USA;Department of Orthopedic Surgery, University of California, 101 The City Drive South Pavilion III, Building 29A Orange, Irvine, California 92868, USA

关键词: Cost variation;    Cost analysis;    Total arthroplasty;    Perioperative care pathway;    Perioperative practice model;    Perioperative surgical home;   

Others  :  1132061
DOI  :  10.1186/2047-0525-3-6

 received in 2014-05-06, accepted in 2014-07-25,  发布年份 2014

【 摘 要 】

Background

The numbers of people requiring total arthroplasty is expected to increase substantially over the next two decades. However, increasing costs and new payment models in the USA have created a sustainability gap. Ad hoc interventions have reported marginal cost reduction, but it has become clear that sustainability lies only in complete restructuring of care delivery. The Perioperative Surgical Home (PSH) model, a patient-centered and physician-led multidisciplinary system of coordinated care, was implemented at UC Irvine Health in 2012 for patients undergoing primary elective total knee arthroplasty (TKA) or total hip arthroplasty (THA). This observational study examines the costs associated with this initiative.

Methods

The direct cost of materials and services (excluding professional fees and implants) for a random index sample following the Total Joint-PSH pathway was used to calculate per diem cost. Cost of orthopedic implants was calculated based on audit-verified direct cost data. Operating room and post-anesthesia care unit time-based costs were calculated for each case and analyzed for variation. Benchmark cost data were obtained from literature search. Data are presented as mean ± SD (coefficient of variation) where possible.

Results

Total per diem cost was $10,042 ± 1,305 (13%) for TKA and $9,952 ± 1,294 (13%) for THA. Literature-reported benchmark per diem cost was $17,588 for TKA and $16,267 for THA. Implant cost was $7,482 ± 4,050 (54%) for TKA and $9869 ± 1,549 (16%) for THA. Total hospital cost was $17,894 ± 4,270 (24%) for TKA and $20,281 ± 2,057 (10%) for THA. In-room to incision time cost was $1,263 ± 100 (8%) for TKA and $1,341 ± 145 (11%) for THA. Surgery time cost was $1,558 ± 290 (19%) for TKA and $1,930 ± 374 (19%) for THA. Post-anesthesia care unit time cost was $507 ± 187 (36%) for TKA and $557 ± 302 (54%) for THA.

Conclusions

Direct hospital costs were driven substantially below USA benchmark levels using the Total Joint-PSH pathway. The incremental benefit of each step in the coordinated care pathway is manifested as a lower average length of stay. We identified excessive variation in the cost of implants and post-anesthesia care.

【 授权许可】

   
2014 Raphael et al.; licensee BioMed Central Ltd.

【 图 表 】

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【 参考文献 】

• [1]Chang RW, Pellisier JM, Hazen GB: A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip. JAMA 1996, 275:858-865.
• [2]Bozic KJ, Saleh KJ, Rosenberg AG, Rubash HE: Economic evaluation in total hip arthroplasty: analysis and review of the literature. J Arthroplasty 2004, 19:180-189.
• [3]Kumar S, Williams AC, Sandy JR: How do we evaluate the economics of health care? Eur J Orthod 2006, 28:513-519.
• [4]Bosco JA, Alvarado CM, Slover JD, Iorio R, Hutzler LH: Decreasing total joint implant costs and physician specific cost variation through negotiation. J Arthroplasty 2014, 29:678-680.
• [5]Rana AJ, Iorio R, Healy WL: Hospital economics of primary THA decreasing reimbursement and increasing cost, 1990 to 2008. Clin Orthop Relat Res 2011, 469:355-361.
• [6]Lovald ST, Ong KL, Malkani AL, Lau EC, Schmier JK, Kurtz SM, Manley MT: Complications, mortality, and costs for outpatient and short-stay total knee arthroplasty patients in comparison to standard-stay patients. J Arthroplasty 2014, 29:510-515.
• [7]Healy WL, Iorio R, Richards JA, Lucchesi C: Opportunities for control of hospital costs for total joint arthroplasty after initial cost containment. J Arthroplasty 1998, 13:504-507.
• [8]Healy WL, Ayers ME, Iorio R, Patch DA, Appleby D, Pfeifer BA: Impact of a clinical pathway and implant standardization on total hip arthroplasty: a clinical and economic study of short-term patient outcome. J Arthroplasty 1998, 13:266-276.
• [9]Robinson JC, Pozen A, Tseng S, Bozic KJ: Variability in costs associated with total hip and knee replacement implants. J Bone Joint Surg Am 2012, 94:1693-1698.
• [10]Schweitzer M, Fahy B, Leib M, Rosenquist R, Merrick S: The Perioperative Surgical Home Model. Am Soc Anesthesiol News Lett 2013, 77(6):58-59.
• [11]Oravetz P, Kelchlin A: Driving value through clinical practice variation reduction. In Presented at 2013 Healthcare Systems Process Improvement Conference. New Orleans; 2013. [http://www.iienet2.org/uploadedFiles/SHSNew/Feature%201%20Paper%20Ochsner%20Joint%20Improvement.pdf webcite]
• [12]Garson L, Schwartzkopf R, Vakharia S, Alexander B, Stead S, Cannesson M, Kain ZN: Implementation of a total joint replacement-focused perioperative surgical home: a management case report. Anesth Analg 2014, 118(5):1081-1089.
• [13]Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, Cannesson M: The Perioperative Surgical Home as a future perioperative practice model. Anesth Analg 2014, 118(5):1126-1130.
• [14]Vetter TR, Boudreaux AM, Jones KA, Hunter JM, Pittet JF: The Perioperative Surgical Home: how anesthesiology can achieve and leverage the triple aim in healthcare. Anesth Analg 2014, 118(5):1131-1136.
• [15]Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF: The Perioperative Surgical Home: how can it make the case so everyone wins? BMC Anesthesiol 2013, 13:615.
• [16]Kozma CM, Slaton T, Paris A, Edgell ET: Cost and utilization of healthcare services for hip and knee replacement. J Med Econ 2013, 16(7):888-896.