Cost Of Cardiac Surgery Research Articles

Understanding and Managing Direct Operating Room Supply Costs in Cardiac Surgery

BackgroundValue-based bundles require surgeons to understand their costs. Current approaches to cost reporting are confusing and difficult to reproduce. Using the Epic surgical receipt function, we describe an intuitive and systematic approach for evaluating financial data within the operating room. MethodsWe conducted a retrospective review of all congenital cardiac procedures performed at a single academic medical center between January 1, 2020, and January 1, 2021. Direct operating room supply costs were obtained using the Epic surgical receipt function. Costs were analyzed on the basis of contribution to total annual cost and variability in case cost. Implications for strategies identified within congenital cardiac surgery were then evaluated in adult cardiac surgery. ResultsFive procedures representing 71 patients accounted for more than 50% of the total direct operating room supply costs (left ventricular assist device, Norwood procedure, pulmonary valve replacement, right ventricle–to–pulmonary artery shunt, and aortic arch augmentation). Disposable vascular clips, suture brand preference, and surgical patch materials accounted for 3.7%, 6.6%, and 26.5% of annual direct operating room supply costs, respectively. Improvements to these categories would represent 12% to 14% ($250 000) in annual savings without an anticipated effect on outcomes. Across adult and congenital cardiac surgery, 95% of all name-brand suture use was tied to preference cards. An opt-in vs default approach to name-brand polypropylene suture could save more than $250 000 annually. ConclusionsThe surgical receipt represents a reliable and intuitive way for reporting surgical costs. Systematically analyzing costs and their impact on outcomes will help surgeons improve the value of care they provide.

The Impact of Preoperative Frailty on the Clinical and Cost Outcomes of Adult Cardiac Surgery in Alberta, Canada: A Cohort Study

BackgroundThere is limited information about the impact of frailty on public payer costs in cardiac surgery. This study aimed to determine quality-adjusted life-years (QALYs) and costs associated with preoperative frailty in patients referred for cardiac surgery. MethodsWe retrospectively compared costs of frailty in a cohort of 529 patients aged ≥ 50 years who were referred for nonemergent cardiac surgery in Alberta. Patients were screened preoperatively for frailty, defined as a score of 5 or greater on the Clinical Frailty Scale. The primary outcome measure was public payer costs attributable to frailty, calculated in a difference-in-difference (DID) model. ResultsThe prevalence of frailty was 10% (n = 51; 95% confidence interval [CI], 7%-12%). Median (interquartile range) costs for frail patients were higher in the first year postsurgery ($200,709 [$146,177-$486,852] vs $147,730 [$100,674-$177,025]; P < 0.001) compared to nonfrail; the difference-in-difference attributable cost of frailty was $57,836 (95% CI, $–28,608-$144,280). At 1 year, frail patients had fewer QALYs realized compared to nonfrail patients (0.71 [0.57-0.77] vs 0.82 [0.75-0.86], P < 0.001), whereas QALYs gained were similar (0.02 [–0.02-0.05] vs 0.02 [0.00–0.04], P = 0.58, median difference 0.003 [95% CI, –0.01-0.02]) in frail and nonfrail patients. ConclusionsFrailty screening identified a population with greater impairment in quality-of-life and greater healthcare costs. Costs attributable to frailty represent opportunity costs that should be considered in future cardiac surgical services planning in the context of our aging population and the growing prevalence of frailty.

Bleeding After Cardiac Surgery Is Associated With an Increase in the Total Cost of the Hospital Stay

Cardiac surgery results in complications for some patients that lead to a longer hospital stay and higher costs. This study identified the presurgery characteristics of patients that were associated with the cost of their hospital stay and estimated how much of that cost could be attributed to a bleeding event, defined as requiring 3 units or more of packed red blood cells or returning to the operating room for bleeding. We also identified the presurgery characteristics that were associated with the bleeding event. This prospective cohort of patients (n= 1459) underwent cardiac surgery at 3 tertiary referral hospitals in Australia during 2014 and 2015. Clinical data included the variables held by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons registry. Cost data were collected as part of a state-level hospital data collection. Many of the baseline patient characteristics were associated with the total cost of cardiac surgery. After adjusting for these characteristics, the cost of cardiac surgery was 1.76 (confidence interval, 1.64-1.90) times higher for patients who had a bleeding event (P < .001), thus resulting in a median increase in costs (in Australian dollars) of $33,338 (confidence interval, $21,943-$38,415). Several baseline characteristics were strongly associated with a bleeding event. The impact of a bleeding event on the cost of cardiac surgery is substantial. This study identified a set of risk factors for bleeding that could be used to identify patients for discussion at the heart team level, where measures to minimize the risk of transfusion may be initiated.

