Implementation of a Streamlined Care Pathway to Reduce Cost and Length of Stay for Patients Undergoing Endoscopic Transsphenoidal Pituitary Surgery.

Abstract

We implemented a streamlined care pathway for patients undergoing endoscopic transsphenoidal (TSA) pituitary surgery. Select patients are recovered in the postanesthesia care unit and transferred to a step-down unit for intermediate neurologic care (INCU), with clinicians trained to manage cerebrospinal fluid leak, diabetes insipidus (DI), and other complications. We evaluated all TSA surgeries performed at 1 academic medical center from 7th January, 2017 to 30th March, 2020, collecting patient factors, tumor characteristics, cost variables, and outcomes. The INCU pathway was implemented on 7th January 2018. Pathway patients were compared with nonpathway patients across the study period. Outcomes were assessed using multivariate regression, adjusting for patient and surgical characteristics, including intraoperative cerebrospinal fluid leak, postoperative DI, and tumor dimensions. One hundred eighty-seven patients were identified. Seventy-nine were on the INCU pathway. Mean age was 53.5years. Most patients were male (66%), privately insured (62%), and white (66%). Mean total cost of admission was $27,276. Mean length of stay (LOS) was 3.97days. Use of the INCU pathway was associated with total cost reduction of $6376.33 (P < 0.001, 95% confidence interval [CI]: $3698.21-$9054.45) and LOS reduction by 1.27days (P= 0.008, 95% CI: 0.33-2.20). In-hospital costswere reduced across all domains, including $1964.87 invariable direct labor costs (P < 0.001, 95% CI: $1142.08-$2787.64) and $1206.52 in variable direct supply costs (P < 0.001, 95% CI: $762.54-$1650.51). Pathway patients were discharged earlier despite a higher rate of postoperative DI (25% vs. 11%, P= 0.011), with fewer readmissions (0% vs. 6%, P= 0.021). A streamlined care pathway following TSA surgery can reduce in-hospital costs and LOS without compromising patient outcomes.