Cost Impact of an Enhanced Recovery Program for Lower Extremity Bypass

Abstract

Enhanced recovery programs (ERPs) have significant potential patient benefits. However, implementation can also lead to increased cost of care with addition of standardized practices such as dedicated wound closure trays and increased use of regional anesthesia. This study's aim was to examine the impact of ERP implementation on cost of care for lower extremity bypass (LEB). A retrospective analysis was performed on LEB patients treated before (n = 145) and after (n = 171) ERP implementation in May 2018. Trauma, patients with concomitant suprainguinal bypass, and length of stay (LOS) outliers were excluded. Clinical data and McKesson-derived variable cost (volume dependent—supplies, nurse labor, medications), fixed cost (volume independent—overhead, admin staff, building maintenance and utilities), and total costs data were analyzed over the entire hospital encounter. Claudication, rest pain, or tissue loss were similar between pre-ERP and ERP patients (P = .335). Pre-ERP patients had similar total cost compared to ERP ($28,881 vs $29,230; P = .381). Overall median (interquartile range [IQR]) postoperative LOS decreased from 6 (IQR, 4-7 days) to 4 days (IQR, 3-7 days) (P < .001). Costs differed by indication, but there was no difference in pre-ERP vs ERP cohorts (Table). When comparing cost centers, we observed significant pre-ERP vs ERP cost declines in nursing (−16.0%; P = .032), intensive care unit (−56.5%; P = .021), and therapy categories (−17.5%; P = .015) but an increase in surgical (14.6%; P = .008) and anesthesia costs (14.8%; P = .004) (Figure). Overall cost of care remained stable with LEB-ERP. ERP implementation was associated with increased surgical and anesthesia costs, likely owing to additional elements of care such as standardized wound dressings, dedicated closure trays, and increased regional block utilization, but these costs overall appear offset by decreased LOS.TablePre-enhanced recovery program (ERP) and ERP costsCostPre-ERP (n = 145)ERP (n = 171)ERP/Pre-ERP differencePercent changeTotal costa$28,881 ± 1,3571$29,230 ± 15,359$3491.2By indication Claudication$21,210 ± 6585$23,149 ± 10,496$19399.1 Rest pain$29,359 ± 14516$29,194 ± 15,082$ (165)−0.6 Tissue loss$36,591 ± 13431$36,483 ± 17,812$ (107)−0.3Intensive care unit cost outliers and patients with a postoperative length of stay >90th percentile were excluded.aFixed and variable costs were also analyzed and found to follow similar trends. Open table in a new tab