Search

Cleveland Clinic partnered with Harvard Business School to conduct a pilot project to explore the differences between time-driven activity-based costing (TDABC) and relative value unit costing. The goal was to determine whether TDABC could improve the accuracy of cost information and identify value-improvement opportunities for two types of heart-value procedures. Using TDABC, leaders gained a detailed look into process steps that could be consolidated, reduced, or performed with a lower cost mix of personnel.

Introduction: Cardiac conduction system injury is a cause of postoperative cardiac morbidity following repair of congenital heart disease (CHD). The national occurrence of postoperative complete heart block (CHB) following surgical repair of CHD is unknown. We sought to describe the occurrence of and costs related to postoperative CHB following surgical repair of common forms of CHD using a large national database., Methods and Results:  Retrospective, observational analysis performed over a 10-year period (2000-2009) using the Kids' Inpatient Database (KID). Visits for patients ≤24 months of age were identified who underwent surgical repair of ventricular septal defects (VSD), atrioventricular canal defects (AVC), and tetralogy of Fallot (TOF). Patients were identified who were diagnosed with postoperative CHB, further identifying those requiring a new pacemaker placement during the same hospitalization. Costs associated with visits were calculated. There were 16,105 surgical visits: 7,146 VSD, 3,480 AVC, and 5,480 TOF. There was a decrease in postoperative mortality (P = 0.0001) with no significant change in postoperative CHB. Hospital stay and cost were higher with CHB and placement of a permanent pacemaker. Repair of AVC (OR 1.77; [1.32-2.38]) was associated with a higher rate of postoperative CHB. Length of hospital stay and total cost were significantly increased with the development of postoperative CHB and increased further with placement of a permanent pacemaker., Conclusion:  There has been little change over time in the frequency of postoperative CHB in patients undergoing repair of VSD, AVC, and TOF. Postoperative CHB results in major added cost to the healthcare system., (© 2012 Wiley Periodicals, Inc.)

Objective: To determine the population number necessary to generate a sufficient volume of pediatric cardiac surgeries to allow accurate prediction of resource utilization., Design: All pediatric cardiac surgical patients receive care in our institution by means of only four clinical pathways that are based on acuity, not diagnosis or procedure. This allows accurate tracking of resource utilization. Based on available information, 750 consecutive surgically treated patients were retrospectively assigned to a pathway. They were subsequently subdivided into study groups of decreasing sizes from 150 to 35. Variability of pathway distribution from group to group was examined as a measure of the ability to predict resource utilization based on group size. Pediatric cardiac statistics from the state of Ohio were then used to extrapolate to the population base necessary to generate each group size., Setting: A regional pediatric cardiac referral center., Patients: All sequential patients who underwent pediatric cardiac surgery between July 1991 and January 1994., Results: Statewide statistics showed that a population base of 1 million people generates 100 pediatric cardiac operations. Groups of 100 patients or greater had minimal variation in pathway distribution from group to group, allowing accurate prediction of hospital charges. This was not true for groups of 50 patients or less., Conclusions: Resource utilization for pediatric cardiac surgery can be accurately predicted in a capitated setting for populations of 1 million covered lives (100 procedures) or greater. For populations of 500 000 covered lives or less, variability of case mix is great enough to suggest the need for a more individualized payment mechanism.

Parsonnet risk estimates and postoperative lengths of stay were studied for two cohorts of cardiac surgical patients. The first cohort consisted of 287 patients and was taken from 1984, the first full year of this cardiac surgical program. The second cohort consisted of all 1,167 patients operated on in the calendar years 1989 to 1991. We found that the mean risk for the patients had nearly doubled in this interval and that the risk distribution changed significantly from one skewed toward good-risk patients to a nearly uniform distribution through all risk categories. A high correlation was identified (0.9761) between the postoperative length of stay and the mean risk estimates for the 1989 to 1991 cohort of patients. This permits a regression equation to be calculated showing that the length of stay could be estimated at 7.06 days + 0.21 times the mean risk for a patient or cohort of patients. This relationship is then used to develop a relationship between the net income for a given case or cohort of patients and the length of stay or risk. These data suggest that, in most hospitals, hospital fixed costs are a major determinant, even more so than daily charges, of the relationship between the hospital's finances and the mean risks of patients undertaken in the cardiac surgical program. The consequences of this are discussed.