Postoperative Atrial Fibrillation: Evaluation of its Economic Impact on the Costs of Cardiac Surgery.

ObjectiveThe objective of this study was to calculate the direct costs of postoperative atrial fibrillation (POAF) in a high-complexity cardiovascular hospital.MethodsWe performed a cost analysis with a pairwise-matched design. Twenty-two patients with POAF and 22 patients without this complication were included. Pair-matching was performed (1:1) based on the following criteria: identical type of surgery, similar EuroSCORE II values, and absence of any other postoperative complication.ResultsThe total hospital cost was significantly higher in the POAF group than in the non-POAF group (US$ 10,880 [± 2,688] vs. US$ 8,856 [± 1,782], respectively, for each patient; P=0.005). This difference was attributable to postoperative costs (US$ 3,103 [± 1,552] vs. US$ 1,238 [± 429]; P=0.0001) for patients with or without POAF, respectively. The median postoperative lengths of stay were 9 (range 5-17) and 5 (3-9) days for patients with and without POAF (P=0.032), respectively. Preoperatively, no differences were found in the EuroSCORE II values (median 1.7 vs. 1.6, respectively; P=0.91) or direct costs (US$ 1,127 vs. US$ 1,063, respectively; P=0.56) between POAF and non-POAF groups.ConclusionPOAF generates a high economic burden in the overall costs of cardiac surgery, and our results reveal the differential contribution of each of the evaluated factors. This information, which was previously unavailable in this setting, is essential for the development of more effective prevention strategies.

Shifts of Transfusion Demand in Cardiac Surgery After Implementation of Rotational Thromboelastometry–Guided Transfusion Protocols: Analysis of the HEROES-CS (HEmostasis Registry of patiEntS in Cardiac Surgery) Observational, Prospective Open Cohort Database

Rotational thromboelastometry (ROTEM)-guided transfusion algorithms in cardiac surgery have been proven to be successful in reducing blood loss in randomized controlled trials. Using an institutional hemostasis registry of patients in cardiac surgery (HEROES-CS), the authors hypothesized that the use of ROTEM-guided transfusion algorithms would save blood products and overall costs in cardiac surgery in every day practice. Observational, prospective open cohort database. Single-center academic hospital. Cardiac surgery patients. Implementation of ROTEM-guided bleeding management. A classical-guided algorithm and a ROTEM-guided algorithm were used for patient blood management in 2 cohorts. Primary outcome was the use and amount of blood products and hemostatic medication. Secondary outcomes were amount of rethoracotomies, length of stay, and 30-day mortality. Finally, costs and savings were calculated. The classical-guided cohort comprised 204 patients, and ROTEM-guided cohort comprised 151 patients. Baseline characteristics showed excellent similarities after propensity score matching of 202 patients. Blood loss was lower after ROTEM guidance (p < 0.001). Absolute risk reduction was 17% for red blood cells (p = 0.024), 12% for fresh frozen plasma (p = 0.019), and 4% for thrombocyte concentrates (p = 0.582). More tranexamic acid was given, but not more fibrinogen concentrate, while desmopressin was given less often. Hospital length of stay was reduced by an overall median of 2 and a mean of 4 days (p < 0.001). Mortality and rethoracotomy rates were not affected. Potential savings were about €4,800 ($5,630) per patient. Implementation of a ROTEM-guided transfusion algorithm in cardiac surgery patients reduced the use of blood products and hemostatic medication, hereby saving costs. Reductions in mortality and rethoracotomy rates could not be found.

