Division of Vascular Surgery, Stanford University, Stanford, Calif.
High Value Care, Quality, Patient Safety, and Clinical Effectiveness Department, Stanford Health Care, Stanford, Calif.
J Vasc Surg. 2019 Jan;69(1):219-225.e1. doi: 10.1016/j.jvs.2018.04.043. Epub 2018 Jun 28.
Effective strategies to reduce costs associated with endovascular aneurysm repair (EVAR) remain elusive for many medical centers. In this study, targeted interventions to reduce inpatient EVAR costs were identified and implemented.
From June 2015 to February 2016, we analyzed the EVAR practice at a high-volume academic medical center to identify, to rank, and ultimately to reduce procedure-related costs. In this analysis, per-patient direct costs to the hospital were compared before (September 2013-May 2015) and after (March 2016-January 2017) interventions were implemented. Improvement efforts concentrated on three categories that accounted for a majority of costs: implants, rooming costs, and computed tomography scans performed during the index hospitalization.
Costs were compared between 141 EVAR procedures before implementation (PRE period) and 47 EVAR procedures after implementation (POST period). Based on data obtained through the Society for Vascular Surgery EVAR Cost Demonstration Project, it was determined that implantable device costs were higher than those at peer institutions. New purchasing strategies were implemented, resulting in a 30.8% decrease in per-case device costs between the PRE and POST periods. Care pathways were modified to reduce use of and costs for computed tomography scans obtained during the index hospitalization. Compared with baseline, per-case imaging costs decreased by 92.9% (P < .001), including a 99.0% (P = .001) reduction in postprocessing costs. Care pathways were also implemented to reduce preprocedural rooming for patients traveling long distances the day before surgery, resulting in a 50% decrease in utilization rate (35.4% PRE to 17.0% POST; P = .021), without having a significant impact on median postprocedural length of stay (PRE, 2 days [interquartile range, 1-11 days]; POST, 2 days [1-7 days]; P = .185). Medication costs also decreased by 38.2% (P < .001) as a hospital-wide effort.
Excessive costs associated with EVAR threaten the sustainability of these procedures in health care organizations. Targeted cost reduction efforts can effectively reduce expenses without compromising quality or limiting patients' access.
对于许多医疗中心而言，降低血管内动脉瘤修复术（EVAR）相关成本的有效策略仍难以实现。本研究旨在确定并实施有针对性的干预措施，以降低住院 EVAR 成本。
从 2015 年 6 月至 2016 年 2 月，我们对一家高容量学术医疗中心的 EVAR 实践进行了分析，以确定、对各项程序相关成本进行排名并最终降低成本。在此分析中，将医院的每位患者的直接成本与干预措施实施之前（2013 年 9 月至 2015 年 5 月）和之后（2016 年 3 月至 2017 年 1 月）进行比较。改进工作集中在占成本大部分的三个类别：植入物、病房费用和在住院期间进行的计算机断层扫描。
在实施前（PRE 期）的 141 例 EVAR 手术和实施后（POST 期）的 47 例 EVAR 手术之间比较了成本。根据通过血管外科学会 EVAR 成本示范项目获得的数据，确定植入设备的成本高于同行业机构。实施了新的采购策略，导致 PRE 和 POST 期间每个病例设备成本降低了 30.8%。修改了护理路径，以减少在住院期间获得的 CT 扫描的使用和成本。与基线相比，每个病例的成像成本降低了 92.9%（P<.001），包括后处理成本降低了 99.0%（P=.001）。还实施了护理路径，以减少前一天长途旅行的患者术前的预住院，使用率降低了 50%（PRE 为 35.4%，POST 为 17.0%；P=.021），而对术后住院时间中位数没有显著影响（PRE，2 天[四分位距，1-11 天]；POST，2 天[1-7 天]；P=.185）。作为一项全院性努力，药物成本也降低了 38.2%（P<.001）。
EVAR 相关的过高成本威胁着这些手术在医疗机构中的可持续性。有针对性的成本降低工作可以在不影响质量或限制患者获得的情况下有效降低费用。
