T. F. Devji1,2, A. Madenci1,3,4, E. Carpino1, M. Samnaliev1,4, C. Weldon1, J. Cravero1 1Boston Children’s Hospital,Boston, MA, USA 2Harvard School Of Dental Medicine,Boston, MA, USA 3Brigham And Women’s Hospital,Boston, MA, USA 4Harvard Medical School,Boston, MA, USA
Introduction: Unprecedented access to health insurance coverage with the Affordable Care Act necessitates cost-conscious delivery of care. As such, health systems must optimize value without sacrificing safety or outcomes. Elective surgical procedures represent one healthcare area that may be value-enhanced by moving to a more cost-efficient setting. The purpose of this study was to assess the safety and cost of performing the removal of implantable central venous access devices (‘ports’) in settings other than the main OR.
Methods: We compared port removal in three settings, specifically: 1) Main OR, 2) Satellite OR, and 3) Clinic procedure room. This was a mixed-methods study, including a retrospective review of health records and prospective observation/interviewing. To calculate cost without the inherent biases of hospital charges, costs, and payments, we utilized the methodology of Time-Driven Activity Based Costing. Specifically, we recorded time spent by the patient in hospital facilities and with hospital personnel. This duration was weighted with the hourly cost of each professional and hospital space. Demographic information and 30-day procedure-related complications data were obtained retrospectively. Time spent by the patient was obtained retrospectively from electronic timestamps. When this information was unavailable, a proxy was obtained from the median time spent during prospective observation. The Mann-Whitney U test compared the continuous variables of time and cost across the three sites. Overall cost at each site was divided by overall cost at the referent site (Main OR) to obtain a ratio of cost savings.
Results: A total of 120 patients (40 per site) were included in the analysis. Demographic and clinical factors were not significantly different between sites. No complication occurred with port removal at any site. Patients in the Main OR spent more time in the procedure room, which was the highest-cost space (Main OR median 56 min vs. Satellite OR 42 min, P<0.001; vs. Clinic 41 min, P<0.001). Median overall cost was decreased by 25% in the Clinic (ratio=0.75, 95% confidence interval [CI]=0.66-0.87) and by 6% in the Satellite OR (ratio=0.94, 95% CI=0.89-1.02), compared to the Main OR (referent; P<0.01).
Conclusion: In this study, port removal in the Clinic procedure room was significantly more cost-effective and not significantly associated with an increased risk of negative outcomes, compared to port removal in the Main OR. Re-locating routine port removal to a non-OR setting, such as a clinic procedure room, appears to be safe and may result in substantial cost savings.