Implementation of an enhanced recovery program for patients undergoing elective cesarean delivery can improve care without incurring a prohibitive expense for hospitals, a study has concluded. The program might even reduce costs considerably.
According to researchers at Saint Peter’s Healthcare System, in New Brunswick, N.J., cost savings associated with a reduction in hospital length of stay (LOS) and an improvement in patient outcomes justify the expense associated with implementation of the program. Indeed, the researchers noted that, considering there are more than 1.3 million cesarean deliveries performed in the United States annually, the potential overall cost savings for their enhanced recovery program might even exceed an eye-popping $1 billion.
In presenting the findings at the annual congress of the American Society for Enhanced Recovery (abstract 31), author Attila Kett, MD, MBA, the chairman of the Department of Anesthesiology at Saint Peter’s University Hospital, said, “Until recently, there has been little interest in enhanced recovery after cesarean section. However, since 2012, multiple obstetrical units in the United Kingdom introduced enhanced recovery programs and demonstrated improved quality of care and significant savings, with superior patient satisfaction. Our partnership with leading experts from the Royal Hallamshire Hospital in the United Kingdom [in Sheffield] provided us with the unique opportunity to pioneer this pathway in the United States.” Dr. Kett cited several references from the International Journal of Obstetric Anesthesia (Lucas et al. 2013;22:92-95; Vickers et al. 2013;22:349; Abell et al. 2013;22:349-350; and Wrench et al. 2015;24:124-130).
Dr. Kett described how the first-year pilot, completed in July 2017, included 100 low-risk patients undergoing repeat cesarean delivery. “In three years, all the low-risk patients having a nonemergency cesarean section at Saint Peter’s University Hospital will have the option to participate in the enhanced recovery program.”
He said empowering patients to take a significant role and ownership of decisions regarding their care, in contrast to the passive role patients traditionally play, is essential. The enhanced recovery program at Saint Peter’s involves a multidisciplinary team approach and provides an option for selected women following a planned cesarean delivery to actively participate in their recovery process (Figure). Team members include anesthesiologists, obstetricians, pediatricians, nurses, lactation specialists, hospital administrators, IT specialists, pharmacists and a care coordinator.
Patients who met the discharge criteria and wished to go home after 48 hours used a personalized mobile communications app and received follow-up calls from the nursing staff. Nurses visited patients’ homes if needed.
Dr. Kett explained how the team at Saint Peter’s partnered with SeamlessMD, a provider of clinical intelligence platforms, to develop the first smartphone application for their pregnant patients. “Our solution has a wide range of capabilities, including a cross-platform application [that] accommodates patient education, reminders and the ability to perform remote monitoring. Other features are email or text reminders and the ability to measure performance through an analytics dashboard.” The use of the app is designed to engage patients with the ER protocol, track their compliance and progress before and after surgery and, ultimately, improve patient outcomes.
Since August 2016, the researchers have enrolled 190 patients, during which time the average hospital LOS decreased from 3.7 to 2.4 days. Using a financial model created by researchers at Johns Hopkins and adjusting for their local context, the researchers estimated the net direct variable costs and savings associated with adoption of their enhanced recovery program. As Dr. Kett noted, “the ROI [return on investment] calculations are based on the 1.3[-day] reduction in hospital LOS, versus 1.0.
“Based on the implementation cost of $48,000 and daily direct variable cost savings of $1,516, the introduction of the enhanced recovery program will yield a 296% ROI during the first year,” Dr Kett said. “The return will increase to 451% in subsequent years.
“There are 1.3 million C-sections in the U.S. annually,” Dr. Kett said. “If we reduce LOS from 3.7 to 2.4 days, we save 1.3 times $1,516 per couplet, or about $1,970. 1.3 million times $1,970 equals $2.56 billion. About half of the C-sections are scheduled, so most of these cases could benefit from enhanced recovery. In the U.K., it is rapidly becoming the standard of care.”