Improvement of medical care quality after implementation of a clinical path monitoring program for transurethral prostatectomy patients

Laparoscopy-assisted vaginal hysterectomy clinical pathway. A multivariate analysis of impact on costs and quality of care

Numerous studies have demonstrated that a well-designed clinical pathway is an effective means of sustaining quality while controlling costs in the management of certain disease entities. We evaluated the impact that cost and medical quality have on the implementation of a clinical pathway for laparoscopy-assisted vaginal hysterectomy (LAVH). This retrospective study involved a sample of 124 patients who underwent LAVH in a medical center in central Taiwan. Patients were divided into two groups on the basis of whether they received treatment before or after implementation of the LAVH clinical pathway. The preclinical pathway group was comprised of 40 patients who underwent LAVH before clinical pathway implementation (May-December 1997). The clinical pathway group included 84 patients who underwent LAVH after implementation of the clinical pathway (January 1998-March 1999). In order to study the impact of the LAVH clinical pathway, patient characteristics were controlled by multiple linear regression. The results showed a significant reduction in cost, average length of hospital stay, and average duration of surgery and anesthesia (p < 0.01). Dependent nominal variables for clinical indicators like postoperative intravenous fluid and injection of antibiotics 48 h after surgery, and complications were analyzed by a logistic regression model. The results noted better control of antibiotic intravenous injection 48 h after surgery in the clinical pathway group (p = 0.03). The other indicators included delay of operation day, blood transfusion, patient mortality, and patients readmitted within 2 weeks. There was one operation day delay and one readmission within 2 weeks of discharge in the preclinical pathway group. Based on our results, the implementation of a clinical pathway for LAVH contains cost while maintaining quality of care, especially when the medical fees are paid under the case payment system.

The Effect of Physician Experience on Costs and Clinical Outcomes of Laparoscopic-Assisted Vaginal Hysterectomy: A Multivariate Analysis

STUDY OBJECTIVE

To evaluate whether or not a physician's experience has an effect on costs and clinical outcomes of an implemented clinical pathway for laparoscopic-assisted vaginal hysterectomy (LAVH).

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

One hundred twenty women.

INTERVENTION

LAVHs, 84 performed by senior physicians and 36 by junior physicians.

MEASUREMENTS AND MAIN RESULTS

According to results of multiple linear regression analysis, after controlling for other independent variables, senior attending physicians, each with over 6 years of experience, managed to reduce all costs related to LAVH, operating time, and length of stay. Logistic regression analysis revealed no differences in the occurrence of intravenous fluid injection, antibiotic injection more than 2 days after surgery, and complications between physicians with and those without experience. Neither group had blood transfusions, patient mortality, or readmissions within 2 weeks of discharge.

CONCLUSION

Physician experience reduces medical costs and maintains the quality of care in LAVH. We suggest regular training courses for less-experienced physicians in order to contain costs and maintain quality of care under the quota case-payment system.

The implementation of clinical paths for six common urological procedures, and an analysis of variances

OBJECTIVE

To evaluate the outcomes of treatment after implementing clinical paths for six common urological procedures, and analyse the variances from these paths.

PATIENTS AND METHODS

The study comprised 1006 consecutive patients treated according to the recommendations of the clinical path for six common urological procedures; the results of treatment were compared with those from 1006 patients treated by the same physicians before implementing the clinical paths. Total admission charges were divided into five categories, i.e. operation and anaesthesia, laboratory, radiology, pharmacy and other. The differences in these five categories before and after implementation were determined; the variance data were also tracked and analysed. Five quality indicators were monitored during implementation and compared with the data before implementation.

RESULTS

The mean length of hospital stay (LOS) and admission charges were significantly lower (P=0.03 and P<0.01) after implementation. The charges for laboratory, radiology, pharmacy and other were significantly decreased after the use of clinical paths. The common variations from the clinical paths were patient-related variance (33%) and discharge variance (26%). Variances affecting the LOS only or the admission charge only were more common than those affecting neither the LOS nor admission charges (both P<0.01), or both (both P<0.01). After implementation, the results of the five quality indicators were significantly improved and the number of patients with surgical complications was significantly reduced (P<0. 01), but the mortality and readmission rate did not increase.

CONCLUSIONS

The implementation of clinical paths for six common urological procedures decreased the LOS, admission charges and surgical complications, and improved the quality of care. During implementation, variances can affect the LOS and/or admission charges.