Critical Pathway Methodology: Effectiveness Congenital Heart Surgery

Transcription

1 Critical Pathway Methodology: Effectiveness Congenital Heart Surgery Kevin Turley, MO, Michael Tyndall, MO, Claude Roge, MO, Michael Cooper, MO, Kerry Turley, RN, MPA, Michael Applebaum, MO, and Harold Tarnoff, MO California Pacific Medical Center and Kaiser Permanente Medical Center, San Francisco, California In Critical pathway methodology has been demonstrated to provide producible reduction in average length of stay (ALOS) in adults in certain diagnostic-related groups and operations such as coronary artery bypass grafting. The efficacy of this approach in congenital heart surgery was explored. Two hundred eighty-six consecutive patients from a health maintenance organization treated by a single surgeon since the institution of diagnostic-related group coding at that health maintenance organization constituted the study group. One hundred fourteen patients were treated at a university hospital without critical pathway methodology (group 1) and 172, subsequently at the health maintenance organization institution using the methodology (group 2). Operation/ lesion, age, and diagnostic-related group matching was possible in 61 pairs of patients. Examination of the ALOS Hospital (operative and postoperative days) for the entire cohort revealed a 43.8% reduction in ALOS Hospital (p < ) and a 39.0% reduction in ALOS Intensive Care Unit (p < ). There was also significant reduction in ALOS Hospital and ALOS Intensive Care Unit in the operation/lesion-matched subsets. Outcome measures including operative and late mortality, readmission, unscheduled emergency room and clinic visits, and health maintenance organization family assessment survey demonstrated no improvement in outcome with increased hospital stay. Thus, critical pathway methodology when used in patients undergoing a congenital heart operation produces a significant reduction in hospital stay and intensive care unit stay as well as quality patient care with uniformity of outcome. (Ann Thorae Surg ) Escalating hospital costs and contraction of available resources mandate the development of effective strategies of cost containment in the new era of health care delivery. Total quality management, an industry technique, teaches that the most effective way to improve quality is to reduce variation in the process of providing a service or producing a product [1, 2]. In the field of health care delivery, physician-directed diagnostic and therapeutic plans, commonly called the critical pathway methodology (CPM), provide such an approach in the hospital setting by reducing variation in clinical processes and, it has been proposed, improving the quality of patient care while reducing hospital stay. Critical pathway methodology is the application of total quality management principles to clinical care [1]. This approach has been used in neurosurgical, emergency room, trauma, orthopedic, neonatal intensive care, and most recently, coronary artery bypass patients [3-8]. The current study explores the efficacy of this approach in patients undergoing a congenital heart operation. Material and Methods The study group included 286 consecutive patients from a health maintenance organization (HMO) treated by a Presented at the Thirtieth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 31-Feb 2, Address reprint requests to Dr Turley, Pediatric Cardiac Surgery, California Pacific Medical Center, 2100 Webster St, #332, San Francisco, CA by The Societyof Thoracic Surgeons single surgeon since the institution of diagnostic-related group coding at the HMO. One hundred fourteen patients were treated at a university hospital without CPM (group 1) and 172, subsequently at the HMO institution using CPM (group 2). Critical pathway methodology involves the preparation and development of a clinical plan for each treatment group, a process to implement that plan to ensure adherence to the process, and the monitoring and evaluation of clinical outcomes to test ways to improve outcomes and efficiency and add to the plan as appropriate. Inherent to every process are predictable variations with controllable common causes and unpredictable variations with uncontrollable special causes. Critical pathway methodology attempts to identify the former and reduce variations in clinical results while actively treating the latter to minimize their effects. The pathways represent a number of planned diagnostic and treatment processes, and they proceed through preoperative days, operative day, and postoperative days 1, 2, 3, and so on. This is demonstrated in Table 1, our pathway form. Illustrative Example An example is the case of 2-year-old patient with ventricular septal defect (VSD) of the perimembranous type. Education and discharge planning is begun during the first contact with the family. Arrangements are made for donor-designated blood donations, and problems are identified by the clinical nurse coordinator in the individual case. Less than 1 week prior to operation, indoctrina /94/$7.00

