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Role of nursing personnel in implementing clinical pathways and decreasing hospital costs for major vascular surgery |
Calligaro K D, Miller P, Dougherty M J, Raviola C A, DeLaurentis D A |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Establishing clinical pathways and a dedicated vascular wing in collaboration with key nursing personnel to reduce resource utilisation and costs in the treatment of patients admitted for major vascular surgery including elective extracranial (EC) arterial surgery, infrarenal aortic (AO) surgery for aneurysmal or occlusive disease, and lower extremity arterial (BYPASS) revascularization procedures.
Economic study type Cost-effectiveness analysis.
Study population Patients admitted for major vascular surgery including elective extracranial (EC) arterial surgery, infrarenal aortic (AO) surgery for aneurysmal or occlusive disease, and lower extremity arterial (BYPASS) revascularization procedures.
Setting Hospital. The economic study was carried out in Philadelphia, USA.
Dates to which data relate The effectiveness and resource use data for group I, containing patients treated in the period before the introduction of the intervention, were collected between September 1992 and August 30 1993. The corresponding data for group II, (patients treated after the introduction of the intervention) were gathered between January 1 1994 and December 31 1994. The fiscal year adopted in the study was not specified.
Source of effectiveness data Effectiveness data were derived from a single study..
Link between effectiveness and cost data The costing was performed retrospectively on the same patient sample as that used for the effectiveness analysis.
Study sample Power calculations were not used to determine the sample size. There were 145 patients with an average age of 68 years (range: 50 - 91) in group I versus 177 patients with an average age of 67 years (range: 49 - 95) in group II. A total of 561 patients who needed emergency surgery, who were transferred from other hospitals, and who needed prolonged preoperative treatment, were excluded from the study.
Study design The study was a non-randomised trial with historical controls, carried out in a single centre. The duration of the follow-up was 30 days after discharge.
Analysis of effectiveness The principle (intention to treat or treatment completers only) used in the analysis of effectiveness was not explicitly specified. The primary health measures adopted were mortality, complication rate, and readmission rate. The groups were shown to be comparable in indication for surgery and clinical risk factors.
Effectiveness results Group I had a mortality rate of 2.1% versus 2.3% for group II. The rate of pulmonary complications was 4.1% in Group I versus 1.7% in Group II. The rate of perioperative stroke was 1.4% (Group I) versus 0% (Group II). The rate of cardiac complications was 3.4% in group I and 4.0% in Group II, and the readmission rates were 11.3% and 9.2%, respectively.
Clinical conclusions The authors concluded that the results of this study suggest that most patients who are admitted on the day of operation and are discharged early have no increased risks and that the study results for patients undergoing EC, AO, and BYPASS surgery did not support the concern that earlier discharge for patients undergoing major surgery would be associated with higher admission rates.
Measure of benefits used in the economic analysis No summary benefit measure was identified in the economic study, and only separate clinical outcomes were reported.
Direct costs Quantities were not reported separately from the costs. The cost items were not reported separately. The cost items included in the cost analysis were not explicitly specified. The perspective adopted in the cost analysis was one of a third-party payer. It was reported that the establishment of a dedicated vascular wing was not associated with extra costs. The cost data were based on the patient billing. A cost to charge ratio was applied to estimate the costs from the charge data. Only the costs in the acute care hospital were included in the cost analysis and not the costs of any short-stay unit and outpatient costs. The costs of the skilled care centre and visiting home nurses were not considered in the cost analysis. The cost analysis did not cover the patients who "experienced unusually prolonged (or shortened) length of stay (LOS) because of complications".
Sensitivity analysis No sensitivity analysis was performed.
Estimated benefits used in the economic analysis Cost results It was only reported that the introduction of guidelines led to an estimated annual hospital cost saving of $1,267,445 for the patients in group II in comparison to the patients in group I.
Synthesis of costs and benefits Costs and benefits were not combined since the intervention was regarded as the (weakly) dominant strategy.
Authors' conclusions The authors concluded that the results suggested that decreased length of hospital stay for patients undergoing major vascular surgery through implementation of clinical pathways via physician and nursing cooperation resulted in dramatic cost savings without sacrifice of acceptable morbidity or mortality rates. Nursing personnel should take a leading role in helping to decrease health care expenses through innovative strategies and cooperative interaction with attending physicians.
CRD COMMENTARY - Selection of comparators The reason for the choice of the comparator is clear.
Validity of estimate of measure of benefit The internal validity of the effectiveness results may be weakened by the lack of a randomised design.
Validity of estimate of costs The resource utilisation was not reported separately from the costs. Adequate details of the methods of cost estimation were not given and several important cost items appear to have been omitted.
Other issues Given the lack of randomisation, and the lack of both sensitivity analysis, and statistical analysis of the costs, the results need to be treated with some caution. The issue of generalisability to other settings or countries was not addressed.
Bibliographic details Calligaro K D, Miller P, Dougherty M J, Raviola C A, DeLaurentis D A. Role of nursing personnel in implementing clinical pathways and decreasing hospital costs for major vascular surgery. Journal of Vascular Nursing 1996; 14(3): 57-61 Indexing Status Subject indexing assigned by NLM MeSH Aged; Aged, 80 and over; Critical Pathways /standards; Female; Hospital Costs; Humans; Length of Stay; Male; Middle Aged; Nursing Staff, Hospital; Vascular Diseases /economics /nursing /surgery AccessionNumber 21997006983 Date bibliographic record published 30/04/1999 Date abstract record published 30/04/1999 |
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