COST-EFFECTIVENESS OF RISK-STRATIFIED POST-HEPATECTOMY CARE PATHWAY IMPLEMENTATION
Ahad M. Azimuddin*1,2, Hop S. Tran Cao1, Elsa M. Arvide1, Jeeva Ajith3, Jason Schmeisser3, Allison N. Martin1, Yun Shin Chun1, Jessica E. Maxwell1, Jean-Nicolas Vauthey1, Ching-Wei D. Tzeng1, Timothy E. Newhook1
1Surgical Oncology, The University of Texas MD Anderson Cancer Center Division of Surgery, Houston, TX; 2Texas A&M University, College Station, TX; 3The University of Texas MD Anderson Cancer Center Department of Financial Planning and Analysis, Houston, TX
Introduction
Previous implementation of risk-stratified post-hepatectomy care pathways (RSPHPs) resulted in decreased length of stay (LOS) for open hepatectomy patients at our hospital. We hypothesized that RSPHPs would also result in decreased overall inpatient hospital costs in the 90-day global period.
Methods
Clinicopathologic data for consecutive patients undergoing open hepatectomy (1/2017-2/2022) were collected from a prospective database. Hospital billing data was acquired from the institution's financial department, normalized to a constant dollar value for fiscal year 2022 and adjusted for inflation and annual institutional cost increase. Patients who underwent hepatectomy after implementation of RSPHPs ("POST," 9/2019-2/2022) were compared to a historical cohort ("PRE," 1/2017-8/2019). Postoperative inpatient costs, including those related to readmissions incurred within 90 days, were compared between the two groups. Costs were presented as a ratio (normalized to a value of 1) of the total cost of a service to the average cost of that service for the PRE cohort.
Results
Of the 673 patients undergoing hepatectomy, 45% (n=303) were part of the POST group. There were no differences between POST and PRE cohorts by age (median 55 vs. 58 years), major complications (9.6% vs 11.4%), or complexity of hepatectomy (47.9% vs. 44.6% Kawaguchi-Gayet Grade III, all p>0.05). Median estimated total hospital normalized cost of post-operative care for POST patients was 17.9% less than those of PRE patients (0.69 vs 0.84, p=0.001; Fig. 1). Cost decreases were primarily driven by a 25.8% reduction in sterile, non-sterile, and take-home supplies (0.66 vs 0.89, p=0.001). The second driver was a 21.3% decrease in pharmacy costs (0.59 vs 0.75, p=0.001). The median room and board cost ratio of the POST group decreased by 17.6% relative to the PRE group (0.56 vs 0.68, p=0.002) concurrently with a downward shift in the interquartile range of expected LOS (median 4 [IQR 3-5] vs 4 days [4-6], p=0.001). Similar cost reductions were seen when observing only cost ratios of index hospitalization, with total cost decreasing by 16.9% in the POST group (0.74 vs 0.89, p=0.001). There was no significant change in intensive care unit and stepdown unit use (1.70% vs 0.50%) or costs (0.91 vs 0.90, both p>0.05) between POST and PRE groups. Median cost ratios for readmissions (4.67 vs 6.08, p = 0.12) highlight the tremendous cost of readmissions in both cohorts, but stable readmission rates (9.5% vs 9.6%) prevented a rebound loss of savings from the index hospitalization.
Conclusion
Implementation of RSPHPs in 2019 was associated with decreased 90-day inpatient costs by standardizing care and reducing LOS without increasing readmissions. Continued iterative improvements in RSPHPs focusing on reducing major drivers of cost could lead to further cost-effective care following hepatectomy.
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