2 58 TURLEY ET AL Ann ThoraeSurg Table 1. Our Critical Pathway Form > 1 <1 Day Day Day Day Pathway Week Week -lor Education and Yes Yes Yes Yes Yes Yes Yes discharge planning Consultation Yes Yes Yes Yes Activity Yes Yes Nutrition Yes Yes Yes Yes Pain prevention! Yes Yes Yes Yes medication Monitoring Yes Yes Yes Yes Extubation/ Yes Yes Yes respiratory Diagnostics Yes Yes Yes Yes Yes Yes Treatments Yes Yes OR = operating day. tion of the family as to the expected course of the patient as well as the family involvement occurs with finalization of the blood product issues. Appropriate consultations are initiated concerning nutrition, special monitoring problems, or pulmonary problems that might influence extubation. Additional diagnostic procedures are identified by the surgeon planner and clinical nurse coordinator, and arrangements are concluded. The day before operation, preoperative teaching is again repeated, and the team involved in the operation consults with the family. Preoperative studies including complete blood count, urinalysis, chest roentgenogram, blood chemistry studies, and coagulation studies are obtained and vital signs, recorded. On the day of operation, family support is provided, activity is bed rest, nutrition is nothing by mouth, and pain prevention is initiated in the form of acetaminophen (10 to 15 mglkg rectally, every 4 hours) as well as narcotic administration. Extubation occurs within the first several hours after operation with arterial, central venous, urine, and blood gas monitoring. Intravenous fluids are administered at full maintenance. On the first postoperative day, an electrocardiogram, chest roentgenogram, and blood tests confirm the appropriate removal of the chest tube and the monitoring devices, including the arterial line, the central venous line, and the Foley catheter. The family's involvement in the child's postoperative care is initiated. Activity is up in a chair all day and ambulation every hour. Nutrition remains nothing by mouth, and the pain prevention regimen is continued with the addition of a nonsteroid, antiinflammatory drug. An electrocardiogram and chest roentgenogram are obtained, and the intravenous fluids are decreased to two-thirds of maintenance with diuretics administered. By the second postoperative day, full activity with family involvement has occurred. Nutrition is returned to a regular diet, and the pain prevention regimen continues. Monitoring is routine, and the intravenous fluids are discontinued. Discharge planning is completed on the third postoperative day with appointments arranged and a postoperative care handbook delivered to the family. Discharge examination, electrocardiogram, chest roentgenogram, and blood work confirm suitability for discharge, and copies are provided to the family. The pain prevention program is continued for 4 additional days with regular administration of the nonsteroid, antiinflammatory drug and then as needed. Discharge planning is completed with follow-up appointments arranged with Cardiology within 1 week and Pediatric Cardiac Surgery within 1 month. Thus, the critical pathway provides a day-by-day plan that specifies the use and timing of procedures in relation to the stage of the patient's recovery. Variations from this plan can be identified and aggressively approached. Patient Population The 114 patients treated at the university hospital using standard cardiovascular surgical service care (group 1) received that care in an era of increasing competition and contracting, with attempts at the institution to minimize both hospital stay and intensive care stay when contracting with the HMO. The method of care had developed over the 15 years of the involved surgeon's participation in that cardiovascular surgical service, contracting, and involvement with the HMO. Operation/lesion, age, and diagnostic-related group matching was possible in 61 pairs of patients (to optimize both patient and payee comparisons). Age distribution was 2 days to 17 years. Age matching was performed using California Children Services age-reporting categories as the minimal standard (>1 month, 1 to 11 months, 1 to 4 years, 5 to 14 years, and 15 to 21 years), with closest-match and within-group comparisons performed to eliminate bias in matching. Operation/lesion subsets included the following: VSD in 13, including 9 with VSD, 1 with VSD and subaortic stenosis resection, 1 with VSD and atrial septal defect, 1 with VSD, atrial septal defect, and patent ductus arteriosus, and 1 with VSD and removal of a pulmonary artery band; atrial septal defect in 11, including 6 with secundum and 4 with primum atrial septal defect, and 1 with atrial septal defect and patent ductus arteriosus; coarctation of the aorta in 8, including 1 with repeat coarctation and 3 with aortic coarctation plus patent ductus arteriosus; patent ductus arteriosus in 6; tetralogy of Fallot in 5, including 1 with VSD and resection of infundibular stenosis; shunts in 5 including three Blalock-Taussig and two central shunts; pulmonary artery banding in 4; bidirectional Glenn repair in 3; subaortic stenosis resection in 3; and a group with miscellaneous complex conditions requiring cardiopulmonary bypass, including 1 with a Fontan procedure, 1 with aortic valve replacement, and 1 with total anomalous pulmonary venous connection repair. Preoperative clinical condition (New York Heart Association class) was matched, and associated conditions were reviewed in each pair; mismatched sets were eliminated. Average length of stay (ALOS) was compared both for hospital days (ALOS Hospital) and intensive care unit days (ALOS ICU) with the days determined by the patient's presence at 12 midnight of the given day (oper-

