Studies: Hospital Stays, Costs, Can be Cut While Maintaining Quality Care of Bypass Patients
ORLANDO, FL. -- Many patients can be sent home in five days or less after heart bypass surgery with no increased complications or loss of quality of care, according to two Duke University Medical Center studies.
The research, prepared for presentation at the American College of Cardiology's annual meeting, offers the most complete picture to date of the growing trend in reducing hospital stays and costs after heart bypass surgery.
The first study is the only one of its kind to look nationally at discharge times for more than 84,000 elderly bypass surgery patients. It found that in 1992, 6 percent of patients were released from the hospital in five or fewer days without an increase in readmission rates or death. Although the Medicare data is the latest available, researchers agree that, today, many more patients are now going home earlier.
The second study is a detailed examination of 1,268 patients who received operations at Duke University Medical Center in 1994, after the hospital designed and tested a protocol for earlier discharge.
At Duke today, the length of stay in the hospital after bypass surgery has been cut almost in half, from about nine days to five days or less, and the rate of complications has not increased, according to researchers. More than half of the patients are released by the fifth day, and 25 percent go home on day four. "What we found is that efficient treatment of these patients meant that they could go home earlier and save significant health care dollars," said Duke cardiothoracic surgeon Dr. Peter Smith, who helped lead the detailed study of Duke patients. "We increased that efficiency by eliminating unnecessary care -- unnecessary tests, treatments, days in the hospital, and excessive intensity of care," he said.
Duke's progress in reducing hospitalization and costs put it at the "cutting edge," not the "bleeding edge," said Smith in an interview. "There probably are ways we can further reduce hospitalization and costs, but we are well aware there is a quality limit we don't want to go beyond."
Duke designed a "care mapping" approach to bypass surgery in which every member of the health care team -- the physicians, nurses, anesthesiologists, respiratory therapists -- as well as the patients and their families, all worked together to plan the patient's treatment and recovery. The care map is a complete guideline for hospital care, including physicians' orders, diagnostic tests, medication, patient education, progressive rehabilitation and early discharge planning.
Duke's care map differs from those used at many hospitals, Smith said, because a majority of those are just a compilation of physicians' orders, and do not have the team commitment in developing them and their agreement to use them. "There are care maps, and then there are care maps that work," he said. "Many care maps don't work well because they lack substantive input from everyone on the health care team."
Duke physicians tested the so-called CABG (coronary artery bypass grafting) care map with a group of 1,268 patients between September 1993 and December 1994. The patients were divided into two groups: 404 were enrolled in a "pre-care map" that reflected clinical care before the study, and 864 patients agreed to the new care mapping protocol. Preoperative risk factors, operative data and postoperative results, including length of stay, cost, and mortality, were obtained on each patient.
The care map called for release of patients on the fifth day after surgery, and 41 percent of the patients enrolled in the protocol did in fact go home that day or even earlier. Only 15 percent of the pre-care map group went home that early. The average length of stay in the pre-map group was 8.5 days, compared to seven days in the care-map patients.
In the care-map patients, substantially fewer diagnostic tests, such as serum chemistry and arterial blood-gas tests, were ordered, and the mean cost of care decreased by more than $2,000 per patient, for a total savings of $1.8 million in the care-mapping group. "No significant differences in postoperative mortality or complications were noted," said study co-leader Dr. Scott Johnson, now at Washington University School of Medicine in St. Louis. "The use of the care map reduced cost and length of stay but maintained the overall quality of patient care." One major cost-saving measure involved extubating (removal of airway tubing) in a timely matter following surgery, Smith said. "Patients traditionally remained intubated until the next morning. We extensively considered the safety issue until everyone agreed that it was a safe thing to do for many of our patients."
"It was a real culture change for everyone," Smith said. "But by implementing one change in procedure, we decreased the patient's time in the I.C.U., decreased the amount of sedative given and decreased the total hospital stay."
The team also found that the number of diagnostic tests performed on patients could be decreased without affecting the quality of care. "Developing a critical pathway improves communication among all the health professionals; the standard treatment plan is evident to everyone, including patients and their families," Smith said. "Patient satisfaction is much higher when they know what to expect and when."
A second team of Duke researchers looked at all the bypass surgeries (84,573) paid for by Medicare that occurred in the United States between January and October 1992. It is the first study to focus on early versus late discharge of CABG patients nationally, according to researcher Patricia Cowper. "Given the pressure upon hospitals to reduce costs, we wanted to see what happened when patients went home fairly quickly," she said. They looked at patients with post-operative stays of 14 days or less and examined when the patients were discharged and what happened up to 60 days later. What Cowper and her colleagues found is that 6 percent of these patients were released from the hospital either four or five days after their bypass. And they concluded from the limited clinical information included in Medicare data that these patients did not have higher rates of readmission or death.