Cost-Effectiveness of the PPAC
The responsibilities of the anesthesiologist are unique in the
preoperative process. He or she is the final clinical pathway or "gatekeeper" for
the patient entering the OR and for the facilitation of postoperative pain therapy.
As such, the PPAC anesthesiologist is a central figure in the review and implementation
of practice guidelines[5]
[292]
[293]
[294]
and
clinical
pathways. He or she also participates in sharing of information (such as patient
evaluation protocols and consultations), efforts to avoid duplication of services,
studies on identification of costs and benefits, and the evaluation of the management
of medical resources and measurements of outcome.
Because the anesthesiologist is the specialist best able to evaluate
intraoperative medical complexities as they relate to anesthesia and surgery, he
or she is also best qualified to define and coordinate the appropriate preoperative
studies needed for optimal intraoperative management of the patient.
Diagnostic Studies and the PPAC
Using guidelines plus clinical judgment seems to be more cost-effective
than using only clinical judgment or batteries of tests. These guidelines are provided
to surgeons for review and are based primarily on the patient's age, medical status,
proposed surgical procedure, and judgment of the clinician.
Four recent studies reported a reduction in testing and hospital
costs when preoperative diagnostic testing was
Figure 25-24
A quality assurance form used by an anesthesia preoperative
evaluation clinic to assess the quality and efficiency of its service. ECG, electrocardiogram;
ECHO, echocardiogram; H&P, history and physical examination; MUGA, multiple uptake
gated analysis; PFT's, pulmonary function tests.
coordinated through the anesthesiologist in the PPAC. The reductions in testing
and in average hospital costs per patient were, respectively, 55.1 percent and $112.09,
[25]
28.6 percent and $20.89,[289]
55 percent and $137.[27]
Roizen and associates
[291]
reported a $100 decrease in costs per patient.
The PPAC and Delays and Cancellations in the Surgery
Schedule
Day-of-surgery delays and cancellations, OR downtime, and loss
of hospital revenue decrease when an unstable medical condition is determined before
the day of surgery (see also Chapter
86
). Several authors have reported
decreased day-of-surgery cancellations when patients were referred to a PPAC prior
to the day of surgery ( Table 25-25
).
The anesthesiologist becomes the primary physician identified with preoperative
cost containment and improved quality of perioperative patient care. Furthermore,
educating the patient about what to expect regarding postoperative pain therapy and
feeding decreases his or her length of stay in the hospital.
Incentives for Cost Reductions
The contribution of the anesthesiologist to cost savings for the
hospital or health system is often not obvious and is frequently difficult to quantify.
However, the PPAC provides several areas of identifiable cost reductions to the
hospital or health system for which the anesthesiologist is directly responsible.
A contractual agreement negotiated with the hospital or health
system can recognize that the anesthesia department influences hospital or health
care system costs. Fischer[25]
reported a one-year
hospital cost reduction of $1.01 million spent for unnecessary preoperative testing,
and Starsnic and colleagues[289]
reported a 1-year
cost reduction of $643,056 when preoperative diagnostic studies were coordinated
through the PPAC.