3 Ann Thorae Surg 1994;58:57...{j5 TURLEY ET AL 59 ative day plus postoperative days). This method avoided variations in arrival from the operating room and discharge time not controlled by the method of care. Discharge from the hospital was to home in all cases, Preoperative day was omitted in the calculations, as variations in its use are independent of the use of CPM, but clearly it can significantly affect total length of stay as an independent variable. Analysis of the ALOS Hospital was performed in 58 of the matched pairs. Three of the matched sets were eliminated because of extended ALOS in the university hospital group (group 1). These stays might have been prevented by CPM, but as a result of the extended stays of 64 days (VSD), 19 days (aortic coarctation), and 25 days (subaortic stenosis resection), a bias in results might have occurred (ALOS Hospital-58 sets). Two additional matched sets were eliminated from the ALOS ICU analysis because of extended stay or readmission for arrhythmias, again in group 1. The stays of 4 days and 6 days might have biased results in the ALOS ICU group (56 sets). Analysis of the entire cohort that is, the matched pairs, and the operation/lesion subsets was performed using the Wilcoxon signed rank test and nonparametric Spearman correlation coefficient to examine the matched pairs and the Mann-Whitney U statistic to examine the subsets. Results in both ALOS Hospital and ALOS ICU groups were expressed as the p value of both the rank test and U statistic and as the r value of the correlation coefficient and the p value in the matched-set comparison. Percent change in ALOS both for the hospital and ICU groups are documented as well as percent 3 days and percent 4 days ALOS Hospital and percent 1 day ALOS ICU for each of the cohorts and subsets. Outcome measures examined included early mortality, late mortality, readmission less than 14 days after discharge, unscheduled clinic or emergency room visit less than 14 days after discharge, and negative assessment on the HMO family assessment survey (only in group 2). Results Two hundred eighty-six consecutive patients treated for congenital heart disease by a single cardiac surgeon for a single HMO were reviewed. One hundred fourteen were treated at a university hospital without CPM (group 1), and 172 subsequently were treated at the HMO facility using CPM (group 2). The operative mortality rate in group 1 was 7.0% (8 patients) and in group 2, 1.2% (2 patients). One late death occurred in group 1 at a completion Fontan procedure after a bidirectional Glenn operation. Readmission within 14 days was necessary for 4 patients in group 1 because of infection (2 patients, 1.8%), arrhythmia (1 patient, 0.9%), and postpericardiotomy syndrome (1 patient, 0.9%) and in 3 patients in group 2 because of infection (1 patient, 0.6%) and postpericardiotomy syndrome (2 patients, 1.2%). Review of the HMO family assessment survey revealed positive comments concerning hospital length of stay and ICU stay with no negative findings. The ALOS Hospital was analyzed in 116 operation/ lesion-, age-, and DRG-matched patients (58 sets), and results are illustrated in Table 2. The ALOS Hospital for the entire group 1 cohort was 6.62, with a standard deviation of 2.65 and a range of 4 to 14 days. In group 2 using CPM, ALOS Hospital was 3.72, with a standard deviation of 1.01 and a range of 3 to 7 days. Analysis revealed marked reduction in ALOS Hospital for the entire cohort (-43.8%; p < ) and for each subset in group 2 compared with group 1. Further, greater uniformity of outcome as demonstrated by a narrow range (3 to 7 days versus 4 to 14 days) and standard deviation (1.01 versus 2.65) was noted in group 2 (Fig 1). The ALOS ICU was analyzed in 112 operation/lesion-, age-, and DRG-matched patients (56 sets), and the results are illustrated in Table 3. The ALOS ICU for the entire cohort was 2.05, with a standard deviation of 1.13 and a range of 1 day to 7 days for group 1 and 1.25, with a standard deviation of 0.48 and a range of 1 day to 3 days for group 2. Analysis revealed a marked reduction in ALOS ICU for the entire group 2 cohort (-39.0%; p < ). Again, when each subset in group 2 was compared with group 1, a greater uniformity of outcome was demonstrated by the narrow range (1 to 3 days versus 1 to 7 days) and standard deviation (1.25 versus 2.05) in group 2 (Fig 2). Examination of the minimal hospital stay data revealed that 53% of the patients in group 2 were discharged on the third postoperative day versus 0% in group 1 (Fig 3) and that 86% of the patients in group 2 were discharged on the fourth postoperative day versus 16% in group 1 (Fig 4). The ALOS ICU data demonstrated that 77% of group 2 patients were discharged on the first ICU day, whereas only 29% of group 1 patients were discharged at that