Outcomes and Costs of Cardiac Surgery in Adults with Congenital Heart Disease.

Advances in pediatric cardiac surgical and medical care have led to increased survival of patients with congenital heart disease (CHD). Consequently, many CHD patients survive long enough to require cardiac surgery as adults. Using the 2013 Nationwide Inpatient Sample (NIS) database, we compared costs and outcomes for adult patients undergoing surgery for treatment of CHD to a reference population of adults undergoing CABG. Patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) procedure codes. We recorded the demographic characteristics, gender, ethnicity, hospital bed size, hospital length of stay, in-hospital mortality, and comorbidities. Patients with ACHD have higher incidences of in-hospital mortality (2.6 vs. 1.8%), and complication rates including neurologic complications (2.6 vs. 0.9%), thromboembolic complications (3.9 vs. 1.4%), arrhythmias (51.6 vs. 29.8%), hepatic failure (4.44 vs. 2.03%), and sepsis (7.24 vs. 4.61%) (all p<0.001). In addition, cost is higher in patients with CHD (Coefficient=0.116, 95% CI, 0.105-0.128; p<0.001), Elixhauser score≥7 (Coefficient=0.114, 95% CI, 0.108-0.121; p<0.001), neurologic complications (Coefficient=0.169, 95% CI, 0.143-0.196; p<0.001), thrombotic complications (Coefficient=0.243, 95% CI, 0.222-0.265; p<0.001), sepsis (Coefficient=0.198, 95% CI, 0.185-0.211; p<0.001), acute kidney injury (Coefficient=0.056, 95% CI, 0.041-0.063; p<0.001), elective cases (Coefficient=0.047, 95% CI, 0.041-0.053; p<0.001), and length of stay>6days (Coefficient=0.703, 95% CI, 0.697-0.710; p<0.001). This study shows that ACHD patients undergoing cardiac surgery experience higher hospital costs and poorer outcomes than a reference population of adult CABG patients. Recognition and treatment of comorbidities in ACHD patients undergoing cardiac surgery may provide an opportunity to improve perioperative outcomes in this growing patient population.

Cost of Cardiac Surgery in Frail Compared With Nonfrail Older Adults

BackgroundFrailty is a risk factor for mortality, morbidity, and prolonged length of stay after cardiac surgery, all of which are major drivers of hospitalization costs. The incremental hospitalization costs incurred in frail patients have yet to be elucidated. MethodsPatients aged ≥ 60 years were evaluated for frailty before coronary artery bypass grafting or heart valve surgery at 2 academic centres between 2013 and 2015 as part of the McGill Frailty Registry. Total costs were summed from the date of the index surgery to the date of hospital discharge. Mutivariable linear regression was used to determine the association between preoperative frailty status and total costs after adjusting for conventional surgical risk factors. ResultsAmong 235 patients included in the analysis, the median age was 73.0 years (interquartile range [IQR], 70.0-78.0 years) and 68 (29%) were women. The median cost was $32,742 (IQR, $23,221-$49,627) in 91 frail patients compared with $23,370 (IQR, $19,977-$29,705) in 144 nonfrail patients. Seven extreme-cost cases > $100,000 were identified, and all of the patients in these cases exhibited baseline frailty. In the multivariable model, total costs were independently associated with frailty (adjusted additional cost, $21,245; 95% confidence interval [CI], $12,418-$30,073; P < 0.001) and valve surgery (adjusted additional cost, $20,600; 95% CI, $9,661-$31,539; P < 0.001). ConclusionsFrailty is associated with a marked increase in hospitalization costs after cardiac surgery, an effect that persists after adjusting for age, sex, surgery type, and surgical risk score. Further efforts are needed to optimize care and resource use in this vulnerable population.

