The Effectiveness, Safety, and Cost-Reductions of an Intervention Bundle for Reducing Length of Stay in Laparoscopic Cholecystectomy Patients

OBJECTIVES: A bundle of interventions was implemented for laparoscopic cholecystectomy (LC) in Singapore General Hospital to reduce post-operative length of stay (LoS). It was implemented in phases: a roadshow (RO) on 1st July 2020 to improve standardization of post-surgery care, default admissions to short-stay wards (SSW) from 1^st March 2021 to reinforce LC as overnight-stay surgery and individual clinician reports (ICR) from 1^st November 2021 for performance monitoring.

This study evaluates the effectiveness of the bundle in reducing LoS and costs without compromising patient safety.

METHODS: This was an observational study of all patients undergoing LC from 1^st October 2019 to 31^st May 2022. Patients were grouped based on the intervention(s) that had been implemented when they had surgery (RO, RO_SSW, RO_SSW_ICR), with LC patients from 1^st October 2019 to 30^th June 2020 as historical control.

Negative binomial regression and chi-square tests were performed to compare LoS and safety outcomes (i.e., blood transfusion, complication, unplanned readmission, unplanned re-operation (RTOT) and unscheduled biliary intervention within 30 days of index surgery) respectively with the control group.

A cost-minimization analysis using a decision tree model was performed to evaluate the cost (hospital stay during index surgery, RTOT and hospital stay due to 30-day readmission after index discharge) reductions by the bundle, followed by probabilistic sensitivity analysis (PSA) using Monte Carlo simulations with 1,000 iterations.

RESULTS: There were 1,056 LC patients (mean±SD age, 58±15 years; mean±SD ASA score: 2.1±0.5). Adjusted LoS for RO_SSW and RO_SSW_ICR groups was 19% and 21% shorter than control group (p < 0.05). No statistically significant differences were found for safety outcomes.

PSA shows a cost change of -S$7,246 for 1,000 individuals (Range: -S$228,404 – S$200,000) with the probability that adoption is cost saving is 54.5%.

CONCLUSIONS: Systematic changes in service structure and provider behaviors can safely reduce costs and LoS of LC patients.