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NESS 2006 Annual Meeting
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Quality Assessment In High-Acuity Surgery: Volume And Mortality Are Not Enough
Charles M Vollmer, Jr., Wande Pratt, Tsafrir Vanouou, Shishir K Maithel, Mark P Callery
Beth Israel Deaconess Medical Center, Boston, MA

Objectives: Current expectations for healthcare quality improvement prompt surgeons to scrutinize outcomes; yet, the impact of variance in preoperative patient risk (acuity) across surgeons, practices, and hospitals is poorly understood. We describe a new model that evaluates the economic impact of variance in patient acuity.
Design: Retrospective case series, cost analysis.
Setting: University tertiary care referral center.
Patients: 261 elective pancreatic resections.
Main Outcome Measures: Expected preoperative morbidity (evaluated by POSSUM) was compared to observed morbidity, and correlated with total hospital costs per patient.
Results: Overall, observed (OM) and expected (EM) morbidity rates were similar (57% vs. 53%) for an O/E ratio of 1.08. As volume increased annually, patient acuity (EM) rose, while complications (OM) declined. Process improvement measures contributed to a steady decrease in the O/E morbidity ratio from 1.76 to 0.95. Despite increasing patient acuity, this still translated to significant cost-savings as total costs per patient declined annually (,088 to ,691). This assessment model predicts that a 0.10 decrease in O/E morbidity equates to a ,258 cost-savings per patient within our practice.
Conclusions: Despite increasing acuity, better clinical and economic outcomes were achieved. Approaches that mitigate the impact of preoperative risk can effectively deliver quality improvement, as measured by a reduced O/E ratio. This model is valuable in analyzing process improvements, and can be employed to assess intra and inter-practice variations.

Table. Quality improvement outcomes for pancreatic resection from 2001 to 2006.
2001 2002 2003 2004 2005
Patients (N) 14 31 42 82 92
Mortality 1 (7.1%) 0 (0%) 1 (2.4%) 1 (1.2%) 1 (1.1%)
Observed Morbidity (OM) 64% 65% 57% 60% 50%
Expected Morbidity (EM) 37% 42% 52% 58% 53%
O/E Ratio 1.76 1.52 1.09 1.03 0.95
Process Improvements
DVT prophylaxis
antibiotic prophylaxis
intraoperative blood loss
tight glucose control
450 ml
400 ml
350 ml
350 ml
300 ml
Total Cost per patient (median) ,088 ,743 ,128 ,989 ,691
Cost-savings per patient(vs. prior year) -- ,345 ,615 ,298

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