Cost Conscious Care Case Studies: Reducing routine radiologic testing after
upper gastrointestinal surgery for peptic ulcer disease.
John Richey MD, Brian McKinley MD
BACKGROUND
• The natural history of peptic ulcer disease
has been altered by the discovery of
Helicobacter pylori and use of regimes to
eradicate this organism.
• Complicated peptic ulcer disease that
requires surgical correction is still an
important problem.
• Partial gastrectomy with anastomosis to the
duodenum or jejunum is a common surgical
procedure.
• Post-operative care of these patients
historically includes a routine upper
gastrointestinal series with oral contrast (UGI
series) to assess for the presence or absence
of a leaking suture line.
• Leaks are uncommon and, if present, usually
produce clinical symptoms.
• We believe that routine UGI series in the
evaluation of asymptomatic patients adds
cost to their post-operative care without
adding to the quality of their care.
• As such, this testing practice offers no value
and should be abandoned.
CASE SCENARIO
• A 35 year old white male has undergone an exploratory laparotomy, truncal vagotomy, antrectomy, and
gastrojejunostomy for refractory peptic ulcer disease.
• Postoperatively, he is recovering uneventfully on the floor.
• A nasogastric tube (NGT) is in place and he is allowed no oral intake for 4 days.
• His vital signs have remained stable, he reports only incisional pain and his abdominal exam reveals a soft
abdomen with no distention and only incisional tenderness.
• On POD 5, two management scenarios are possible:
SCENARIO A
SCENARIO B
• His (NGT) is removed and he is started on
clear liquids on morning rounds.
•
•
•
•
He tolerates this diet for his morning
meal.
He is advanced to regular diet for his
noon meal.
The patient is discharged later that day or
the next day (POD 5 or 6).
IMAGE FROM UPPER GI
•
An UGI series is ordered on morning rounds. He is
transported to the radiology department and undergoes an
upper gastrointestinal (UGI) series, with the NGT still in
place.
The study, which demonstrates no evidence of leak at the
anastomosis, is read by the radiologist and reviewed by the
surgical team in the afternoon.
•
On afternoon rounds, the NGT is removed and he is started
on clear liquids that evening.
•
The next morning his diet is advanced and he is discharged
later that day (POD 6).
•
Routine administration of the UGI series is
associated with an increase in cost
•
Repeated between 30 and 40 times per year,
it represents a significant sum of money.
•
Because of the DRG payment system, this
money cannot be recovered by the health
system.
•
Potential for an additional day in the hospital
is also a source of increased cost.
•
Strains system resources as it requires
transport and radiology services to be
involved, thus limiting their ability to serve
other patients.
•
From a cost perspective, Scenario A is
favored over Scenario B.
QUALITY CONSIDERATION
•
In our competing scenarios, the clinical
outcomes would appear to be equivalent
since each one ends with a patient discharge
in good condition.
•
But since consideration of quality also
requires us to examine patient-centered
outcomes, it seems likely that Scenario A
would lead to a more happy and satisfied
patient.
•
The contribution of improvement in patientfocused metric cannot be underestimated, as
it will become an increasingly important
component of the reimbursement
mechanisms in the future.
COST ESTIMATE
•
Scenario A- No Additional Cost
•
Scenario B:
•
UGI series (CPT code 74241) estimated charge
•
Professional Fee (Radiologist interpretation
$110
•
Possible added day in hospital
$>1,000
•
Potential for patient dissatisfaction
•
Opportunity cost of limiting access to radiology services to
other patients
•
Arrows indicate patent Gastrojejunostomy
without leak.
COST CONSIDERATION
$180
Utilization of transportation resources
CONCLUSSION: VALUE= QUALITY/COST
Scenario B =
Quality =
Scenario A =
Quality =
(Value)
Cost
(Value)
Cost
REFERENCES
•
Sonnenberg A, Everhart JE. Health impact of peptic ulcer
in the United States. Am J Gastroenterol 1997; 92:614
•
Doerfer J, Meyer T, Klein P, et al. The importance of
radiological controls of anastomoses after upper
gastrointestinal tract surgery - a retrospective cohort
study. Patient Safety in Surgery. 2010;4:17.
doi:10.1186/1754-9493-4-17.
•
Jeroukhimov, Et al. The Role of Upper Gastrointestinal
Swallow Study in Patients Undergoing Proximal or Total
Gastrectomy, IMAJ, Vol 12, September 2010.