1. 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. IMAGE FROM UPPER GI 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: COST CONSIDERATION 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 patient- focused metric cannot be underestimated, as it will become an increasingly important component of the reimbursement mechanisms in the future. SCENARIO B 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). SCENARIO A 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). COST ESTIMATE Scenario A- No Additional Cost Scenario B: UGI series (CPT code 74241) estimated charge $180 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 Utilization of transportation resources 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. CONCLUSSION: VALUE = QUALITY/COST Scenario A= Quality = (Value) Cost Scenario B= Quality = (Value) Cost Arrows indicate patent Gastrojejunostomy without leak.