time (Fig 5). These results are consistent in the group 1 and group 2 subsets, as demonstrated in Table 4. Thus, CPM produces a marked reduction in overall ALOS Hospital of -43.8% and ALOS ICU of -39.0% while achieving narrow ranges of ALOS and providing uniformity of outcome and predictability for the entire cohort and the specific subsets. Dramatically improved ICU and hospital discharge data are demonstrated in the group 2 patients, both for the total cohort and each subset (-34.0% to -51.1% ALOS Hospital and -22.2% to -53.6% ALOS ICU). Outcome measures for the 58 matched pairs in the ALOS Hospital group are demonstrated in Table 5. There were no early deaths and one late death in group 1 at reoperation for a completion Fontan procedure, as previously noted. There was one readmission for infection and one readmission for a rhythm disturbance in group 1, and only one readmission for postpericardiotomy syndrome in group 2. Two unscheduled clinic or emergency room visits were noted in group 1 versus only 1 in group 2. The HMO family assessment survey in group 2 confirmed positive patient response to shortened ALOS Hospital and ALOS ICU experience without negative comments.

4 60 TURLEY ET AL Ann Thorac Surg Table 2. Hospital a Operation/ Lesion ALOS Standard % Subset Group N (d) Mean Deviation Range Change p r p VSD ASD ToF ]- O.OOOl b ]- O.OOOl b ~ l Complex CoA PDA Shunt PAS Total ] a Analysis was done using Wilcoxon signed rank test and nonparametric Spearman correlation coefficient to examine matched pairs and Mann-Whitney U statistic to examine subsets. b This is p value for U statistic. ALaS = average length of stay; ASD = atrial septal defect; CoA = coarctation of aorta; PAB = pulmonary artery banding; PDA = patent ductus arteriosus; ToF = tetralogy of Fallot; VSD = ventricular septal defect. Comment The CPM has been used in the care of multiple patient groups including neurosurgical, emergency room, trauo '--_L--_ * CPS * Non CPS o Group 1 Group 2 p < Fig 1. Average length of stay in hospital for group 1 versusgroup 2 matched sets with operations requiring cardiopulmonary bypass (CPB), not requiring cardiopulmonary bypass (Non CPB), and total (58 sets). * Total rna, orthopedic, neonatal intensive care, and, most recently, coronary artery bypass patients [3---8]. In these studies, overall adherence to the critical path were found to be significant predictors of postoperative length of stay [8]. The critical path is a day-by-day plan that notes the appropriate use and timing of procedures in relationship to the stage of patient recovery. It is divided into a number of categories. These include education and discharge planning, consultation, activity, nutrition, pain prevention/medication, monitoring, extubation/respiratory, diagnostics, and treatments in the current study. Each is individualized to the patient, operation/lesion, age, coexisting morbidities, and other factors. Critical Pathway Methodology as used in the current study is derived from total quality management techniques, a method used in industry to reduce variation in the process of providing a service or producing a product. This method when applied to medical practice has been called physician-directed diagnostic and therapeutic plans. However, as used in the current study, the term

5 Ann Thorac Surg TURLEYET AL CRlTICAL PATHWAYS IN CONGENITAL HEART SURGERY 61 Table 3. Average Length of Stay Intensive Care Unit" Operation! Lesion ALaS Standard Subset Group N (d) Mean Deviation Range % Change p p VSD ASD ToF ] ] b Complex CoA PDA Shunt PAB Total ]_ ] a Analysis was done using Wilcoxon signed rank test and nonparametric Spearman correlation coefficient to examine matched pairs and Mann-Whitney U statistic to examine subsets. b This is p value for U statistic. ALOS = average length of stay; ASD = atrial septal defect; CoA = coarctation of aorta; PAB = pulmonary artery banding; PDA = patent ductus arteriosus; ToF = tetralogy of Fallot; VSD = ventricular septal defect. Critical pathway method is more applicable because all the elements of the team-the surgeon planner, the clinical nurse coordinator, physician and nurse implernenters, o CPS Non CPS Total D Group 1 Group 2 p < P < 0.01 Fig2. Averagelength of stay in intensive care unit for group 1 versus group 2 matched sets with operations requiring cardiopulmonary bypass (CPB), not requiring cardiopulmonary bypass (Non CPB), and total (56 sets). and family-were actively involved in the successful use of the pathways [1, 2, 9, 10]. Central to the methods used in the current study is the concept of the clinical nurse coordinator whose position ~60 ~ ~ " CPS Non-CPS o Group 1 Group 2 Total Fig3. Percentage of patients discharged on third postoperative day in groups 1 and 2. (CPB = cardiopulmonary bypass,)

