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James Cohen, MD, PhD; Mary Stock, MN; Benjamin Chan; Mary Meininger, MN; Mark Wax, MD; Peter Andersen, MD; Edwin Everts, MD

Arch Otolaryngol Head Neck Surg. 2000;126:947-949.

Background  Successful "critical pathway" design and implementation are dependent on appropriate patient stratification according to those factors that are primary determinants of resource utilization.

Objectives  To test the validity of our previously reported critical pathway design and to determine whether tracheotomy and microvascular reconstruction (MR) are primary determinants of resource utilization.

Design  Cost-effectiveness analysis.

Setting  Tertiary referral academic institution.

Methods  Retrospective analysis of data from 133 head and neck surgery cases in which the treatment regimen was based on critical pathways over a 26-month period.

Outcome Measures  Length of stay and total patient charges were used as indices of resource utilization. One-way analysis of variance and t tests were used for statistical analysis of significance.

Results  Ninety patients (67.7%) underwent MR; 43 (32.3%) did not. Seventy-five patients (56.4%) underwent tracheotomy; 58 (43.6%) did not. Four patient groups were constructed in decreasing order of complexity as follows: group 1, patients who underwent both tracheotomy and MR (n = 58); group 2, patients who underwent MR alone (n = 32); group 3, patients who underwent tracheotomy alone (n = 17); and group 4, patients who did not undergo either procedure (n = 26). Both tracheotomy and MR were found to be independent determinants of resource utilization and were additive when both were present. The length of stay varied from 8.4 days (in patients who underwent both procedures) to 6.7 days (in patients who did not undergo either procedure), with intermediate values in cases in which only 1 procedure was performed. The total charges varied in a similar manner from a high of $33,371 to a low of $19,994. Subanalysis with respect to intensive care unit, ward, and operating room charges showed a similar stratification.

Conclusion  Tracheotomy and MR are both significant determinants of charges and length of stay in head and neck surgery cases and must be considered in the design of strategies to promote efficient resource utilization.

From the Department of Otolaryngology–Head and Neck Surgery (Drs Cohen, Wax, Andersen, and Everts), the Division of Nursing (Mss Stock and Meininger), and the Division of Medical Informatics and Outcomes Research (Mr Chan), Oregon Health Sciences University, Portland.

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