Safety and cost-effectiveness of port removal outside of the operating room among pediatric patients.
OBJECTIVE
The current emphasis on fiscally responsible health spending in the era of the Affordable Care Act and other health care reform necessitates cost-conscious delivery of care. "Value" in health care is defined as the quality of care divided by the cost. As such, health systems optimize value by providing the most cost-effective care possible without sacrificing safety or outcomes. Elective, minimal risk surgical procedures in children may be value-enhanced by moving from an operating room (OR) to a more cost-efficient setting. The purpose of this study was to assess the safety and cost of performing the removal of implantable central venous access devices ("ports") in locations other than the main OR.


METHODS
We compared port removal at three sites: 1. Main OR, 2. Satellite OR, and 3. Clinic Procedure Room. This was a mixed-methods study including a retrospective review of medical records and prospective observation/interviewing. To calculate cost without the inherent biases of hospital charges, costs, and payments, we utilized the methodology of time-driven activity based costing. Specifically, we recorded time spent by the patient in hospital facilities and with health care personnel. This duration was then weighted with the hourly cost of each health care professional and hospital space. The Mann-Whitney U test compared time and cost across the three sites. Overall cost at each site was divided by overall cost at the referent site (Main OR) to obtain a ratio of cost savings.


RESULTS
A total of 120 patients (40 per site) were included in the analysis. Demographic and clinical factors were not significantly different between sites. No complication occurred with port removal at any site. Time of the entire care episode was significantly decreased in the Clinic (median 161min, 95% confidence interval [CI] 134-188min), compared to the Main OR (median 235min, 95% confidence interval [CI] 209-251min) or Satellite OR (median 228min, 95% confidence interval [CI] 211-245min). Overall cost was decreased by 25% (95% CI: 13-34%) at the Clinic and by 6% (95% CI: -2-11%) at the Satellite OR, compared to the Main OR (referent, P<0.01).


CONCLUSIONS
In our study, port removal in the Clinic Procedure Room was not associated with increased risk of negative outcomes. Shifting port removal from the Main OR to the Clinic may result in substantial cost savings.
Department of Anesthesiology, Preoperative and Pain Medicine, Boston Children's Hospital, Boston, MA; Harvard School of Dental Medicine, Boston, MA.
Tehsina F
TF
Devji
Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA.
Arin L
AL
Madenci
Department of Anesthesiology, Preoperative and Pain Medicine, Boston Children's Hospital, Boston, MA.
Elizabeth
E
Carpino
Department of Anesthesiology, Preoperative and Pain Medicine, Boston Children's Hospital, Boston, MA.
Izabela C
IC
Leahy
Department of Anesthesiology, Preoperative and Pain Medicine, Boston Children's Hospital, Boston, MA.
Mihail
M
Samnaliev
Department of Anesthesiology, Preoperative and Pain Medicine, Boston Children's Hospital, Boston, MA.
Jennifer L
JL
Dearden
Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA.
Brent R
BR
Weil
Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA.
Christopher B
CB
Weldon
Department of Anesthesiology, Preoperative and Pain Medicine, Boston Children's Hospital, Boston, MA. Electronic address: joseph.cravero@childrens.harvard.edu.
Joseph
J
Cravero
D062905:Central Venous Catheters; D002648:Child; D003362:Cost-Benefit Analysis; D020878:Device Removal / Q000191:economics* / Q000592:standards*; D005260:Female; D017722:Hospital Charges; D006801:Humans; D008297:Male; D009873:Operating Rooms; D058991:Patient Protection and Affordable Care Act; D011446:Prospective Studies
Health care value; Operative care; Time-driven activity based costing