Prashant Sinha (NYU Langone Health), Nilufar Tursunova (NYU Langone Health), Heekoung Allison Youn (NYU Langone Health)
Laparoscopic sleeve gastrectomy (LSG) is a high volume procedure with relatively few variables within its care delivery framework, making it an ideal candidate for standardization. Two hospitals in our system are accredited bariatric centers, but did not previously share resources or workflow. Both centers used pathways to independently standardize care.
Our main hospital (MH) utilized its internal Value Based Medicine (VBM) team to create a standard pathway, while its satellite hospital (SH) utilized an external program called ENERGY, and mentors from the American Society for Metabolic and Bariatric Surgery to deploy a pre-developed pathway. We wished to retrospectively compare the VBM and ENERGY pathways in achieving performance improvement goals through pre and post implementation data analysis.
Surgeons performing LSG at the MH worked with an internal VBM task force to identify pre-, peri- and postoperative diet, medications, nursing care, imaging and implants to improve anesthesia recovery, reduce nausea, length of stay (LOS) and readmission. Variable direct cost (VDC) data were available at this site. Independently, surgeons at the SH upon program review by the ASMBS were given the option to enroll in its quality improvement program, ENERGY. They were assigned a mentor from the ASMBS and given instruction through virtual consultation and materials targeting similar pre-, peri- and postoperative variables. Data for LOS and readmission were available but not VDC at this site.
Three hundred thirty VBM pathway patients were matched against 330 historical controls from the MH while 48 ENERGY pathway patients were matched against 357 historical controls from SH. In the MH median LOS was reduced to 1.5 from 1.94 days and VDC was reduced by $792. At the SH, median LOS was reduced to 1.47 from 1.81 days. Each of these changes were significant with a p<0.01. Readmissions were reduced at both hospitals, but the subgroup analysis was underpowered to detect significance. A review of pathway elements in both programs revealed nearly identical pathways.
Care pathways are powerful tools that improve quality and reduce costs. Prepackaged and custom built pathways were equally effective means to drive similar performance in bariatric surgery. Health care systems that do not have resources for internal analytics teams may still derive equal benefit through dissemination of knowledge via hospital networks and professional societies. The significant findings between our hospitals created an opportunity to share and synchronize the pathways and unify our performance dashboards.
Implications for the Patient
Pathways can and should be disseminated to other members in a healthcare system. The Michigan Bariatric Collaborative is a well implemented example. We are increasing surgical pathway development in other areas such as spine surgery, in order to unify performance between our hospitals in our healthcare system.