6 62 TURLEY ET AL Ann Thorac Surg o L-----'- CPS Non-CPS Total Fig. 4. Percentage of patients discharged on fourth postoperative day in groups 1 and 2. (CPB = cardiopulmonary bypass.) 100 o Group 1 80 Group 2 -c:: 60 Q) o Group 1 80 c: 60 Q) 0... ~40 20 ~40 20 Group 2 and responsibilities are modeled on those of transplant coordinators. The clinical nurse coordinator interacts with the family before admission to develop both a rapport and family involvement in the patient's care and ultimate outcome; the coordinator informs and indoctrinate the family as to the methods by which it will affect a successful outcome (a care plan for the family). Planning by both the clinical nurse coordinator and the surgeon planner produces the specific critical pathway method for the individual patient. It is designed to optimize treatment, reduce variability, and maximize outcome measures. Understanding the mechanism of this approach demands an appreciation of the models of CPM that have been used. We have identified three models. The first, most commonly described, we characterize as reactive. It is designed around an in-hospital clinical nurse specialist/ educator or case manager who monitors and reports variations from the clinical pathway, thus policing the system. This model takes its origin in standard qualityassurance programs. It can reduce variation over the long term but fails to produce total team and family involvement in the process and tends to codify the maximal improvement possible. The problem with this approach is that if a 5- or 7-day course is predetermined by the plan, this is the maximal result possible, and patient progress that exceeds that outcome is prohibited. The second model, developed with the concept of the 0 CPS Non-CPS Total Fig5. Percentage of patients discharged from intensive care unit on first postoperative day in groups 1 and 2. (CPB = cardiopulmonary bypass.) Table 4. Hospital and Intensive Care Unit Days ALaS = average length of stay; ASD = atrial septal defect; CoA = coarctation of aorta; ICU = intensive care unit; PAB = pulmonary artery banding; PDA = patent ductus arteriosus; ToF = tetralogy of Fallot; VSD = ventricular septal defect. Variable ALOS Hospital Group 1 Mortality, early 0 Mortality, late 1 Readmission 2 Unscheduled ERiclinic 2 Negative family NA assessment ER = emergency room; NA = not applicable. ALOS lcu 3 Days 4 Days 1 Day Operation! Group Group Group Group Group Group Lesion Subset n (%) (%) (%) (%) n (%) (%) VSD ASD ToF Complex CoA PDA Shunt PAB Total clinical nurse coordinator, is the interactive approach. This was how the management of the current study was begun. In it, active involvement to ensure progress in the pathways by the clinical nurse coordinator and surgeon planner, from preadmission indoctrination of the family through postoperative pathway development and postdischarge care, was proposed. In this approach, the entire team, including the physicians and nurses implementing the pathway as well as the family members, are actively involved in assuring the pathway's progress. Although it may provide successful implementation of the critical pathway method, this approach still tends to codify outcome within the preoperative plan. Finally, over the course of the current study, a third model, which we characterize as proactive (so distinctive from the others that the new name radical outcome method has been applied) was developed. This model attempts to anticipate both problems and opportunities to accelerate recovery by altering and upgrading the pathway design to conform to the individual response of the patient. This dynamic approach reduces negative variation as with other CPM models while providing the potential to produce positive variations. Again, the involvement of the entire team, including family members, potentiates this process, thus allowing a patient to out- Table 5. Outcome Data for 58 Pairs in Average Length of Stay Hospital Group Group 2 o o 1 1 o

7 Ann ThoraeSurg TURLEY ET AL 63 perform the system. Using this model, the codification of maximal results problematic to CPM design can be overcome with a resulting marked reduction in ICU days, use of diagnostic procedures, and reduction in total hospitalization, as those factors are most greatly influenced by positive variations from the pathway plan. In the current era of spiraling medical costs and need of cost containment, both for the HMO and for the providers of care, practice guidelines designed to decrease variability in outcome and provide reproducible results are necessary. For the HMO, internal costs of a program as described here are directly influenced by the ALaS Hospital, ALaS ICU, and outcome measures. For a provider in the current setting of contracting and capitation, these same factors influence the ability to contract and the profitability of a capitation system [2]. In the current study, ALaS Hospital was significantly reduced, thereby providing a shorter hospitalization in group 2 and decreasing the cost for the HMO and potentially for the contracting providers. However, the cost of hospitalization is not linear; as ALaS increases, so do costs and in a noncapitation system, reimbursement tends to decrease. Further, although decreasing ALaS Hospital significantly reduces costs, it cannot be viewed alone. The first several days of hospitalization, and ICU days in particular, can profoundly increase actual costs. In the current study, ALaS ICU was significantly reduced with a l-day ICU stay noted in 77% in group 2 versus 29% in group 1. Finally, outcome data demonstrated no increase in mortality or