Think laparoscopy is best? Here’s how to prove it
Follow these steps for a cost-benefit analysis
"My patients do just as well." "My outcomes are just as good." "My OR time is shorter, and my patients return to work just as quickly."
Those were some excuses endoscopic coordinator Vangie Paschall, RN, CNOR, heard from physicians at Promina Gwinnett Health System in Lawrenceville, GA, when she urged them to consider a laparoscopic approach to appendectomies. Paschall, who chaired Promina Health Systems’ advanced technology task force in Atlanta, spoke at the recent Same-Day Surgery Conference, also in Atlanta.
She needed data to prove the effectiveness of the laparoscopic approach. In a cost-benefit analysis, she was able to show that patients undergoing laparoscopic appendectomies spent less time in the hospital, required fewer doses of Demerol postoperatively, lost less blood, and returned to work more quickly.
The additional cost was minimal: An average of 12 minutes more in the OR and $200 more per procedure. (For a detailed comparison of laparoscopic vs. open appendectomy costs, see p. 97.)
When she presented those results at a physician meeting, Paschall faced some resistance. But she says the number of laparoscopic appendectomies has grown slightly. "Even if I did one extra [laparoscopic procedure] a month, that’s one more patient who’s benefiting," she says.
Detailed cost comparisons can resolve ongoing OR debates, such as the relative benefits of reusables vs. disposables, says Angela Christensen, RN, MBA, CPA, administrative director of surgical services at Baptist Health Systems in Miami. "The only way you’re able to make a truly informed decision is through a cost-benefit analysis," she says.
Here are the steps Paschall followed to analyze the costs and benefits of laparoscopy vs. open appendectomy:
1. Research best practices to establish baselines.
Paschall reviewed more than 50 articles to determine the relative outcomes of laparoscopic vs. open appendectomy. For example, she found that laparoscopic patients had fewer complications, better cosmetic results, and were less likely to develop intestinal obstruction.1
2. Set criteria for cases to include in analysis.
Paschall wanted to compare only similar cases noncomplicated laparoscopic and open procedures. She decided to rule out patients that could skew an analysis, such as those with a negative appendix (clinical symptoms but no appendicitis). Paschall also excluded patients requiring other procedures as a result of complications of an appendectomy or those with additional diagnoses both of which could add to the costs.
3. Gather data and compute direct surgical costs.
Calculating true costs of equipment and supplies was Paschall’s most difficult task in developing the cost-benefit analysis. To obtain surgical supply costs and purchase price of equipment, she contacted the hospital’s accounting department and materials manager.
She determined, for example, that each time surgeons used a Bovie electrocautery unit, it cost $2.22. To arrive at that figure, she counted Bovies in her 28 ORs, divided their total cost by the number of procedures in which they were used, then divided that number by five (to amortize or spread the capital cost over the five-year expected life of the equipment).
4. Add indirect and personnel costs.
Indirect costs are those not associated with the direct care of the patient, Christensen says; for example, salaries for the same-day surgery director, managers, scheduler, and receptionist.
To determine indirect costs, add overhead costs not associated with direct patient care and divide by the total number of cases performed per year, Christensen says. The resulting figure is a per-unit cost. Then multiply that per-unit cost by the annual number of cases for a given procedure, such as appendectomies.
Paschall calculated her indirect and personnel costs on a per-minute basis so she could compare the time differences of the open vs. laparoscopic appendectomy. Her OR overhead (including electricity, water, and cleanup) was $2.72 per minute.
She averaged salary costs of performing emergency vs. scheduled appendectomies and of using a mix of OR techs and RNs. She calculated personnel costs of $2.33 per OR minute, which were the same in open and laparoscopic procedures.
Paschall then reviewed six months of data: 71 open cases averaged 103.8 minutes of OR time, while 21 laparoscopic cases averaged 115.9 minutes. Both included 30 minutes for turnover.
5. Compare the lengths of stay.
The last piece of financial information Paschall needed was for the postoperative stay. Based on six-month data, laparoscopic noncomplicated appendectomies had an average length of stay of 1.66 days vs. 2.26 for noncomplicated open procedures and 6.66 for complicated open procedures.
Inpatient costs, including dietary and nursing services, average $497.25 at Promina Gwinnett Health System. Paschall received this information from the accounting department.
6. Add total surgical costs and length of stay costs. Compare all data.
When Paschall added together her surgical costs and inpatient costs, she discovered that laparoscopic appendectomies are more expensive by about $200. The open, noncomplicated cases cost $1,744.26, while the laparoscopic noncomplicated cases cost $1,962.13. (See box, above.)
She says that additional cost is outweighed by patient benefits and competitive advantages of offering the laparoscopic procedure. For example, one self-insured employer prefers laparoscopic procedures because they enable employees to return to work more quickly. "This is what allowed us to get the contract with this company."
Though physicians determine the approach, a cost-benefit analysis can influence their decision. "What was my real goal for showing doctors this? To give them a choice to do what was best for patients," Paschall says.
Reference
1. Nowzaradan Y, Barnes JP Jr., Westmoreland J, et al. Laparoscopic appendectomy: treatment of choice for suspected appendicitis. Surg Laparosc Endosc 1993; 3:411-416.
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