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A Service Based Mid Level Provider Utilizing Peri-Operative Pathways Can Reduce Length of Stay and Hospital Costs Related to Pancreaticoduodenectomy Patients
William C. Conway*, John S. Bolton
Surgical Oncology, Ochsner Medical Center, New Orleans, LA
Introduction
Healthcare costs are growing at an unsustainable rate making it imperative that physicians become leaders in cost reduction and quality improvement programs. After partnering with administration to hire a mid-level NP for our service, we implemented a comprehensive peri-operative pathway for patients undergoing pancreaticoduodenectomy (PD) with the goal of standardizing care to improve quality and reduce costs. Significant NP coding education was also provided to ensure accurate DRG assessment.
Methods
After a service-specific nurse practitioner (NP) was hired, a standardized peri-operative program, including an evidence-based post-op critical pathway, was created and implemented. Data was collected for all PD patients from January 2011 through Q1 2013, including length of stay (LOS), morbidity and mortality, hospital costs, revenue, comorbidity capture and readmissions.
Results
Initial formal NP education included pathway/post-op care familiarity, coding, and home health/discharge coordination for PD patients. 151 patients were identified from Q1 2010 through Q1 2013. Implementing the comprehensive program lead to a reduction in LOS from 15.29 to 8.91 days (mean, p=0.013). There was a trend toward reduced average direct costs from $27,878 (2010) to $22,715 (2013) per case (p=0.271). Coding improved from a no comorbidity/complication rate of 23% in 2010 to 0% in 2013. Unfortunately, this did not improve contribution (2010: $24,262/case; 2013: $14,896/case) due to changes in payer mix and reduced reimbursement. Quality was maintained throughout this period with a complication index less than one for each year. 30 day readmissions were reduced from over 30% in 2010 to 16.7% in 2013, likely related to implementation of a formal discharge instruction set and 48 hour post-discharge phone call.
Conclusion
A service-specific NP can foster a peri-operative critical pathway, reduce LOS and readmissions, improve hospital coding, and reduce direct hospital costs for PD patients. The addition of a mid level provider to an upper GI/HPB surgical oncology service is cost effective.
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