A Standardized Perioperative Pathway Reduces Costs And Improves Outcomes In Below Knee Amputation
Daniel Y. Cho, MD, PhD, Stefan Czerniecki, MSc, Mackenzie French, BA, Janna Friedly, MD, Kari A. Keys, MD.
University of Washington, Seattle, WA, USA.
PURPOSE: Despite advances in lower extremity reconstruction, particularly with microvascular free tissue transfer, there are instances where lower extremity amputation with prosthetic rehabilitation cannot be avoided or results in more efficient patient care and improved functional outcomes. With the increasing rates of BKA, it is important to develop evidence-based frameworks that standardize and guide perioperative patient care to expedite patient recovery and reduce costs of care.
METHODS: A standardized perioperative care pathway combining pre-operative integration with rehabilitation services, standardized surgical technique, multi-modal pain control, and early post-operative rehabilitation was implemented by all surgeons performing BKAs at Harborview Medical Center beginning November 2017 (https://occam.uwmedicine.org/media/2218/lower-extremity-amputation-pathway-2019-05-14-new-format.pdf). Patient outcomes for a 12-month study period were compared to the 12 months preceding implementation. The primary outcome was length of stay (LOS); secondary outcomes included mortality, cost, and opiate use. Cox proportional-hazards regression was used to compare LOS between study arms while controlling for differences between the pre- and post-implementation patient population.
RESULTS: Controlling for potential confounders, pathway recipients had a 13.5% (1.88 day) reduction in LOS compared to non-pathway patients (12.06 vs 13.94, p=0.04) and a 31.84% decrease in opiate use. Pathway care among patients receiving non-urgent BKAs resulted in a 31.6% reduction in mean cost compared to non-recipients ($19,339 vs $33,204, p=0.03), but did not lower costs for urgent amputations ($99,007 vs $91,981, p=0.66).
CONCLUSIONS: Despite the diverse nature of causes of amputation, standardized perioperative care for BKA improves patient outcomes through reduced LOS and opiate use, and lowers cost in non-urgent BKA.
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