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Anesth Analg 2002;95:824-827 © 2002 International Anesthesia Research Society
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Abstract |
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We sought to determine how frequently intraoperative transesophageal echocardiography (TEE) altered the planned surgical procedure and to assess the potential cost implications associated with these changes. A retrospective chart review was conducted at one university hospital. Cardiac surgical operative notes from July 1999 through June 2000 were reviewed. We interrogated all adult cardiac surgical records for patients scheduled for repair of coronary artery disease or valvular disease requiring the use of cardiopulmonary bypass. Cancellations based on TEE findings were included in the analysis. Of the 430 patient records reviewed, 24 procedures were ether canceled or changed on the basis of the intraoperative TEE examination (5.6%; 95% confidence interval, 3.6%–8.2%). Six of these cases involved valvular heart disease, and the remaining 18 involved the intraoperative diagnosis and repair of a patent foramen ovale. A cost-benefit analysis based on the 6 valvular diagnoses revealed a saving of $230 per patient. Assuming that unnecessary present or future operations may be avoided by altering the surgical plan on the basis of TEE findings, these preliminary data suggest that routine intraoperative TEE in cardiac surgery is beneficial and cost-effective.
IMPLICATIONS: A review of 430 adult cardiac surgical records indicates that routine transesophageal echocardiography during cardiac surgery, including coronary artery surgery, is beneficial and cost-effective.
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Transesophageal echocardiography (TEE) is now routinely used in many cardiac centers. The cost-benefit of routine TEE in cardiac surgery is still an unresolved question (1). There have been two studies published that address the cost-benefit of TEE. Whereas these studies evaluated all changes in intraoperative management, neither specifically addressed the frequency of TEE-induced changes in the planned surgical procedure. We also considered the potential costs and benefits associated with these changes in a cohort of surgical procedures (2,3). If routine intraoperative TEE in cardiac surgery improves outcome by ensuring that a more appropriate surgical procedure is performed, then the potential savings could be significant. We conducted a retrospective chart review in an attempt to provide preliminary data to address this question.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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With IRB approval, anesthesia records and cardiac surgical operative notes from July 1999 through June 2000 were reviewed. All cardiopulmonary artery bypass cases at our institution have TEE, an intraarterial catheter, and a pulmonary artery catheter as routine hemodynamic monitoring. Operative notes for off-pump coronary artery bypass, congenital heart repairs, descending thoracic aortic aneurysms, thoracoabdominal aneurysms, and pericardial effusions were excluded. Off-pump coronary artery bypasses were excluded because our overall experience in this operation was limited at that time. We retrieved 430 patients’ data from that time period that met those criteria. The data extracted from the surgical operative notes and anesthesia records included original diagnosis, planned operative procedure, actual procedure, and findings of the TEE examination. Specifically, we sought operative notes in which the TEE findings were cited as justification for changing the operative procedure. Cancellations of surgery that were based on TEE findings were included in the analysis. The cardiac anesthesiologists at our institution performed all the TEE examinations.
A cost-benefit analysis was then performed on the basis of estimates obtained from our institution and articles written by other authors (2–4). Machine costs were calculated on the basis that a TEE machine costs $250,000 and has a life span of 10 yr. At that time, we had four TEE machines dedicated to the cardiothoracic operating room (OR) suite at our institution. Our institution uses a $25,000 per year service contract for these machines that includes one free TEE probe per year. Probe breakage across 4 cardiac ORs necessitates on average the purchase of 4 new probes per year, which adds a further $64,000 in costs. The cleaning, storage, and recording costs are difficult to quantify, but using the figures produced by other authors, these would total $4800 per year across our program (2–5). We have not included the costs of staff (anesthesiologists and anesthetic technicians) because TEE has a minimal effect on our staffing requirements. Professional charges for TEE are not included in this analysis. There were no adjustments for inflation in the projected costs or savings.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Of the 430 patient records reviewed, 24 procedures (5.6%; 95% confidence limits, 3.6%–8.2%) were either canceled or changed on the basis of the TEE examination. Eighteen of these procedures involved the unplanned repair of a patent foramen ovale (PFO) that was diagnosed by TEE after anesthetic induction, in addition to the planned surgical intervention. PFOs that were diagnosed but were not repaired surgically were not included in the analysis. There were no specific criteria that were used by surgeons or anesthesiologists in determining which PFOs were repaired. The decision was entirely at the discretion of the surgeon. There were no serious TEE-related complications in the cohort studied.
