Implementation of Critical Path Reduces Prostatectomy Costs

MARINA DEL REY, Calif--The changing reimbursement system in Californiaprovides a "real challenge" for academic institutionto compete on cost with other area hospitals, said Robert B. Smith,MD, professor of surgery/urology, UCLA School of Medicine, ata conference cosponsored by the Clark Urological Cancer Centerand the UCLA School of Medicine.

In 1992, changes had been made in nursing care practices and inareas such as laboratory and radiology procedures that saved UCLA$45 million out of an approximately $400 million flexible annualbudget, he said.

The second phase of cost cutting, called the "clinical effectivenessinitiative," expects to save another $25 million annually.Dr. Smith, chairman of the program development committee, saidthat critical paths and care management programs for selectedprocedures were formulated, using algorithms and guidelines asinputs to the process.

"Our goal was to decrease cost of care and at the same timekeep outcomes the same and perhaps even improve them," hesaid.

Radical prostatectomy was selected as the first procedure to beplaced in a critical path, because it is a high volume, high chargeprocedure that physicians deemed fairly easy to standardize.

The length of stay for radical prosta-tectomy patients at UCLAhad already been decreased from almost 9 days in 1987, to 5 daysin 1993. And although, in general, UCLA was "more expensivethan other area hospitals, for the radical prosta-tectomy procedure,the charges were comparable," Dr. Smith said.

Spelling Things Out

The critical care pathway plan that was developed for radicalprostatectomy spelled out, in great detail, what a patient shouldbe given, day by day, in terms of medicines, patient education,treatments, nutrition, and physical activities. Beginning in January,1994, the plan was utilized by all caregivers and patients.

The results of putting the plan in place were dramatic. "Itwas almost like flipping a switch, and immediately hospital stayswent down," Dr. Smith said. In fact, in the first 3 monthsthe plan was implemented, hospital stays dropped from 5.6 daysto 4.1 days. After 1 year of following the plan, the length ofstay had dropped to 2.8 days, compared with 5 to 6 days at mostcomparable institutions.

Charges for the radical prostatectomy procedure were reduced by33%, and the cost per case also decreased by 33%.

Dr. Smith identified two factors that had a large impact on thedecreased length of hospital stay and costs. First was the abilityof the plan to empower patients with regard to their surgery.They fully understood what was necessary to recover from the procedure.

In fact, the men tended to evaluate their physical capabilitiesagainst those listed in the plan--and asked to be dismissed early,if they felt they were at that stage of progress. Almost halfleft on the second postoperative day.

Second was the negative impact of epidural pain management onlength of stays. "When epidurals were used for anesthesiaand pain management, none of the patients got out early,"Dr. Smith said. But if ketorolac (Toradol) was used as the majorpain medication, patients were able to walk the day after surgery,had no bowel paralysis from morphine, and reported very littlepain. This enabled them to leave much sooner, he said.

No Apparent Downside

Has the downside of saving money been decreased quality of careand lower patient satisfaction? Not at all, Dr. Smith said. In1994, with 160 men undergoing the procedure, there was only onere-admission following discharge, and it was not related to theshorter stay.

When patients were surveyed for their opinions about their discharge,82% "strongly agreed" (and the other 18% "agreed")that they were ready to leave the hospital on the second or thirdpostoperative day. "At UCLA, this process is going on withall of our services," Dr. Smith said. "For us as anacademic medical center, it is something we absolutely have todo to survive."