morbidity, readmission, or unscheduled clinic or emergency room visits in group 2. These potential hidden costs are thus avoided in the current approach, and the HMO family assessment survey demonstrated satisfaction with the pathway method without negative input. This latter observation reflects the preparation and indoctrination of the families concerning the method and their involvement in the ultimate successful outcome. Early transfer from the ICU and early discharge are considered positives reflecting the successful course of the patient. Rapid recovery is considered the desired norm and variations are actively and aggressively treated by the physician, nursing staff, and family members. The critical question asked is, What are we doing special for you in the hospital today that cannot be done at home? The families know this question; the families expect this question. When the answer is, Nothing, successful outcome and discharge are the hard-earned reward of their efforts. In appreciation to Helen Archer-Duste, RN, MS, Wendy Leutgens, RN, MS, Peggy Cafferty, RN, BSN, physicians, and pediatric nursing staff at Kaiser San Francisco without whose help this study would not be possible and to Sophia Seto for research and preparation of the manuscript. References 1. Critical paths: a pre-existing tool ready-made for TQM implementation. QlffQM 1992;2: Hart R, Musfeldt C. MD-directed critical pathways: it's time. Hospitals 1992;66: Richards JS, Sonda LP, Gaucher E, Kocan MJ, Ross DA. Applying critical pathways to neurosurgery patients at the University of Michigan Medical Center. Qual Lett Healthc Lead 1993;5: Nelson MS. Critical pathways in the emergency department. J Emerg Nurs 1993;19: Latini EE, Foote W. Obtaining consistent quality patient care for the trauma patient by using a critical pathway. Crit Care Nurs Q 1992;15: Metcalf EM. The orthopedic critical path. Othrop Nurs 1991; 10: Neidig JR, Megel ME, Koehler KM. The critical path: an evaluation of the application of nursing case management in the NICU. Neonatal Netw 1992;11: Strong AG, Sneed NV. Clinical evaluation of a critical path for coronary artery bypass surgery patients. Prog Cardiovasc Nurs 1991;6: Hofmann PA. Critical path method: an important tool for coordinating clinical care. [t Comm Qual Improv 1993;19: Crummer MB, Carter V. Critical pathways-the pivotal tool. J Cardiovasc Nurs 1993;7:30-7. DISCUSSION DR JOHN E. MAYER, JR (Boston, MA): I appreciate the invitation to discuss this work, and I thank Dr Turley for providing me a manuscript copy in advance of the meeting. There are several messages in this presentation that are of great importance to cardiothoracic surgeons regardless of their type of practice. In the past, our efforts to improve the quality of care were focused on reducing mortality and morbidity, but it is becoming increasingly clear to us in Massachusetts, as it obviously is to our colleagues in California, that we must expand our idea of quality to include the cost of what we do. This concept of value for outcome rather than simply good outcome alone is one that I think we all have to embrace if we are to survive. Doctor Turley has shown us data that suggest that length of stay in the hospital and in the intensive care unit can be reduced by this technique of critical pathway management. Clearly length of stay is important, but there are other resources that can be similarly managed, such as use of the laboratory, roentgenograms, and electrocardiograms. A similar although less proactive approach, known as case management as Dr Turley very nicely explained, was used in our hospital in an attempt to reduce utilization of these kinds of resources in patients having repair of atrial septal defects only. Reductions in hospital charges were on the order of 10% to 15%, without any effort made to change the length of stay, which was already relatively short. This was a fairly painless process, and we were amazed at how many things we were doing that we did not need to do. My first question for Dr Turley is whether he has any data on either costs or charges or utilization of specific resources in the two groups of patients, for example, office visits after discharge, laboratory tests, and roentgenograms. I think as prospective payment and capitation become more prevalent, we will have to look at all the costs involved, not just what happens in the hospital. There is a major problem in our hospital, and probably in others, in identifying what "costs" are, because they actually can be quite at variance with what the hospital charges. The second concept that this presentation emphasizes is the

