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Why Time-driven Activity-based Costing may be the "gold standard" to measure costs of surgical pathways? J Clin Anesth 2023; 85:111051. [PMID: 36641936 DOI: 10.1016/j.jclinane.2023.111051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 01/02/2023] [Indexed: 01/15/2023]
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Etges APBS, Stefani LPC, Vrochides D, Nabi J, Polanczyk CA, Urman RD. A Standardized Framework for Evaluating Surgical Enhanced Recovery Pathways: A Recommendations Statement from the TDABC in Health-care Consortium. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2021; 8:116-124. [PMID: 34222551 PMCID: PMC8225410 DOI: 10.36469/001c.24590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/01/2021] [Indexed: 06/13/2023]
Abstract
Background: Innovative methodologies to redesign care delivery are being applied to increase value in health care, including the creation of enhanced recovery pathways (ERPs) for surgical patients. However, there is a lack of standardized methods to evaluate ERP implementation costs. Objectives: This Recommendations Statement aims to introduce a standardized framework to guide the economic evaluation of ERP care-design initiatives, using the Time-Driven Activity-Based Costing (TDABC) methodology. Methods: We provide recommendations on using the proposed framework to support the decision-making processes that incorporate ERPs. Since ERPs are usually composed of activities distributed throughout the patient care pathway, the framework can demonstrate how the TDABC may be a valuable method to evaluate the incremental costs of protocol implementation. Our recommendations are based on the review of available literature and expert opinions of the members of the TDABC in Healthcare Consortium. Results: The ERP framework, composed of 11 steps, was created describing how the techniques and methods can be applied to evaluate the economic impact of an ERP and guide health-care leaders to optimize the decision-making process of incorporating ERPs into health-care settings. Finally, six recommendations are introduced to demonstrate that using the suggested framework could increase value in ERP care-design initiatives by reducing variability in care delivery, educating multidisciplinary teams about value in health, and increasing transparency when managing surgical pathways. Conclusions: Our proposed standardized framework can guide decisions and support measuring improvements in value achieved by incorporating the perioperative redesign protocols.
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Affiliation(s)
- Ana Paula B S Etges
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (project: 465518/2014-1), Porto Alegre, RS, Brazil; School of Technology, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil; Postgraduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Dionisios Vrochides
- Division of Hepatobiliary & Pancreas Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Junaid Nabi
- Harvard University, Harvard Business School, Boston, MA, USA
| | - Carisi Anne Polanczyk
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (project: 465518/2014-1), Porto Alegre, RS, Brazil; Postgraduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Richard D Urman
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (project: 465518/2014-1), Porto Alegre, RS, Brazil; School of Technology, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil; Postgraduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Division of Hepatobiliary & Pancreas Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
- Harvard University, Harvard Business School, Boston, MA, USA
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (project: 465518/2014-1), Porto Alegre, RS, Brazil; Postgraduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Khanijow AN, Wood LN, Xie R, Theiss LM, Hollis RH, Hardiman KM, Gunnells DJ, Kennedy GD, Morris MS, Cannon JA, Chu DI. The impact of an enhanced recovery program (ERP) on the costs of colorectal surgery. Am J Surg 2020; 222:186-192. [PMID: 33246551 DOI: 10.1016/j.amjsurg.2020.11.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Enhanced Recovery Programs (ERPs) benefit patients but their effects on healthcare costs remain unclear. This study aimed to investigate the costs associated with a colorectal ERP in a large academic health system. METHODS Patients who underwent colorectal surgery from 2012 to 2014 (pre-ERP) and 2015-2017 (ERP) were propensity score matched based on patient and operative-level characteristics. Primary outcomes were median variable, fixed, and total costs. Secondary outcomes included length-of-stay (LOS), readmissions, and postoperative complications (POCs). RESULTS 616 surgical cases were included. Patient and operative-level characteristics were similar between the cohorts. Variable costs were $1028 less with ERP. ERP showed savings in nursing, surgery, anesthesiology, pharmacy, and laboratory costs, but had higher fixed costs. Total costs between the two groups were similar. ERP patients had significantly shorter LOS (-1 day, p < 0.01), but similar 30-day readmission rates and overall POCs. CONCLUSIONS Implementation of an ERP for colorectal surgery was associated with lower variable costs compared to pre-ERP.
