The use of clinical practice guidelines (CPGs) to evaluate practice and control costs in ventriculoperitoneal shunt management.
BACKGROUND
As a step toward maximizing the quality and cost-effectiveness of neurosurgical care, we designed clinical practice guidelines (CPGs) for the management of VP shunt malfunctions and infections at a tertiary care pediatric teaching institution. The detailed CPGs determine the use of radiographic studies, laboratory tests, and invasive procedures in the management of this problem. One purpose of the CPGs is to provide clear clinical guidelines for the medical trainee, thereby reducing variability in care and unnecessary utilization of resources.


METHODS
The CPGs were developed in stages over a 2-year period. The practice patterns in our institution for the management of shunt malfunctions and infections were articulated. They were compared with those published in the neurosurgical literature, and areas of clinical decision-making variability were identified. Preliminary guidelines were formulated, and data regarding patient care were prospectively collected. Based on this data, final CPGs were formulated and implemented. Total and itemized hospital charges for patients managed according to the CPGs were compared with those for patients in the 3 years before CPG implementation.


RESULTS
CPG-managed patients had generally lower total and itemized charges as compared with control patients. Decreased charges per hospital day and charges for shunt films in the CPG group were statistically significant.


CONCLUSIONS
The process by which the CPGs were developed and implemented, as well as the CPGs themselves, are described. We also present the clinical, demographic, and financial data that were prospectively collected for all patients managed within the CPGs over an initial 1-year period and compare it with data obtained for control groups of shunt malfunction patients admitted during the 3 years before implementation of the CPGs. We find a trend toward reduction of charges after implementation of the CPG.
Park
J K
JK
Department of Neurosurgery, Children's Hospital, Boston, MA 02115, USA.
Frim
D M
DM
Schwartz
M S
MS
Reidy
P
P
Farley
J A
JA
Black
P M
PM
Scott
R M
RM
Goumnerova
L C
LC
Madsen
J R
JR
D001900:Boston; D003363:Cost Control; D006745:Hospital Bed Capacity, 300 to 499; D017722:Hospital Charges / Q000706:statistics & numerical data*; D006776:Hospitals, Pediatric / Q000191:economics* / Q000592:standards; D006801:Humans; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000191:economics* / Q000592:standards; D017287:Ventriculoperitoneal Shunt / Q000191:economics* / Q000592:standards*