Economies of scale: body mass index and costs of cardiac surgery in Ontario, Canada

An obesity paradox has been described, whereby obese patients have better health outcomes than normal weight patients in certain clinical situations, including cardiac surgery. However, the relationship between body mass index (BMI) and resource utilization and costs in patients undergoing coronary artery bypass graft (CABG) surgery is largely unknown. We examined resource utilization and cost data for 53,224 patients undergoing CABG in Ontario, Canada over a 10-year period between 2002 and 2011. Data for costs during hospital admission and for a 1-year follow-up period were derived from the Institute for Clinical Evaluative Sciences, and analyzed according to pre-defined BMI categories using analysis of variance and multivariate models. BMI independently influenced healthcare costs. Underweight patients had the highest per patient costs ($50,124±$36,495), with the next highest costs incurred by morbidly obese ($43,770±$31,747) and normal weight patients ($42,564±$30,630). Obese and overweight patients had the lowest per patient costs ($40,760±$30,664 and $39,960±$25,422, respectively). Conversely, at the population level, overweight and obese patients were responsible for the highest total yearly population costs to the healthcare system ($92 million and $50 million, respectively, compared to $4.2 million for underweight patients). This is most likely due to the high proportion of CABG patients falling into the overweight and obese BMI groups. In the future, preoperative risk stratification and preparation based on BMI may assist in reducing surgical costs, and may inform health policy measures aimed at the management of weight extremes in the population.

Epidural dexmedetomidine and bupivacaine in off-pump coronary artery bypass graft: does it help in fast tracking?

Background Fast-track cardiac surgery is an important global concern as it can decrease the duration of ICU stay, duration of hospitalization, and total cost of cardiac surgery. The greater the success in fast-track cardiac surgery, the greater the survival rate as there will be fewer cancellations due to unavailability of beds. Objective Our aim is to assess the impact of thoracic epidural dexmedetomidine-bupivacaine on the hemodynamics and analgesic profile, and thus in fast-tracking surgery in patients subjected to off-pump coronary artery bypass grafts (CABG). Patients and methods Fifty-six patients of either sex, aged 50–70 years, subjected to off-pump CABG were randomly assigned to two groups: a control group receiving general anesthesia (GA); and an epidural general group receiving GA combined with thoracic epidural dexmedetomidine 1 μg/kg with 8 ml 0.25% bupivacaine and top-up doses of 2 ml. Bupivacaine 0.25% was given hourly during the operation until closure of the sternum. Perioperative hemodynamics (heart rate, mean arterial pressure, and central venous pressure) and PaCO2, PaO2, and pH were recorded at the following intervals: at baseline, before skin incision, before sternotomy, after sternal closure, and in the ICU. Time to awakening and time to extubation were recorded. Also, analgesics and vasoactive and vasodilator medications were recorded. Pain assessment was made using the visual analogue scale on a scale of 0–10. Total duration of stay in ICU and hospital stay was recorded. Results Postoperative heart rate and mean arterial pressure were significantly lower in the epidural group when compared with the control group. Time to first awakening and extubation was also significantly earlier in the epidural group than in the control group. Total intraoperative fentanyl dose (μg/kg) was less in the epidural group than in the general group, and postoperative morphine requirements (mg/kg) were significantly lower in the epidural group than in the control group. There was lesser need for cardiovasoactive drugs (β-blockers, inotropes) and vasodilators in the epidural group compared with the control group. Visual analogue scale revealed better analgesic profile at the time of extubation in the epidural group. Total ICU and hospital stay was significantly shorter in the epidural group than in the control group. Conclusion GA supplemented with thoracic epidural dexmedetomidine with bupivacaine in off-pump CABG resulted in more perioperative hemodynamic stability, earlier extubation, lower pain score, and less analgesics, vasoactive and vasodilator drug requirements compared with GA alone. Successful fast tracking of cardiac surgery in off-pump CABG can be achieved using this anesthetic technique.

A structured blood conservation programme reduces transfusions and costs in cardiac surgery.