Of the valvular findings, two valvular procedures were canceled when the TEE failed to confirm the presence of a clinically significant valvular lesion. The remaining four valvular procedures involved the following scenarios: a tricuspid valve replacement was added to a coronary artery bypass grafting (CABG) when significant tricuspid regurgitation was visualized; a mitral valve replacement was changed to mitral valve repair after intraoperative TEE; a mitral valve replacement was added to a CABG after intraoperative TEE; and a mitral valve replacement was not performed after intraoperative TEE in a patient scheduled for both CABG and mitral valve replacement (Table 1).
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The cost of each TEE examination was calculated by using estimates of both fixed and variable costs (Table 2). Our institution performs approximately 1200 intraoperative TEE examinations per year, yielding a cost per examination of approximately $162. There are also costs associated with TEE morbidity that have been estimated at approximately $26 per examination (2–4). This would give a total cost per examination of approximately $188. Others have estimated a cost of $260 per patient per examination (2–4).
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Using a cost per examination of $188 leads to a total estimated cost of $80,840 for the 430 patients in our cohort. It is not possible to know which unrecognized PFOs would have required a second operation, although it is very likely that some would have. Nevertheless, we have excluded the PFOs for the purpose of cost-benefit analysis. This leaves six valvular patients that almost certainly were saved from an inappropriate or extra operation. If we divide $80,840 by 6, we estimate that the cost of TEE is $13,473 per operation saved. To calculate the benefit, we used the figure of $30,000 for the cost of a second cardiac procedure (which was averted). Therefore, the benefit for 6 operations would be $180,000. When we subtract the cost of the routine intraoperative TEE examinations in our cohort from the cost of saved surgery, we are left with a total savings of $99,162. Dividing the savings of $99,162 by the 430 patients in the cohort, the estimated savings of routine intraoperative TEE were $230 per patient.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Other studies have shown that TEE changes patient management in the OR (5–7). No study has shown any change in ultimate patient outcome or cost-benefit analyses of routine intraoperative TEE. In this study, the TEE resulted in actual changes to the planned operation in 5.6% of patients, which is also not a direct measure of patient outcome. If the TEE-mediated change in operation, however, led to the avoidance of unnecessary procedures and prevented some later reoperations, then patient morbidity and costs should be reduced. Therefore, it is reasonable to use TEE-mediated changes in the operation performed as an indirect measure of improvement in patient outcome as a result of intraoperative TEE.
Nevertheless, it is highly unlikely that the closure of every PFO resulted in a saved operation, because many defects may have remained asymptomatic for the duration of the patient’s life (8). The closure of some PFOs will, however, definitely prevent some further procedures and some strokes (9,10). Furthermore, some preliminary studies have linked PFOs to both migraine headaches and cryptogenic brain abscesses (11,12). Thus, there is evidence that PFO closure reduces patient morbidity to some extent. Despite this evidence, we chose not to include PFOs in our cost-benefit analysis so as not to overstate the potential benefits.
The financial savings are difficult to precisely determine and vary from center to center, because the cost per TEE examination and the yield of diagnostic findings differ. These costs depend on several variables, such as the number of patients in a program, the skill level of the echocardiographers, the staffing levels of the institutions, the type of equipment used, and the estimated cost of a saved operation.
The previous studies have included fixed costs, such as anesthesiology staffing and ultrasound technicians (2–4). In our institution, the anesthesiologist is a preexisting fixed cost, and no ultrasound technicians are used in the OR. This may explain the smaller cost of TEE calculated for our institution.
The clinical implications of this study must be considered in light of the retrospective analysis of a small cohort from only one institution. Nevertheless, these data support the use of routine intraoperative TEE by anesthesiologists on the basis of the cost-benefit of alterations in the surgical plan. It is remarkable that planned valvular surgery was not a sine qua non of TEE cost-effectiveness, because many patients scheduled for coronary artery surgery also benefited. Thus, targeted TEE, as opposed to routine TEE, in planned cardiac surgery may be less likely to provide the full benefit of the technology. Furthermore, the wider benefits of TEE, such as improved hemodynamic management, were not addressed by this study. Although hemodynamic management benefits are difficult to quantify, they may have further improved the benefit side of the cost-benefit equation.
