Abstract
Purpose
This study evaluates medical and economic effects of a clinical pathway (CP) for open lobectomy and bilobectomy with respect to process quality, outcome quality, and hospital cost.
Methods
We compared 38 consecutive patients who underwent open lobectomy or bilobectomy between April 2007 and June 2008 and were treated with a CP (CP group) with 43 consecutive patients treated without CP between 2005 and 2007 (pre-pathway group). Indicators for process quality were duration of catheter placement, pain intensity, respiratory exercising, and mobilization. Outcome quality was measured through morbidity, mortality, re-operations, and re-admissions. Cost of hospital stay was calculated using an imputed daily rate.
Results
Central venous catheters were used in 90% of patients in the CP group (pre-pathway group 40%; p < 0.0001). Epidural catheters were placed in 84% of patients in the CP group (pre-pathway group 56%; p = 0.01). Variation in duration of catheter placement was reduced in the CP group. The reduction of hospital stay was 3 days (−19%, p = 0.003). Perioperative outcome quality remained unchanged. There was a significant cost reduction of €1,614 per stay after CP introduction (−19%; p = 0.003).
Conclusions
After CP implementation for open lobectomy the quality and standardization of care improved. Although length of hospital stay was significantly reduced, there was no significant increase of re-admissions or morbidity. Patients benefited from a shortened hospital stay while the hospital achieved cost reduction. This early analysis shows that the implementation of CP for open lobectomy has positive effects in terms of quality and cost of care.
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References
D’Addario G, Felip E (2008) Non-small-cell lung cancer: ESMO clinical recommendations for diagnosis, treatment and follow-up. Ann Oncol 19(Suppl 2):ii39–ii40
Stephan F, Boucheseiche S, Hollande J, Flahault A, Cheffi A, Bazelly B, Bonnet F (2000) Pulmonary complications following lung resection: a comprehensive analysis of incidence and possible risk factors. Chest 118:1263–1270
Ayed AK, Bazerbashi S, Chandrasekaran C, Sukumar M, Jamaleddin H (2006) Pulmonary complications following major lung resection for benign and malignant lung diseases. Med Princ Pract 15:114–119
Pezzella AT, Adebonojo SA, Hooker SG, Mabogunje OA, Conlan AA (2000) Complications of general thoracic surgery. Curr Probl Surg 37:733–858
Stiller KR, Munday RM (1992) Chest physiotherapy for the surgical patient. Br J Surg 79:745–749
Renholm M, Leino-Kilpi H, Suominen T (2002) Critical pathways. a systematic review. J Nurs Adm 32:196–202
Ronellenfitsch U, Rössner E, Jakob J, Post S, Hohenberger P, Schwarzbach M (2008) Clinical Pathways in surgery-should we introduce them into clinical routine? a review article. Langenbeck’s Arch Surg 393:449–457
Maruyama R, Miyake T, Kojo M, Aoki Y, Suemitsu R, Okamoto T, Wataya H, Ichinose Y (2006) Establishment of a clinical pathway as an effective tool to reduce hospitalization and charges after video-assisted thoracoscopic pulmonary resection. Jpn J Thorac Cardiovasc Surg 54:387–390
Soria V, Coll A, Flores B, Miguel J, Torralba JA, Andres B, Carrasco M, Aguayo JL (2005) Clinical pathway for the treatment of primary spontaneous pneumothorax in a general surgery department. Am J Med Qual 20:268–276
Vigneswaran WT, Bhorade S, Wolfe M, Pelletiere K, Garrity ER (2007) Clinical pathway after lung transplantation shortens hospital length of stay without affecting outcome. Int Surg 92:93–98
Wright CD, Wain JC, Grillo HC, Moncure AC, Macaluso SM, Mathisen DJ (1997) Pulmonary lobectomy patient care pathway: a model to control cost and maintain quality. Ann Thorac Surg 64:299–302
Zehr KJ, Dawson PB, Yang SC, Heitmiller RF (1998) Standardized clinical care pathways for major thoracic cases reduce hospital costs. Ann Thorac Surg 66:914–919
Campbell H, Hotchkiss R, Bradshaw N, Porteous M (1998) Integrated care pathways. BMJ 316:133–137
Schwarzbach MH, Ronellenfitsch U, Wang Q, Rössner ED, Denz C, Post S, Hohenberger P (2010) Effects of a clinical pathway for video-assisted thoracoscopic surgery (VATS) on quality and cost of care. Langenbeck’s Arch Surg 395:11–17
McKenna RJ, Mahtabifard A, Pickens A, Kusuanco D, Fuller CB (2007) Fast-tracking after video-assisted thoracoscopic surgery lobectomy, segmentectomy, and pneumonectomy. Ann Thorac Surg 84:1663–1667
Kehlet H (2008) Fast-track colorectal surgery. Lancet 371:791–793
Gregor JI, Schwenk W, Mall J, Kilian M, Spies C, Bloch A, Muller JM, Ruckert JC (2008) "Fast-track" rehabilitation in thoracic surgery. First experiences with a multimodal, interdisciplinary, and proven perioperative treatment course. Chirurg 79:657–664
Mühling BM, Halter GL, Schelzig H, Meierhenrich R, Steffen P, Sunder-Plassmann L, Orend KH (2008) Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway. Eur J Cardiothorac Surg 34:174–180
Curtis LT (2008) Prevention of hospital-acquired infections: review of non-pharmacological interventions. J Hosp Infect 69:204–219
Schilling MK, Richter S, Jacob P, Lindemann W (2006) Clinical pathways—first results of a systematic IT-supported application at a surgical department of a university hospital. Dtsch Med Wochenschr 131:962–967
Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J, Fazio VW (2003) Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum 46:851–859
Avital S, Hermon H, Greenberg R, Karin E, Skornick Y (2006) Learning curve in laparoscopic colorectal surgery: our first 100 patients. Isr Med Assoc J 8:683–686
Acknowledgments
We thank Bärbel Rothhaar for providing cost data from hospital controlling systems and Brigitte Pagel for the invaluable support in teaching the nursery staff and explaining the value of process improvement. We thank the German Society for Process Management (DGKPM) for supporting this project.
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Matthias Schwarzbach and Eric Rössner contributed equally to this paper.
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Schwarzbach, M., Rössner, E., Schattenberg, T. et al. Effects of a clinical pathway of pulmonary lobectomy and bilobectomy on quality and cost of care. Langenbecks Arch Surg 395, 1139–1146 (2010). https://doi.org/10.1007/s00423-010-0600-y
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DOI: https://doi.org/10.1007/s00423-010-0600-y