8 64 TURLEY ET AL Ann Thorac Surg 1994;58: role of the cardiothoracic surgeon as a team leader. I infer from the manuscript and from discussions with Dr Turley that the clinical nurse coordinator plays a major role in ensuring that this process is implemented, including selling the family on the idea that if we are not doing something for you in the hospital, you should go home. Many, if not most, of us have already begun to evolve into team leaders, and I think it is going to be critical for us to focus our team's attention on issues such as those identified by Dr Turley. My second question for Dr Turley is, who paid for the clinical nurse coordinator: you or the Health Maintenance Organization (HMO)? Do you have an estimate of how much the involvement of this personnel resource, that is, the clinical nurse coordinator, added to the total cost of the hospitalization? That is clearly going to offset some of the gains made by reducing length of stay and resource utilization. My final question is whether or not there were any other systematic differences between the two groups, particularly as the operations were carried out in two different institutions. In particular, I wonder if you looked at anesthesia techniques or pain management techniques. I think those are built into this system, but maybe Dr Turley could elaborate a little bit for us. I congratulate Dr Turley on his study, and I congratulate the Program Committee on selecting this manuscript because it focuses attention on what I believe is an extraordinarily important topic. DR JOHN TERRANCE DAVIS (Columbus, OH): I add my congratulations. We at Children's Hospital in Columbus have had this methodology in place since 1991 for patients with less complex conditions and have found similar results. Your paper compares results at two different institutions. Our data describe the changes after introducing these methods in a teaching hospital. We reviewed the average length of stay after 65 consecutive atrial septal defect repairs performed before and after initiation of this methodology. With the initiation of the program, we realized an immediate 54% decrease in the overall length of stay. We also reviewed the effect on hospital charges. We had roughly a 34% decrease in average charge with this program. We have been so pleased with these results that we have extended this methodology to all of our patients by adding a second and third level of complexity. I gather that your pathways are individually defined for each patient. Do you think there might be a way to standardize these into a few pathways? Finally, how do you track variances? We find this needs constant attention to detail and some policing, which is done by our clinical specialists. DR STEVEN W. GUYTON (Seattle, WA): My colleagues and I are not involved in congenital heart procedures, but in our coronary bypass clinical pathway, we are in the second revision of our idealized pathway. One concern I have is in developing the pathway and tracking patients through it, what methods have you built in for eventually revising the pathway, the tests involved, the length of stay predicted, and those sorts of changes as time goes on? I have one caution, which involves administration of laboratory and radiological services. As we have inculcated this spirit of cost cutting throughout our institution, we have seen about a onethird drop in laboratory and radiological utilization. That has very greatly affected the income from those services. DR HASSAN NAJAFI (Chicago, IL): I think this is a very important paper. I congratulate not only Dr Turley but also the Program Committee for having the insight to put this issue on the program. Two years ago, we established a critical pathway for adult cardiac surgery at Rush-Presbyterian-St. Luke's Medical Center in Chicago. Although I am pleased with the reduction in length of stay by some 30%, from 11 days to 8 days or less, the cost has not been equally reduced. The reason is obvious: we are seeing sicker and older patients who stay in the intensive care unit longer, and that is where the majority of the costs are incurred. I believe that if we could establish the reduction in intensive care unit stay by a step-down unit or other methods, we could also reduce costs. DR BENSON R. WILCOX (Chapel Hill, NC): My question concerns the admission time for these children. Were they admitted the day before operation or the day of operation? DR TURLEY: I thank the discussants for their kind comments and insightful discussion. I will begin my response with the last question from Dr Wilcox. All the children in the study, both at the university and the HMO, were allowed a preoperative day. The HMO provided this at the university, and members of the HMO team found it to be most cost-effective for them to provide their usual service and still have a preoperative evaluation and contact with the family within their schedules. In the HMO setting, a hospital bed was provided. The difference obviously would be noted in the private setting, where increased costs accrue for this hospital day, and this was present in the university group, group 1. In examining our results for critical pathway methodology in our private population, no difference is noted between patients allowed a preoperative day and those having same-day operation. This is due to the extended preoperative evaluation in our method with introduction, indoctrination, and preparation of the patient and his or her family beginning at the initial referral and not dependent on contact the day before operation. Consultations (for example, for anesthesia) can occur on an out-patient basis during this preoperative time without altering pathway effectiveness. Doctor Najafi identifies a major problem in cost containment, which centers