Active postdischarge intervention reduces ER visits and costs in major thoracic surgery

SEATTLE, WA—An active, postdischarge intervention after thoracic surgery resulted in shorter hospital stays, fewer ER visits, cost savings, and no increase in adverse outcomes, as well as a trend toward fewer hospital admissions. These findings were presented at the 95th American Association for Thoracic Surgery (AATS) Annual Meeting 2015.

Hospital readmission rates after major thoracic surgery can run as high as 10% to 17%. Alarmingly, readmission after pulmonary resection for lung cancer has been associated with worse outcomes, including higher mortality.

This Canadian study describes the benefits of an active, postdischarge intervention for patients who have undergone thoracic surgery. The intervention, known as the Integrated Comprehensive Care (ICC) project, is based on a one team–one approach principle and is initiated while the patient is still hospitalized.

"Given the simplicity of the ICC model, we believe that it could straightforwardly be duplicated within other health care systems and will likely result in better outcomes and reduced costing," explained Yaron Shargall, MD, who is head of the Division of Thoracic Surgery and holds the Juravinski Professorship in Thoracic Surgery at McMaster University in Hamilton, Ontario, Canada.

The ICC team consists of a nurse coordinator, eight registered and practical nurses, and six physiotherapists, with additional support available as needed from respiratory therapists, dietitians, and occupational therapists. Within the first 48 hours after surgery, the nurse coordinator meets with the patients and families to develop a discharge plan.

To evaluate the effectiveness of the ICC project, the researchers conducted a retrospective case-control analysis of a prospective database. They compared 355 patients who underwent major thoracic surgery between April 1, 2012, and March 31, 2013, and received ICC care with a historical control group of 331 patients who underwent similar major thoracic surgeries prior to the implementation of ICC (April 1, 2011, to March 31, 2012).

Three-quarters of the ICC patients made use of telephone support from the ICC coordinator. Overall, each ICC patient received an average of 6 hours of home care during 8.7 visits after discharge, with an average cost of $500 per patient enrolled. Registered practical nurses saw 75% of the patients. As needed, assistance was provided by respiratory therapists, occupational therapists, dietitians, and speech pathologists. Patient satisfaction with the program was high, with more than 90% rating it as excellent or very good.

The researchers compared the ICC vs. control groups by stratifying by type and extent of resection to minimize selection bias (ie, open partial, open total, VATS partial, VATS total). Sixty-day mortality was similar for both groups (1%). Overall, no significant differences were found in 60-day readmission rates (8.4% ICC vs. 12.2% controls, P = .105), although there was a trend for fewer readmissions in the subgroups (e., open partial: 7.0% ICC vs. 18.3% controls, P = .145).

Within 30-days postdischarge, ICC patients made fewer visits to the ER. For example, in the open total subgroup, 18.3% of patients enrolled in the ICC project made ER visits compared with 30% of controls (P = .042) and in the VATS total subgroups the rates were 10.2% vs. 23.5% (P = .048, respectively).

The ICC program yielded economic benefits, too. For example, total costs in the VATS partial ICC group were $8,505 compared with $11,038 for controls (P = .007).

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