DVT project finds budget balance at the intersection of cost, quality
Two rather uncomplicated clinical practice changes could save one hospital system about $4 million over 1 year, proof that adopting a uniform best practice can improve the bottom line without sacrificing patient care.
The changes – switching from low-molecular-weight to unfractionated heparin and limiting postsurgical sequential compression devices to short-stay and outpatients only – consolidated practice and lowered expenses in eight hospitals in the Washington, D.C., area. If those same changes could be applied to larger systems, the associated health care savings could be enormous, according to Dr. John. R. Kirkpatrick, a former surgeon in the MedStar Health system and one of the forces behind the project.
"These savings were based on 120,000 surgeries in 1 year," he said in an interview. "There are 30 or 40 million surgeries done in the United States every year. So do the math – the savings could be almost $1 billion every year."
A report published in the April issue of the Journal of the American College of Surgeons describes the project’s genesis, implementation, and results (J. Am. Coll. Surg. 2013;216:800-13). The seed was planted in 2007, when Dr. Kirkpatrick stepped down from his post as the chair of surgery at MedStar Washington Hospital Center. He founded the Surgical Advisory Group, a company he described as a "surgical think tank" offering strategic planning aimed at increasing quality, operational efficiencies, and enhancing patient care.
Value, defined
The new team wanted to examine value in terms of health care – defining it as the intersection of quality and cost. They chose to investigate five perioperative variables: preoperative testing, prophylactic antibiotics, deep venous thrombophlebitis prophylaxis, operating room fluid resuscitation, and invasive monitoring in the OR. For each analysis, they would perform an extensive literature search to describe the currently accepted best clinical practice.
"The reason we chose DVT prophylaxis for the first case was that the data supporting the practices were so clear and compelling that they made our case," Dr. Kirkpatrick said. Studies clearly indicated that unfractionated heparin was just as effective as low-molecular-weight heparin, suitable for all but a select few patient types, and about 10 times cheaper. Low-molecular-weight heparin should be reserved for those cases and for patients who had experienced a DVT while on unfractionated heparin, the group advised.
Data also confirmed that sequential compression devices (SCDs) were most clinically and cost effective when used in the OR, at a price of about $22/stocking. Once the patient returned to the floor, however, the nursing time required to care for the device and patient noncompliance after discharge chipped away at the value without adding to quality. In-hospital daily cost could rise to about $150, and there was no way to even gauge the at-home cost, since many patients simply eventually abandoned the stockings.
Therefore, the group advised, SCDs should be employed only for outpatient or short-stay surgeries.
Assessing each hospital’s current practice was next. A survey sent to top hospital staffers and showed a wide variation in the use of both heparin and SCDs, Dr. Kirkpatrick said. "Four of the hospitals were already following the best practices," but the others were not.
It wasn’t immediately clear why four of the hospitals were almost exclusively using low-molecular-weight heparin and others, unfractionated heparin. Dr. Kirkpatrick said some use seemed related to institutional memory and whether the hospital served as a large teaching facility. Nevertheless, prophylaxis failure rates were similar (1%-1.8%) at all the facilities, confirming that both types of heparin effectively reduced DVT risk.
Stocking up on savings
While the average systemwide cost per dose was around $4, it varied widely depending on the type used: about $2.50 at the four centers using unfractionated heparin and $8.14 at those using low-molecular-weight heparin. The highest cost was $16.60 for low-molecular-weight heparin and the lowest, about $2, for unfractionated. Switching everyone to unfractionated heparin, except patients with failed prophylaxis or those special cases, was projected to save about $3 million/year.
The cost of SCDs was not as clear cut, since it included the difficult-to-measure "hidden costs" of extra nursing time to care for the stockings and loss of nursing time spent on other duties. But all of the facilities employed the devices in all surgical patients, regardless of the postoperative length of stay, at a materials cost of $22. Since 52% of the cases were outpatient or short-stay procedures, limiting the stockings to those patients alone was projected to save about $1 million each year.
The changes have been in place about 3-8 months now, depending on the facility, Dr. Kirkpatrick said. "The thing that changed immediately was the heparin usage. We saw immediately that we were going to get about $1.5 million in savings there. That put us almost to the halfway point of our projected $4 million. The compression devices will take a little longer to measure."
