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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
| -
0%
79%
450 ml
44% | -
6%
87%
400 ml
61% | -
60%
88%
350 ml
63% | -
85%
94%
350 ml
55% | -
100%
100%
300 ml
69% | | Total Cost per patient (median) | ,088 | ,743 | ,128 | ,989 | ,691 | | Cost-savings per patient(vs. prior year) | -- | ,345 | ,615 | | ,298 |
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