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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
-
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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