P77. Enhanced perioperative care decreases cost after major spinal surgery

Abstract

BACKGROUND CONTEXT Enhanced recovery after surgery (ERAS) standardizes surgical care, reducing unnecessary variation. The goals are outcome improvement and secondarily cost reduction. ERAS has been applied successfully to many different surgical specialties but not yet comprehensively to spinal surgery. PURPOSE The purpose of this study is to investigate the financial effectiveness of an enhanced perioperative care pathway (EPOC) on patients undergoing elective major spinal surgery compared with patients receiving traditional perioperative care. STUDY DESIGN/SETTING Retrospective cohort comparison. PATIENT SAMPLE Patients undergoing elective major spinal surgery at a quaternary academic spine center. OUTCOME MEASURES Financial measures were direct costs B, separated into those expected not to change such as implant and supply costs, and direct costs A such as bed, nursing, pharmacy, imaging, laboratory, pathology and perioperative services. Indirect costs, noted as shared patient resources such as patient transport, environmental services, resident salaries and interpreter services, were also analyzed. Secondary outcome measures were hospital and intensive care length of stay. METHODS Consecutive adults undergoing major elective spine surgery were identified to be placed into the enhanced perioperative care pathway. Major spine surgery was identified utilizing CPT and ICD codes that represented, arthrodesis for deformity, anterior lumbar spine surgery greater than two levels or posterior lumbar greater than 3 levels, corpectomy in any area of the spine or pelvic fixation. Patients with significant medical comorbidities were also included. Two comparison groups were made. First, a historical cohort of patients from prior to EPOC implementation was identified as the TRDC or traditional care group. Second, a concurrent cohort of patients that failed to make entry into EPOC due to patients not attending preoperative sessions, scheduling conflicts or insurance authorization issues. This second group was labeled the Nopathway care or NOPC group. Briefly the EPOC pathway focused on coordination of preoperative care, patient counseling, and medical optimization before surgery. Carbohydrate loading preoperativley and nasal povidone iodine swabs were also utilized. Preoperative multi-modal analgesia was initiated with acetaminophen and gabapentin. Intraoperatively, focus on goal-directed fluid management, continuation of multi-modal analgesia with the addition of ketamine, and selective use of tranexamic acid. Postoperatively, oral intake was encouraged early, as well as early ambulation. Also ketamine, acetaminophen and gabapentin were continued post-operatively. Costs were broken into Direct A, B and indirect costs and analyzed using two-tailed t-tests. The TRDC cohort costs were adjusted for inflation. Length of stay was analyzed using student's t-test with equal variances not assumed. RESULTS A total of 620 patients had EPOC care. Among them, 183 and 129 patients received TRDC or NOPC, respectively. Total cost decreased by $19,344 after pathway in comparison to the TRDC group. Total cost decreased $5,889 comparing EPOC to a concurrent NOPC group. Direct costs B, implant and supply, were similar between NOPC and EPOC, however there was a small difference between TRDC and EPOC, possibly explained by the time difference in surgical care. There was a significant cost savings when comparing EPOC to TRDC and NOPC for other Direct costs (A) of $11,160 and $4,102, respectively. Hospital length of stay was significantly lower in EPOC than in both TRDC and NOPC. Similarly EPOC patients had significantly lower intensive care length of stay than both TRDC and NOPC. CONCLUSIONS Implementation of an ERAS strategy such as EPOC decreases cost and length of stay in patients undergoing major spine surgery. Length of stay was significantly lowered at both the intensive care and overall hospital level. The implementation of an EPOC pathway also achieved direct, indirect and total cost savings in elective major spine surgery. FDA DEVICE/DRUG STATUS Unavailable from authors at time of publication.