Introduction: Between 2007 and 2019, the peri-operative patient management protocol for elective open repair of abdominal aortic aneurysms (AAA) was modified twice in our institution. These changes stemmed from systematic revisions of internal protocols, aiming to optimise quality of care and hospital resources. In 2015 a full peri-operative bundle (POB), comprising 19 evidence based pre-operative, intra-operative, and postoperative interventions, was implemented as a standard protocol for open repair of AAA. This modification translated into lower rates of complications, faster ambulation, and return of bowel function; better postoperative nausea/vomiting and pain control; and, consequently, a shorter length of hospital stay. As the value of a patient’s care cycle is defined as clinical outcomes relative to costs, we aimed to analyse the cost effectiveness of the full POB as compared to previous protocols implemented in our institution.
Methods: Three groups were identified based on the applied peri-operative protocol: (1) 66 patients (September 2007 – March 2009) treated according to a traditional protocol; (2) 225 patients (April 2009 – March 2015) treated in line with a partial POB, which incorporated five peri-operative interventions; and (3) 103 patients (April 2015 – February 2019) treated according to a full POB, including 19 peri-operative items. For each group the monetary value of required clinical resources and the average total cost per patient from admission to discharge were determined. The following were analysed (including nurse and anaesthesiologist time): diagnostic tests; medications; materials; operating time; surgical team time (one hour for admission and discharge, one hour per day of ward stay, and operation time with three surgeons), blood transfusion, ward stay, and intensive care unit stay. Throughout the study period, the required pre-operative examinations were mostly completed in advance in an outpatient clinic. These diagnostic tests, if not performed externally, were included in the analysis. The resource use was converted to direct costs using 2020/2021 values.
Results: The full POB consumed the least human and material resources, constituting the cheapest approach. The length of stay variable provided the largest reduction in total costs, being, on average, 3.47 days shorter (–44%) than the traditional protocol and 4.3 days shorter (–50%) compared to the partial POB. The reduction of length of stay (and complication rates) in the full POB group led to savings in the diagnostics examinations and human resources. The full POB, alongside enhancement of clinical outcomes, permitted optimisation of resources on two levels: (1) the direct reduction of the overall clinical resources cost (total clinical cost was 26% lower than the traditional approach [€4 437 vs. €6 005] and 39% lower than the partial POB [€4 437 vs. €7 305]); and (2) the social benefits deriving from the opportunity cost (saving human and material resources can increase the hospital capacity due to the potential accommodation for patients in need). We adopted a 30 day follow up. Although no re-admissions occurred in that time for the full POB group, additional costs related to the potential late complications were not accounted for.
Conclusion: The full POB for open repair of AAA enhances the patient pathway towards recovery while allowing for efficient utilisation of limited hospital resources, thus creating a high social value. This cost effectiveness analysis could provide a template for optimisation of healthcare resources from a micro-economic to a macro-economic scale.
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