Transfusions of blood products can be lifesaving, but they are also associated with considerable risks and adverse effects, including immune response and infections. In cardiac surgery, transfusions have also been associated with increased mortality. We prospectively studied the effects of a structured programme to reduce transfusions and transfusion-associated costs in cardiac surgery. The programme included: (i) education of all staff about the risks and benefits of blood transfusions; (ii) revised guidelines for transfusions; and (iii) a transfusion log where indication for transfusion, status of the patient and prescribing physician were registered. Transfusion prevalence, complications and costs for blood products were registered for all acute and elective cardiac operations during a 12-month period before (n = 1128) and after (n = 1034) the programme was started. The two time periods were compared. In addition, the prevalence of transfusions was registered for 2 more years after the programme was initiated. The first year after the programme was initiated the proportion of patients transfused with red blood cell concentrate decreased by 21.8% (from 58.2 to 45.5%, P <0.001), plasma by 37.4% (from 30.8 to 19.3%, P <0.001) and platelets by 21.0% (from 20.5 to 16.2%, P = 0.010). Reoperations for bleeding (5.8 vs 5.0%), early complication rate and 30-day mortality (2.5 vs 2.6%) were not significantly different before and after the start date. Based on the 2009 institutional prices for red blood cell concentrate (102 €/unit), plasma (35 €/unit) and platelets (290 €/unit), the savings on blood products were €161,623 during the first 12 months after the programme was launched. The proportion of patients transfused with any blood product was 60.9% before the programme was started and 48.3, 54.0 and 50.7% 1-3 years after its start (all P <0.001), respectively. A structured blood conservation programme reduces transfusions and costs for blood products in cardiac surgery, without any signs of compromised medical safety. The effects of introducing such a programme are maintained over at least 3 years.

The universal bed model for patient care improves outcome and lowers cost in cardiac surgery

With the escalating demands to increase the efficiency and decrease the cost, innovations in postoperative cardiac surgical patient care are needed. The universal bed model is an innovative care delivery system that allows patient care to be managed in one setting from postoperation to discharge. We hypothesized that the universal bed model in the context of cardiac surgery would improve outcomes and efficacy. A total of 610 consecutive patients were admitted to the universal bed unit and prospectively entered into the Society of Thoracic Surgeons National Cardiac Database. Intensive care unit level of care was determined by acuity and staffing needs. Telemetry was employed from admission to discharge, and multidisciplinary rounds were conducted twice daily. Postoperative outcomes were recorded during hospital stay, and comparisons were made with the Society of Thoracic Surgeons National Cardiac Database using identical variables over the same period of time. Decreased ventilation time, intensive care unit and hospital stay, and reduction in the incidence of atrial fibrillation and infectious complications yielded a financial benefit in the universal bed group compared with the traditional model of admission. Stroke rate and in-hospital mortality were the same compared with regional and national centers. Compared with regional centers, there was an average cost savings between $6200 and $9500 per patient depending on the operation. Patient care satisfaction by independent survey was in the 99th percentile. The universal bed patient care model allows for expedient and efficacious care as measured by decreased length of intensive care unit and hospital stay, improved postoperative outcomes, patient satisfaction, and cost savings.

Outcomes and Cost of Cardiac Surgery in Octogenarians is Related to Type of Operation: A Multiinstitutional Analysis

Given recent economic implications in caring for an aging population, we sought to determine if postoperative complications and costs for octogenarians differed based on the type of cardiac operation. From 2003 to 2008, patients who underwent cardiac operations at 16 different centers were identified from the Virginia Cardiac Surgery Quality Initiative and selected into two cohorts (<80 years and ≥80 years). Octogenarians (≥80 years) were stratified into isolated primary coronary bypass graft, aortic valve, mitral valve, or combined operation. Preoperative risks, outcomes, and costs were analyzed. Case-mix adjusted models for mortality and major complication rate were developed. We examined 45,731 patients, of which 3,079 were octogenarians (82.7 ± 2.5 years). Compared with younger patients, octogenarians incurred higher mortality (6.5% vs 3.1%, p < 0.001) and major complication rates (13.2% vs 8.4%, p < 0.001) with only incrementally higher total costs (p < 0.001). Among octogenarians mortality was similar despite the operation. Cross-clamp and cardiopulmonary bypass time (p < 0.001), hospital length of stay (p = 0.001), and major complication rate (p = 0.002) were highest for combined operation. Despite the fewest complications, mitral valve operation had the highest total costs (p < 0.001). Type of operation was not predictive of mortality or major complication rate. However, age, female gender, emergent status, and prolonged cardiopulmonary bypass time were independently associated with death despite risk-adjustment. Advanced age confers increased risks and incrementally higher costs in patients undergoing cardiac operations. Isolated mitral and combined procedures have the highest complications and costs. Any proposed cardiac operation in octogenarians mandates careful consideration of resource utilization.

