Endovascular aneurysm repair delivery redesign leads to quality improvement and cost reduction

Abstract

Objective Endovascular aneurysm repair (EVAR) is now a mainstay of therapy for abdominal aortic aneurysm, although it remains associated with significant expense. We performed a comprehensive analysis of EVAR delivery at an academic medical center to identify targets for quality improvement and cost reduction in light of impending health care reform. Methods All infrarenal EVARs performed from April 2011 to March 2012 were identified (N = 127). Procedures were included if they met standard commercial instructions for use guidelines, used a single manufacturer, and were billed to Medicare diagnosis-related group 238 (n = 49). By use of DMAIC (define, measure, analyze, improve, and control) quality improvement methodology (define, measure, analyze, improve, control), targets for EVAR quality improvement were identified and high-yield changes were implemented. Procedure technical costs were calculated before and after process redesign. Results Perioperative services and clinic visits were identified as targets for quality improvement efforts and cost reduction. Mean technical costs before the intervention were $31,672, with endograft implants accounting for 52%. Pricing redesign in collaboration with hospital purchasing reduced mean EVAR technical costs to $28,607, a 10% reduction in overall cost, with endograft implants now accounting for 46%. Perioperative implementation of instrument tray redesign reduced instrument use by 32% (184 vs 132 instruments), saving $50,000 annually. Unnecessary clinic visits were reduced by 39% (1.6 vs 1.1 clinic visits per patient) through implementation of a preclinic imaging protocol. There was no difference in mean length of stay after the intervention. Conclusions Comprehensive EVAR delivery redesign leads to cost reduction and waste elimination while preserving quality. Future efforts to achieve more competitive and transparent device pricing will make EVAR more cost neutral and enhance its financial sustainability for health care systems.

A systematic review of intraoperative process mapping in surgery

“…One study described a prospective longitudinal quasi-experimental study (13), and another study described an observational prospective design (14). All studies were of non-randomised study design; five were purely observational (with no specific improvements/interventions applied) (14-18), one was a controlled before-and-after study (19), and the remainder had before-and-after study designs without controls (7,13,(20)(21)(22)(23)(24)(25)(26)(27)(28). Table 1 lists more detailed study characteristics.…”

“…Four studies named time-motion principles (15,17,18,26); one cited a combination of strategies from Six Sigma, and process and resource analysis (20); two studies specified lean principles (13,22); and three applied Lean Six Sigma principles (21,27,28). One study explicitly stated process mapping as the QI tool (7), and another described a technique similar to process mapping but named it "standardized step-wise technique" (29).…”

“…In doing so, they identified improvement areas which some studies used as the basis to formulate interventions. The major aims identified were to: identify preventable disruption sources (15); increase OT utilisation (19,20); analyse time spent for each step of a surgical procedure (17,18); increasing intraoperative efficiency (7,13,21,23,27,28); improve educational opportunities (13,14,17,18); redesign intraoperative pathways (24,25); determine limitations of surgical procedure (16); improve costing activities (25); refine surgical practices (26); and determine variance in surgical performance (29). The process mapping approach was applied across a range of surgical specialties, shown in Table 2.…”

“…Eight studies used a multidisciplinary team discussion approach to identify the steps in the intraoperative period (13,(19)(20)(21)(22)24,27,28). This was advantageous as other staff responsibilities (i.e., anaesthetists, nurses and OT technicians) in surgical care could also be included in the process map (19).…”

“…PACU, post-anaesthetic care unit. (29) Tebbetts (26) Lee (24), Marsh (7), Warner (27) McLaughlin (25) Schwarz (19) Warner (28) (14,17,18,26). Thus the steps pertained to the surgeons themselves, and other surgical staff tasks were not included.…”