Perioperative surgical home model reduces LOS

The perioperative surgical home (PSH) is a promising model for delivering high-quality, cost-effective care for patients undergoing inpatient urologic procedures, according to the experience of urologists from Loma Linda University, Loma Linda, CA.

At the 2016 World Congress of Endourology in Cape Town, South Africa, they reported findings from a retrospective study that examined the impact of PSH implementation on patient outcomes and institutional direct costs. The study included data for patients undergoing robotic radical cystectomy; open and robotic partial nephrectomy; and open, laparoscopic, and robotic radical nephrectomy from January 2014 through March 2016. The PSH was introduced in January 2015, and there were 118 patients in the pre-PSH cohort and 193 patients managed through the PSH model.

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Compared to the pre-PSH group, patients operated on after implementation of the PSH had a significantly shorter average length of stay (3.19 vs. 4.79 days; p=.00) and a significantly lower complication rate (5.7% vs. 15.3%; p=.00). There was no significant difference in the readmission rate for the PSH and pre-PSH groups (5.7% vs. 5.9%; p=.93).

In a multivariate analysis accounting for a significantly lower rate of open procedures in the PSH group, PSH was identified as an independent factor accounting for the decrease in length of stay. Factoring in that the average length of stay was reduced by about 1.5 days for the 193 patients in the PSH cohort, it was determined that the PSH model reduced direct hospital costs by over $1.2 million.

Next: PSH ‘a paradigm shift'

PSH ‘a paradigm shift’

Dr. Ruckle“The PSH is a paradigm shift to a more integrated, reliable, team-oriented surgical journey for the patient. Almost all medical centers have the people and the tools to enact successful variations of the PSH; the culture change required to cede responsibility to the other participants and follow protocols can be the largest barrier. In the future, there will be increased pressure on urologists to use PSH-type measures to help decrease waste in the surgical care continuum,” said co-author Herbert C. Ruckle, MD, professor and chair of urology at Loma Linda University School of Medicine.

The Loma Linda PSH model is a collaboration between the department of urology and anesthesia, and the multidisciplinary care team includes anesthesiologists, urologists, and ancillary staff.

“The PSH streamlines both preoperative testing and postoperative management, and we believe it particularly improves the quality of postoperative care by integrating the expertise of our anesthesiologist colleagues,” said first author Isaac L. Kelly, MD, urology resident at Loma Linda.

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Dr. Kelly acknowledged that assessment of any cost benefit of the PSH must take into account the added cost of patients being seen by non-urology members of the multidisciplinary team, which he estimated is equivalent to a half-time physician position. Looking further into how the PSH impacts costs, the authors will be evaluating whether shortening the duration of the inpatient stay resulted in increased costs for nursing home care.

Dr. Kelly“The fact that the PSH group had significantly fewer complications than the pre-PSH group and the same readmission rate supports the idea that the PSH model was truly associated with better in-hospital care, allowing for earlier discharge. However, it will be important to show that the benefit of a shortened hospital stay was not offset by a shift in the burden of care,” Dr. Kelly said.

Considering his personal experience, Dr. Kelly proposed that the PSH model reduces the average length of stay mainly by reducing the number of outlier patients who have very extended hospital stays.

“I believe that the real benefit of the PSH comes from providing more consistent postoperative care that enables early identification and management of problems that can otherwise result in a prolonged hospital stay,” he told Urology Times.

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