La chirurgie cardiaque en Chine en 2010

In China, cardiac surgery has been developing fast over the past 30 years, but it still cannot meet the huge demand created by the high prevalence of risk factors for cardiovascular disease, such as hypertension, diabetes and smoking, and the high frequency of congenital cardiopathies. In China, cardiac surgery is available in about 600 centers, but fewer than 10 centers account for the bulk of operations. Most of these high-volume centers are located in well-developed eastern cities, but cardiac surgery is growing at an extremely rapid pace in the western provinces too. Private structures are appearing alongside public and military hospitals. Huge efforts are being made to train medical staff and to develop basic and clinical research. The Chinese biomedical industry is also developing rapidly, providing local alternatives to imported products. Large university centers in major eastern cities are assisting the development of less experienced centers. The high cost of cardiac surgery remains an obstacle, but the improving economic situation and the expansion of insurance coverage is rapidly improving patient access to these treatments.

Does Coronary Artery Bypass Grafting Without Cardiopulmonary Bypass Reduce Costs in Cardiac Surgery?

Technical improvements in coronary revascularization over the past decade have led to a revival of interest in off-pump coronary artery bypass surgery. Cost containment in coronary artery bypass surgery is becoming increasingly important in modern hospital management. Therefore, further savings could be obtained by using a surgical technique able to decrease the fixed direct cost while maintaining clinical quality of care. Economic considerations are an extremely important issue in evaluating the role of off-pump coronary artery bypass grafting in the future of cardiac surgery, as off-pump coronary artery bypass grafting is expected to lower costs by reducing perioperative morbidity and recovery time. However, the acceptance of this procedure as a routine alternative for the treatment of coronary artery disease will depend on both long-term graft patency rates as well as a competitive market cost. This review examines these effects.

Congenital cardiac surgery in the less privileged regions of the world

Pediatric cardiac surgery has been available for several decades. With advances in recent years, the majority of children born with congenital heart disease, if repaired in time, are expected to lead normal productive lives. This privilege of early diagnosis and timely management is restricted to children in developed countries only. The majority of children born with congenital heart disease in developing countries do not get the necessary care, leading to high morbidity and mortality. Several reasons exist for this state of affairs. Most centers for congenital cardiac surgery are located in developed countries, whereas most children requiring cardiac surgery do not live in these countries. In less privileged regions of the world, the high cost of cardiac surgery makes it unaffordable for the families of these children. Furthermore, issues such as late presentation of cases, associated comorbid conditions, understaffing of units and limited resources contribute to suboptimal outcome in those who undergo surgery. This review discusses the current status of pediatric cardiac surgery in developing countries and the reasons for it. Some of the strategies for improvement, in the wake of limited resources, are suggested. Often, the resources are not only limited but improperly utilized.

EuroSCORE is of predictive value to estimate prospective complication-related costs in cardiac surgery

EuroSCORE is of predictive value to estimate prospective complication-related costs in cardiac surgery

Impact of intraoperative myocardial tissue acidosis on postoperative adverse outcomes and cost of care for patients undergoing prolonged aortic clamping during cardiopulmonary bypass

Background This study examined the impact of intraoperative myocardial acidosis and adverse postoperative outcomes on the cost of cardiac surgical care. Methods Myocardial tissue pH corrected to 37°C (pH 37C) was measured in 162 patients with cross-clamp (XC) duration of 119 minutes or longer. Perioperative data and outcomes were collected prospectively. The Veterans Affairs cost accounting system was used to determine the cost of care in a subset of 57 patients. Results Long XC duration was associated with significantly increased acidosis and adverse postoperative outcomes. The cost of care for patients with adverse outcomes was increased by 110% ( P < .0001). Patients with acidosis at the end of reperfusion had significantly ( P = .0470) increased costs of care. End reperfusion of myocardial tissue pH 37C of less than 7.0, diabetes mellitus, and body surface area were significant determinants of postoperative adverse outcomes. Conclusions Intraoperative myocardial acidosis is a determinant of postoperative adverse outcomes and cost in cardiac surgery. Reducing XC duration and improving intraoperative myocardial protection should improve outcomes and reduce cost.