on the nonlinear nature of true hospital cost. The greatest costs occur on the operative day and intensive care unit days, and both shortening and reduction in this area maximize cost containment. Likewise, Dr Guyton makes an important point, namely, that these cost-cutting measures result in decreased utilization of laboratory and radiological services, thus lowering the income of such services. These changes are ideally experienced in the HMO setting, where total cost containment is the objective. A culture shock will be experienced by the service areas in the managed competition system. Doctor Guyton's question identifies an important point in our approach to critical pathway methodology. With the reactive method, late identification of variance is possible but fails to progressively improve results. In the interactive approach, a more dynamic identification of variance can occur. However, only in the proactive method, which we have most recently developed, are "critical moments" identified at which the individual patient can outperform the plan, and acceleration of the plan is possible. Combined with regular evaluation and internal monitoring, this proactive approach maximally shortens both average length of hospital stay (ALOS Hospital) and average length of stay in the intensive care unit (ALOS ICU). Doctor Davis's point concerning the different institutions is well taken and was important in our selection of patient matching in our analysis. He confirms the decrease in ALOS Hospital in his

9 Ann ThoraeSurg TURLEY ET AL 65 experience but identifies several levels of critical pathways that may be developed. We agree that several pathway levels can be identified preoperatively and the critical moment that most influences these is extubation. However, we believe the individualization of the patient is very important in designing pathway methodology, and even complex repairs can be accelerated to a "simple" pathway. When failure occurs because of complications in the operative critical moment or late complications, the patients move to the longer pathway designs, but trying to predetermine the result will inappropriately condemn them to a longer pathway design. The proactive method aggressively deals with variances, both real time and at subsequent review, and I agree completely that monitoring for days to weeks can contain only extraneous costs. I appreciate Dr Mayer's important observation that the concept of value for outcome rather than simply good outcome is critical today. His questions identify two important areas. First, what are the costs, when did they occur, and are there increased costs after discharge? Second, are there differences in care that separate our group 1 from group 2? Decrease in ALOS Hospital and ALOS K'U clearly reduced the use of laboratory and radiological services. These costs differ between an HMO institution, or group 2, and a linear hospital charge, or group 1, thus making comparison difficult. However, in a capitation system, cost analysis is similar to that of an HMO, namely, true cost and reduction in utilization reflect reduction in cost. Important to our approach is the use of the clinical nurse coordinator. The cost of such a person must be weighed against the important outcome measures to be identified, ALOS Hospital, ALOS K'U, and late problems. As a contracted capitation provider, I must weigh that cost against the savings incurred by a shortened ALOS leu and ALOS Hospital and the total decrease in variation in delivering the service. Differences between the two institutions are seen in many areas but mainly in the use of the critical pathway method. However, as noted by Dr Mayer, anesthesia technique and other areas must develop and change if this aggressive approach is to be used. In our experience in group 2, no change in intraoperative technique occurred. However, early extubation was the goal, and a method of continuous pain management, "pain prevention" as we call it, was used, with pain medication in the form of Tylenol (acetaminophen) given perrectum every4 hours and the use of nonsteroid, antiinflammatory drugs on a regular basis to prevent pain rather than as occasion arises, which I have always considered to be waiting until the patient has pain and then trying to alleviate it. We also use intrapleural catheters for administration of Marcaine (bupivacaine hydrochloride) on a regular basis in patients with a thoracotomy. Finally, we have used a technique that is more proactive in the last 200 consecutive patients and have noted a continued drop in ALOS leu as well as ALOS Hospital over time. We have identified variances and identified which groups of patients have in fact improved their performance. We have also developed critical moments, times during hospitalization when the patient can outperform our plan, and take measures to allow the patient to proceed faster. This method requires an individualized approach, which begins many weeks before the patient enters the hospital so as to have a clear idea of the patient's history and potential problems. Rapid pathway design is always possible. We call this approach radical outcome method, and it has accelerated the entire process.