title: Specialized vascular floors after open aortic surgery: cost containment while preserving quality outcomes.
abstract: BACKGROUND
  Postoperative care of open abdominal aortic surgery (OAAS) traditionally involves the intensive care unit (ICU). We hypothesized that in patients without an indication for postoperative ICU admission, admission to a specialized vascular floor unit (hemodynamic monitoring, 2:1 nursing) offers cost savings to both payer and institution without compromising care.
  
  
  METHODS
  The electronic medical record was used to collect perioperative data for patients who underwent OAAS between July 2007 and July 2011. The university's cost accounting system provided information on revenue, total margin, and professional billing. Patients with ICU indications (spinal drain, Swan-Ganz monitoring, vasopressors, intubation, or blood product resuscitation) were excluded. Comparative cost and outcome analysis was performed on vascular ward and ICU admissions using the Fisher's exact test for dichotomous categorical variables and the Student's t-test for continuous variables. Long-term survival comparison was calculated using Kaplan-Meier survival estimates.
  
  
  RESULTS
  One hundred thirty of 215 patients were included for analysis (85 excluded, 51 floor, 79 ICU). Perioperative data amongst the floor and ICU cohorts were similar. Day of operation professional billing fees were comparable (ICU $13,365 vs. floor $12,626; P = 0.18); however, postoperative professional fees were significantly higher in the ICU cohort (ICU $3,258 vs. floor $2,101; P = 0.001) primarily because of intensivist billing. The hospital generated an average of 8.7% more revenue from the ICU cohort (ICU $37,770 vs. floor $34,756; P = 0.023). This was offset by greater expenses in the ICU cohort (ICU $30,756 vs. floor $25,144; P = 0.02), yielding a hospital profit margin of 107.5% favoring floor admission (ICU $2,858 vs. floor $5,931; P = 0.19). Duration of stay was similar (ICU 8.0 days vs. floor 7.8 days; P = 0.86). Kaplan-Meier survival analysis was not significantly different between cohorts (ICU 10.1%, median follow-up, 1,070 days vs. floor 0%, median follow-up, 405 days; P = 0.13).
  
  
  CONCLUSIONS
  Postoperative admission to the ICU is not always necessary after OAAS. Specialized vascular floors offer a financial savings to both payer and institution, which allows for simultaneous cost containment while preserving quality outcomes.
authors.affiliation: University of Michigan Cardiovascular Center, Ann Arbor, MI, USA.
authors.forename: Frank C
authors.initials: FC
authors.lastname: Vandy
authors.forename: Dani
authors.initials: D
authors.lastname: Campbell
authors.forename: Anna
authors.initials: A
authors.lastname: Eliassen
authors.forename: John
authors.initials: J
authors.lastname: Rectenwald
authors.forename: Jonathan L
authors.initials: JL
authors.lastname: Eliason
authors.forename: Enrique
authors.initials: E
authors.lastname: Criado
authors.forename: Guillermo
authors.initials: G
authors.lastname: Escobar
authors.forename: Gilbert R
authors.initials: GR
authors.lastname: Upchurch
mesh_terms: D000368:Aged; D001012:Aorta, Abdominal / Q000601:surgery*; D017046:Cost Savings; D005251:Fees, Medical; D005260:Female; D005102:Health Expenditures; D006439:Hemodynamics; D017721:Hospital Costs; D006757:Hospital Units / Q000191:economics* / Q000592:standards; D006801:Humans; D007182:Income; D007362:Intensive Care Units / Q000191:economics; D053208:Kaplan-Meier Estimate; D007902:Length of Stay / Q000191:economics; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000191:economics* / Q000592:standards; D009738:Nursing Service, Hospital / Q000191:economics* / Q000592:standards; D011182:Postoperative Care / Q000009:adverse effects / Q000191:economics* / Q000401:mortality / Q000592:standards; D019984:Quality Indicators, Health Care / Q000191:economics* / Q000592:standards; D013997:Time Factors; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000191:economics* / Q000401:mortality / Q000592:standards