„Bedside“-Thrombelastographie

Demographic changes and aggressive medication with platelet aggregation inhibitors have resulted in a marked increase in blood and coagulation product expenditure and costs in cardiac surgery. We analyzed the bedside coagulation test (ROTEM) in order to verify clot forming quality and to find a cost-effective treatment algorithm. Annual treatment costs of all cardiosurgical patients were retrospectively analyzed before (729 patients) and after (693 patients) implementation of the bedside ROTEM test. Cumulative numbers and costs of platelet concentrates (PltC), fresh frozen plasma (FFP), red blood cell units (RBC), and the coagulation factors prothrombin complex concentrates (PCC), recombinant factor VIIa (rFVIIa), factor XIII (FXIII), and fibrinogen were assessed. Average monthly numbers and costs were compared. The number of rethoracotomies and early mortality were assessed and compared in both periods. After ROTEM implementation cumulative RBC expenditure showed a 25% decrease and PltC a 50% decrease. FFP expenditure remained unchanged. PCC, FXIII were markedly reduced (-80%) while rFVIIa was entirely omitted. Fibrinogen, however, showed a two-fold increase. Cumulative average monthly costs of all blood products decreased from 66,000 EUR to 45,000 EUR (-32%). Coagulation factor average monthly costs decreased from 60,000 EUR to 30,000 EUR (-50%) yielding combined savings of 44%. In contrast, average monthly costs for ROTEM were 1,580 EUR. The total number of rethoracotomies decreased from 6.6% to 5.5% while early mortality (5.9%; 6.0%) remained stable. Cumulative costs for treatment of perioperative coagulation disorders were reduced by bedside ROTEM analysis to achieve a selective substitution management. Saved costs for blood and coagulation products clearly outweighed the expenses of ROTEM. Adequate differential coagulation management can therefore be cost-effective.

Cost reduction of perioperative coagulation management in cardiac surgery: value of ‘bedside’ thrombelastography (ROTEM)☆

Demographic changes and aggressive platelet inhibition have resulted in a marked increase in blood- and coagulation product expenditure and costs in cardiac surgery. We analyzed "bedside" coagulation test (ROTEM) in order to verify clot forming quality for the purpose of finding a cost-effective treatment path. Annual treatment costs of all cardiosurgical patients were analyzed before (729 patients) and after (693 patients) implementation of "bedside" ROTEM. Cumulative numbers and costs of platelet concentrates (PltC), fresh frozen plasma (FFP), red blood cell units (RBC), and coagulation factors: pooled coagulation concentrates (PCC), recombinant factor VIIa (rFVIIa), factor XIII (FXIII), and fibrinogen were assessed. Average monthly numbers and costs were compared. Number of resternotomies and early mortality was assessed and compared in both periods. After ROTEM implementation cumulative RBC expenditure showed 25% decrease while PltC exhibited 50% decrease. FFP expenditure remained unchanged. PCC, FXIII were markedly reduced (-80%) while rFVIIa were entirely omitted. Fibrinogen, however, increased two-fold. Cumulative average monthly costs of all blood products decreased from 66,000 euro to 45,000 euro (-32%). Coagulation factor average monthly costs decreased from 60,000 euro to 30,000 euro (-50%) yielding combined savings of 44%. In contrast, average monthly costs for ROTEM were 1.580 euro. Total number of resternotomies decreased from 6.6% to 5.5% while early mortality (5.9%; 6.0%) remained stable. Cumulative costs for treatment of perioperative coagulation disorders can be reduced by "bedside" ROTEM analysis to achieve a selective substitution management. Saved costs for blood- and coagulation products clearly outweighed the expenses of ROTEM. Adequate differential coagulation management can therefore be cost-effective.

ICU costs in cardiac surgery

ICU costs in cardiac surgery