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Affiliation(s)
- Anisha N Khanijow
- Division of Gastrointestinal Surgery, Department of Surgery, 1720 2nd Avenue South, KB427, University of Alabama at Birmingham, Birmingham, 35294, AL, USA
| | - Lauren N Wood
- Division of Gastrointestinal Surgery, Department of Surgery, 1720 2nd Avenue South, KB427, University of Alabama at Birmingham, Birmingham, 35294, AL, USA
| | - Rongbing Xie
- Division of Gastrointestinal Surgery, Department of Surgery, 1720 2nd Avenue South, KB427, University of Alabama at Birmingham, Birmingham, 35294, AL, USA
| | - Lauren M Theiss
- Division of Gastrointestinal Surgery, Department of Surgery, 1720 2nd Avenue South, KB427, University of Alabama at Birmingham, Birmingham, 35294, AL, USA
| | - Robert H Hollis
- Division of Gastrointestinal Surgery, Department of Surgery, 1720 2nd Avenue South, KB427, University of Alabama at Birmingham, Birmingham, 35294, AL, USA
| | - Karin M Hardiman
- Division of Gastrointestinal Surgery, Department of Surgery, 1720 2nd Avenue South, KB427, University of Alabama at Birmingham, Birmingham, 35294, AL, USA
| | - Drew J Gunnells
- Division of Gastrointestinal Surgery, Department of Surgery, 1720 2nd Avenue South, KB427, University of Alabama at Birmingham, Birmingham, 35294, AL, USA
| | - Gregory D Kennedy
- Division of Gastrointestinal Surgery, Department of Surgery, 1720 2nd Avenue South, KB427, University of Alabama at Birmingham, Birmingham, 35294, AL, USA
| | - Melanie S Morris
- Division of Gastrointestinal Surgery, Department of Surgery, 1720 2nd Avenue South, KB427, University of Alabama at Birmingham, Birmingham, 35294, AL, USA
| | - Jamie A Cannon
- Division of Gastrointestinal Surgery, Department of Surgery, 1720 2nd Avenue South, KB427, University of Alabama at Birmingham, Birmingham, 35294, AL, USA
| | - Daniel I Chu
- Division of Gastrointestinal Surgery, Department of Surgery, 1720 2nd Avenue South, KB427, University of Alabama at Birmingham, Birmingham, 35294, AL, USA.
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Zheng Y, Mao M, Ji M, Zheng Q, Liu L, Zhao Z, Wang H, Wei X, Wang Y, Chen J, Zhou H, Liang Q, Chen Y, Zhang X, Wang L, Cheng Y, Zhang X, Teng M, Lu X. Does a pulmonary rehabilitation based ERAS program (PREP) affect pulmonary complication incidence, pulmonary function and quality of life after lung cancer surgery? Study protocol for a multicenter randomized controlled trial. BMC Pulm Med 2020; 20:44. [PMID: 32070326 PMCID: PMC7029521 DOI: 10.1186/s12890-020-1073-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 01/31/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Lung cancer surgery is associated with a high incidence of postoperative pulmonary complications (PPCs). Preliminary evidence suggests that ERAS processes can reduce overall incidence of PPCs as short- and long-term recovery improved by supporting units to adopt evidence-based care. However, the evidence is inconclusive due to insufficient high-level studies in this research field. No well-designed, adequately powered, randomized controlled trials (RCTs) have investigated the effects of pulmonary rehabilitation based ERAS program (PREP) on post-operative pulmonary complications, pulmonary function, and health related quality of life following lung cancer surgery. METHODS The PREP trial is a pragmatic, investigator-initiated, multi-center, randomized controlled, parallel group, clinical trial. Five hundred patients scheduled for minimally invasive pulmonary resection at six hospitals in China will be randomized with concealed allocation to receive either i) a pre-operative assessment and an information booklet or ii) a pre-operative assessment, an information booklet, plus an additional education, a 30-min pulmonary rehabilitation training session and the post-operative pulmonary rehabilitation program. The primary outcome is incidence of PPCs defined with the Melbourne Group Scale diagnostic scoring tool. Secondary outcomes include incidence of cardiopulmonary and other complications, pulmonary function, cardiopulmonary endurance, muscle strength, activity level, health-related quality of life (HRQoL), pre- and post-operative hospital length of stay (LOS), and total hospital LOS. DISCUSSION The PREP trial is designed to verify the hypothesis that pulmonary rehabilitation based ERAS program reduces incidence of PPCs and improves pulmonary function and HRQoL in patients following lung cancer surgery. This trial will furthermore contribute significantly to the limited knowledge about the pulmonary rehabilitation based ERAS program following lung cancer surgery, and may thereby form the basis of future recommendations in the surgical community. TRIAL REGISTRATION Chinese Clinical Trial Registry: ChiCTR1900024646, 21 July 2019.
