Laparoscopic Cholecystectomy:How We Control Costs Without Sacrificing Quality

For an ambulatory surgery center, we do a relatively high volume of laparoscopic cholecystectomies, so our financial performance depends in no small part on our ability to control costs for these procedures. Fortunately, over the past year and a half, we have discovered several ideas that have helped us improve our facility's profits without reducing our standard of care for our laparoscopic cholecystectomy patients. Here are a few of them.

Thorough Patient Evaluation
Complications are not only bad for patients. They are bad for profitability. When our surgeons have to convert to an open procedure, we do not receive additional reimbursement, and whenever recovery time is extended, we must bear greater costs in staff time. For both reasons, we work especially hard to minimize the risk of complications.

We generally refer patients with medical conditions such as coronary artery disease or diabetes to the hospital. Before every case, our nurses also perform a detailed health history over the telephone. This helps determine if the patient has a history of or strong disposition toward postoperative nausea or vomiting, and we sometimes uncover unreported conditions that necessitate further preoperative testing. Apfel et al identified four predictors of postoperative nausea and vomiting: Female gender, prior history of nausea/vomiting or motion sickness, nonsmoker, and postoperative opiods. We don't necessarily rule out patients who have these predictors, but we do take added measures to prevent postoperative nausea and vomiting-such as administration of PO/IV prophylactic antiemetics (e.g., Reglan) and elimination of inhalation anesthetics-when the evaluation uncovers two or more predictors.

No Routine Cholangiography
Physicians and researchers have been debating the necessity of intraoperative cholangiography during laparoscopic cholecystectomy for some time. Here at Far Hills, our surgeons no longer perform intraoperative cholangiography as a matter of course. Instead, they reserve cholangiography for patients who have risk factors for common bile duct stones (e.g., abnormal liver function tests, large diameter common bile duct, history of gallstone pancreatitis or jaundice). Recent research shows this approach to be valid and safe. By eliminating routine cholangiography, we save as much as $50 per case on supply and staffing costs. Since intraoperative cholangiography is not billable, this translates into a significant cost savings.

Tailored Anesthesia Regimen
Although bispectral index (BIS) monitoring is controversial and the research is still scant, we routinely use a BIS monitor for our lap choly patients. The BIS monitor essentially measures the depth of hypnosis by measuring electroencephalogram (EEG) activity. We have not formally studied the outcomes of BIS monitoring, but we strongly believe that it offers three important benefits. First, by enabling the anesthesiologist to titrate anesthesia more accurately, the BIS monitor has reduced the amount of anesthetic drugs we use. Second, because patients don't go ????-??too deep,' their recovery is faster and side effects are fewer. Third, BIS has helped us ensure that no patient goes to recovery intubated.

BIS monitoring is not cheap. The list price of the single-use sensor, which adheres to the patient's forehead, is $17. However, it's possible to get discounts on the sensors.

Isoflurane
A couple of years ago, we routinely used one of the newer inhaled anesthetics. Although we still keep that drug on hand, we encourage our anesthesiologists to use isoflurane during laparoscopic cholecystectomy whenever possible because it is so much less expensive. We have not seen dramatically increased recovery time due to this change.

Streamlined OR Staffing
We work hard to minimize excess staffing during all procedures. In addition to the anesthesiologist or CRNA, we have one circulating nurse and one surgical technician in the OR to aid the surgeon during laparoscopic cholecystectomy. With our surgeons' blessing, we do not provide an assistant to hold the video camera. During surgery, an X-ray technician is on call should the need for a cholangiogram arise. In this instance, we pay the technician for two hours of his or her time. We also staff one nurse in preop and one nurse in PACU to care for these patients.

Few Disposables
Depending on the reimbursement, disposables can make or break these cases. The only disposable our surgeons use is a gallbladder retrieval bag. We use reusable trocars. In addition, we use a ligating clip applier that has a reusable gun; each clip cartridge costs just over $50.

Patient Push-Through
We continually strive to keep our patients moving through each stage of the process by actively managing their expectations. We focus on reducing recovery time, in particular, because this results in significant cost savings. This effort begins with good preoperative patient education in the doctor's office. We tell patients they'll be going home the same day and reinforce this message at every step. We also tell patients they need to take an active role in their care, and to inform the nurse right away if they experience postoperative pain or nausea.

We do not have phase 2 recovery, and our nurses set goals with the patients to expedite recovery. For example, the nurse and patient may agree on a time that the patient will move from a bed to a recliner, or the nurse may strongly encourage a patient to get up and go to the bathroom. There is a fine line between moving patients along and making them feel as if they're being pushed, however, so we take great care to treat them with kindness and respect.

We also keep our recovery nurses abreast of recovery times, and this helps us address any slowdowns that arise. In randomly selected groups of lap choly patients treated here in 1999 and 2000, recovery time increased from 120 to 137 minutes. Because we were all aware of this problem, however, we were able to pinpoint the cause and address it. Since then, recovery time has declined.

Keeping Quality High,
To safely serve our laparoscopic cholecystectomy patients, we maintain a highly skilled and well-trained surgical staff that is ready and able to convert to an open procedure in case of complications. We have transfer agreements in place with local hospitals for this purpose. After performing more than 80 laparoscopic procedures, we have converted just one case. All of our preop and PACU staff members are also ACLS certified.

Overall, we have turned laparoscopic cholecystectomy into a winner for our facility, our surgeons, and our patients. Our average cost per procedure is down, and although the reimbursement varies greatly depending on the insurer and contract, we are able to show a profit for these cases. Our high-quality, effective laparoscopic cholecystectomy service also attracts new patients to our facility.