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Perioperative Medicine

, 3:6

First Online: 27 August 2014Received: 06 May 2014Accepted: 25 July 2014


BackgroundThe numbers of people requiring total arthroplasty is expected to increase substantially over the next two decades. However, increasing costs and new payment models in the USA have created a sustainability gap. Ad hoc interventions have reported marginal cost reduction, but it has become clear that sustainability lies only in complete restructuring of care delivery. The Perioperative Surgical Home PSH model, a patient-centered and physician-led multidisciplinary system of coordinated care, was implemented at UC Irvine Health in 2012 for patients undergoing primary elective total knee arthroplasty TKA or total hip arthroplasty THA. This observational study examines the costs associated with this initiative.

MethodsThe direct cost of materials and services excluding professional fees and implants for a random index sample following the Total Joint-PSH pathway was used to calculate per diem cost. Cost of orthopedic implants was calculated based on audit-verified direct cost data. Operating room and post-anesthesia care unit time-based costs were calculated for each case and analyzed for variation. Benchmark cost data were obtained from literature search. Data are presented as mean ± SD coefficient of variation where possible.

ResultsTotal per diem cost was $10,042 ± 1,305 13% for TKA and $9,952 ± 1,294 13% for THA. Literature-reported benchmark per diem cost was $17,588 for TKA and $16,267 for THA. Implant cost was $7,482 ± 4,050 54% for TKA and $9869 ± 1,549 16% for THA. Total hospital cost was $17,894 ± 4,270 24% for TKA and $20,281 ± 2,057 10% for THA. In-room to incision time cost was $1,263 ± 100 8% for TKA and $1,341 ± 145 11% for THA. Surgery time cost was $1,558 ± 290 19% for TKA and $1,930 ± 374 19% for THA. Post-anesthesia care unit time cost was $507 ± 187 36% for TKA and $557 ± 302 54% for THA.

ConclusionsDirect hospital costs were driven substantially below USA benchmark levels using the Total Joint-PSH pathway. The incremental benefit of each step in the coordinated care pathway is manifested as a lower average length of stay. We identified excessive variation in the cost of implants and post-anesthesia care.

KeywordsPerioperative surgical home Perioperative practice model Perioperative care pathway Total arthroplasty Cost analysis Cost variation AbbreviationsASAAmerican Society of Anesthesiologists

BMIBody mass index

CMSCenters for Medicaid and Medicare

EMRElectronic medical record

GDFTGoal directed fluid therapy

LOSLength of Stay

LSSLean Six Sigma

OROperating room

PACUPost-anesthesia care unit

PODPost-operative day

PSHPerioperative Surgical Home

TATotal arthroplasty

THATotal hip arthroplasty

TJAtotal joint arthroplasty

TKATotal knee arthroplasty.

Electronic supplementary materialThe online version of this article doi:10.1186-2047-0525-3-6 contains supplementary material, which is available to authorized users.

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Autor: Darren R Raphael - Maxime Cannesson - Ran Schwarzkopf - Leslie M Garson - Shermeen B Vakharia - Ranjan Gupta - Zeev N K


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