There are several additional limitations to our study. It is very likely that some TEE-mediated changes in surgery were not detected. There is also no way of knowing which changed or canceled operations ultimately resulted in a saved procedure. Although we assume the effect is small, we do not know how many patients were harmed by erroneous TEE findings. There are also costs associated with TEE-induced patient injury. Although there were no serious injuries in our cohort, others have suggested that morbidity occurs in 0.2% of cases (13). The cost-benefit analysis also does not include indirect costs such as workdays lost, intangible costs such as pain and suffering, or quality of life benefits (14).
Why should intraoperative TEE have resulted in so many surgical plan alterations? It is logical to assume that good preoperative medical evaluations should have detected these lesions. There are several reasons: some echocardiograms are performed at outside centers by less experienced echocardiographers; not all patients received a preoperative echocardiogram if there was no obvious indication for it; and not all lesions are optimally assessed by transthoracic echocardiography. It may have been possible to detect some of these lesions with routine preoperative TEE, but this is at least as costly as intraoperative TEE, involves greater discomfort, and would deny the patient the benefits of intraoperative TEE hemodynamic monitoring.
In conclusion, this retrospective study demonstrated that routine intraoperative TEE was associated with an estimated cost savings of $230 per patient presenting for cardiac surgery. Intraoperative TEE changed the planned surgical procedure in 5.6% of cases. Although these are not direct measures of improved patient outcome, they strongly suggest that routine TEE in cardiac surgery reduces patient morbidity and therefore improves patient outcome. These preliminary data suggest that routine intraoperative TEE in cardiac surgery is beneficial both in terms of patient morbidity and cost-benefit. A randomized, prospective, multicenter trial will be required to verify this preliminary finding.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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- Hines RL. Transesophageal echocardiography: is it for everyone? J Card Surg 1990; 5 (Suppl 3): 240–3.[Medline]
- Benson MJ, Cahalan MK. Cost benefit analysis of transesophageal echocardiography in cardiac surgery. Echocardiography 1995; 12: 171–83.[Web of Science][Medline]
- Siwik ES, Spector ML, Patel CR, Zahka KG. Costs and cost-effectiveness of routine transesophageal echocardiography in congenital heart surgery. Am Heart J 1999; 138: 771–6.[Web of Science][Medline]
- Murphy PM. Cost effectiveness of transesophageal echocardiography during cardiac surgical procedures. J Cardiothorac Vasc Anesth 1997; 11: 246–9.[Web of Science][Medline]
- Mishra M, Chauhan R, Sharma KK, et al. Real time intraoperative transesophageal echocardiography: how useful? Experience of 5016 cases. J Cardiothorac Vasc Anesth 1998; 12: 625–32.[Web of Science][Medline]
- Sousa RC, Garcia-Fernandez MA, Moreno M, et al. The contribution and usefulness of routine intraoperative transesophageal echocardiography in cardiac surgery: an analysis of 130 consecutive cases. Rev Port Cardiol 1995; 14: 15–27.[Medline]
- Click RL, Abel MD, Schaff HV. Intraoperative transesophageal echocardiography: 5 year prospective review of impact on surgical management. Mayo Clin Proc 2000; 75: 241–7.[Abstract]
- Alp N, Clarke N, Banning AP. How should patients with patent foramen ovale be managed? Heart 2001; 85: 242–4.
[Free Full Text] - Devuyst G, Bogousslavsky J, Ruchat P, et al. Prognosis after stroke followed by surgical closure of patent foramen ovale: a prospective follow-up study with brain MRI and simultaneous transesophageal and transcranial Doppler ultrasound. Neurology 1996; 47: 1162–6.
[Abstract/Free Full Text] - Dearani JA, Ugurlu BS, Danielson GK, et al. Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events. Circulation 1999; 100 (Suppl 19): II171–5.
- Kawamata T, Takeshita M, Ishizuka N, Hori T. Patent foramen ovale as a possible risk factor for cryptogenic brain abscess: report of two cases. Neurosurgery 2001; 49: 204–6.[Medline]
- Wilmshurst PT, Nightingale S, Walsh KP, Morrison WL. Effect on migraine of closure of cardiac right-to-left shunts to prevent recurrence of decompression illness or stroke or for haemodynamic reasons. Lancet 2000; 356: 1648–51.[Web of Science][Medline]
- Kallmeyer IJ, Collard CD, Fox JA, et al. The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients. Anesth Analg 2001; 92: 1126–30.
[Abstract/Free Full Text] - Greenhalgh T. How to read a paper: papers that tell you what things cost (economic analyses). BMJ 1997; 315: 596–9.
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