Endovascular aneurysm repair delivery redesign leads to quality improvement and cost reduction.
OBJECTIVE
Endovascular aneurysm repair (EVAR) is now a mainstay of therapy for abdominal aortic aneurysm, although it remains associated with significant expense. We performed a comprehensive analysis of EVAR delivery at an academic medical center to identify targets for quality improvement and cost reduction in light of impending health care reform.


METHODS
All infrarenal EVARs performed from April 2011 to March 2012 were identified (N = 127). Procedures were included if they met standard commercial instructions for use guidelines, used a single manufacturer, and were billed to Medicare diagnosis-related group 238 (n = 49). By use of DMAIC (define, measure, analyze, improve, and control) quality improvement methodology (define, measure, analyze, improve, control), targets for EVAR quality improvement were identified and high-yield changes were implemented. Procedure technical costs were calculated before and after process redesign.


RESULTS
Perioperative services and clinic visits were identified as targets for quality improvement efforts and cost reduction. Mean technical costs before the intervention were $31,672, with endograft implants accounting for 52%. Pricing redesign in collaboration with hospital purchasing reduced mean EVAR technical costs to $28,607, a 10% reduction in overall cost, with endograft implants now accounting for 46%. Perioperative implementation of instrument tray redesign reduced instrument use by 32% (184 vs 132 instruments), saving $50,000 annually. Unnecessary clinic visits were reduced by 39% (1.6 vs 1.1 clinic visits per patient) through implementation of a preclinic imaging protocol. There was no difference in mean length of stay after the intervention.


CONCLUSIONS
Comprehensive EVAR delivery redesign leads to cost reduction and waste elimination while preserving quality. Future efforts to achieve more competitive and transparent device pricing will make EVAR more cost neutral and enhance its financial sustainability for health care systems.
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH. Electronic address: courtney.j.warner@hitchcock.org.
Courtney J
CJ
Warner
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Alexander J
AJ
Horvath
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Richard J
RJ
Powell
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Jesse A
JA
Columbo
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Teri R
TR
Walsh
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Philip P
PP
Goodney
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Daniel B
DB
Walsh
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
David H
DH
Stone
D000046:Academic Medical Centers; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D003695:Delivery of Health Care / Q000191:economics* / Q000592:standards; D057510:Endovascular Procedures / Q000191:economics* / Q000592:standards; D018166:Health Care Reform; D006801:Humans; D058996:Quality Improvement