IOWA CITY, Iowa -- In the era of managed health care, controlling costs has become crucial. Some health care economists have suggested that achieving financial savings in the operating room could mean patients in the future will have to wait longer for elective surgery -- as much as a year in some cases, which most Americans would be unwilling to do.
However, a University of Iowa Health Care researcher has found a better way to satisfy both insurance companies and patients. It is all about using information technologies to increase operating room staff productivity, said Franklin Dexter, M.D., Ph.D., UI associate professor of anesthesia. Articles about Dexter's approach to controlling operating room costs for elective surgeries appear in the July issues of Anesthesiology, and Anesthesia and Analgesia. An accompanying editorial in Anesthesia and Analgesia calls Dexter's research a "landmark study."
"There has been no evidence of any increase in productivity of the operating room perioperative workforce over the years," Dexter said. "The only way you can substantively increase operating room productivity is to ensure that you never have down time. The problem is there is a lot of down time -- on the order of 35 percent."
The solution in other fields to increase productivity without increasing costs has been to use information technology, Dexter said. In addition to coming up with this idea for health care, Dexter and his colleagues from the UI, Stanford University and Duke University have developed software that hospital operating room managers can use with their existing information systems to identify how much down time the staff is experiencing and why.
"What the software will do is let you know what the source of the problems is and how much it is costing the operating room," Dexter said. "Hospitals, anesthesiologists and surgeons can then decide, based on data, what changes should be made."
Dexter suspects that at most hospitals, the choice of the day on which each patient has elective surgery is the most critical factor in assuring high productivity. In other countries, the solution to higher productivity has been to increase patients' waiting times, with some patients waiting a year for surgery. The logic being that when an operating room staff has a large queue of patients, the operating room manager can choose the day on which each patient has surgery so as to achieve high operating room utilization. However, the long waiting time would never be acceptable in the United States. According to a survey of patients that Dexter and his colleagues conducted, the longest wait patients would consider acceptable averages about two weeks.
Using information technologies, the United States can achieve the same high productivity without the same long waits seen in Europe, Dexter said. Although buying a cheeseburger is hardly like having an operation, the principle of patients waiting for elective surgery can be compared to customers standing in an order line, Dexter said.
"To keep the counter cashier always busy," he explained, "you have to have at least three customers in line. If you get less than three or four people in line, every once in awhile the cashier is not going to be busy. On the other hand, you never need more than say six people in line to keep the cashier occupied. The cashier is analogous to an operating room planned for a surgeon every other week. If the surgeon cares for two or three patients during his or her planned sessions, then with an average of six patients in line, the average wait for surgery will be two to three weeks, which is much less than the European wait."
Dexter's data suggest that there is dramatic improvement in productivity when the maximum wait time goes from two weeks to four weeks. There is a slight improvement from four weeks to six weeks.
"With information technologies, it should be possible for the United States to improve productivity by increasing the maximum length of time that patients wait for surgery to something like four weeks," Dexter said. "If you use information technologies, it shouldn't really be necessary to have waits of three months to a year."
By using Dexter's suggested four-week wait, the increase in productivity would decrease the cost of each surgery by $150.
"When you think of the millions of elective surgical procedures performed in the United States each year, a savings of $150 per case is a lot of money," Dexter said. "Right now, you hear about how managed care companies are interested in decreasing pharmaceutical costs. The savings to be gained from changes in each patient's scheduling are more than twice as much as the total costs of all drugs used for a person's anesthetic."