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Affiliation(s)
- Yu Zheng
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Nanjing, 210029, China
| | - Mao Mao
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Nanjing, 210029, China
| | - Meifang Ji
- Department of Rehabilitation Therapy, the Second Affiliated Hospital of Hainan Medical University, No. 368 Yehai Road, Haikou, 570100, China
| | - Qiugang Zheng
- Department of Rehabilitation Therapy, the Second Affiliated Hospital of Hainan Medical University, No. 368 Yehai Road, Haikou, 570100, China
| | - Liang Liu
- Department of Rehabilitation Medicine, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210008, China
| | - Zhigang Zhao
- Department of Rehabilitation Medicine, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210008, China
| | - Haiming Wang
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Zhengzhou University, No. 1 East of Jianshe Road, Zhengzhou, 450052, China
| | - Xiangyang Wei
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Zhengzhou University, No. 1 East of Jianshe Road, Zhengzhou, 450052, China
| | - Yulong Wang
- Department of Rehabilitation Medicine, Shenzhen Dapeng New District Nan'ao People's Hospital, No. 6 Renmin Road, Dapeng New District, Shenzhen, 518000, China
| | - Jiamin Chen
- Department of Rehabilitation Medicine, Shenzhen Dapeng New District Nan'ao People's Hospital, No. 6 Renmin Road, Dapeng New District, Shenzhen, 518000, China
| | - Huiqing Zhou
- Department of Rehabilitation Therapy, Taizhou Enze Medical Center, Enze Hospital, No. 1 East of Tongyang Road, Taizhou, 318050, China
| | - Qiaoqiao Liang
- Department of Rehabilitation Therapy, Taizhou Enze Medical Center, Enze Hospital, No. 1 East of Tongyang Road, Taizhou, 318050, China
| | - Ying Chen
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Nanjing, 210029, China
| | - Xintong Zhang
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Nanjing, 210029, China
| | - Lu Wang
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Nanjing, 210029, China
| | - Yihui Cheng
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Nanjing, 210029, China
| | - Xiu Zhang
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Nanjing, 210029, China
| | - Meiling Teng
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Nanjing, 210029, China
| | - Xiao Lu
- Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Nanjing, 210029, China.
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Kirks RC, Cochran A, Barnes TE, Murphy K, Baker EH, Martinie JB, Iannitti DA, Vrochides D. Developing and validating a center-specific preoperative prediction calculator for risk of pancreaticoduodenectomy. Am J Surg 2018. [PMID: 29519551 DOI: 10.1016/j.amjsurg.2018.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The American College of Surgeons (ACS) Surgical Risk Calculator predicts postoperative risk based on preoperative variables. The ACS model was compared to an institution-specific risk calculator for pancreaticoduodenectomy (PD). METHODS Observed outcomes were compared with those predicted by the ACS and institutional models. Receiver operating characteristic (ROC) analysis evaluated the models' predictive ability. Institutional models were evaluated with retrospective and prospective internal validation. RESULTS Brier scores indicate equivalent aggregate predictive ability. ROC values for the institutional model (ROC: 0.675-0.881, P < 0.01) indicate superior individual event occurrence prediction (ACS ROC: 0.404-0.749, P < 0.01-0.860). Institutional models' accuracy was upheld in retrospective (ROC: 0.765-0.912) and prospective (ROC: 0.882-0.974) internal validation. CONCLUSIONS Identifying higher-risk patients allows for individualized care. While ACS and institutional models accurately predict average complication occurrence, the institutional models are superior at predicting individualized outcomes. Predictive metrics specific to PD center volume may more accurately predict outcomes.
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Affiliation(s)
- Russell C Kirks
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Allyson Cochran
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - T Ellis Barnes
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Keith Murphy
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin H Baker
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David A Iannitti
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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