Control Charts Reduce Healthcare Costs and Bed-Days.

Surgical complications represent a considerable proportion of hospital expenses, making up a large part of healthcare spending. Therefore, interventions that improve surgical outcomes and enhance patient safety could also reduce the economic burden on healthcare systems. But can quality improvement methods in surgery both improve patient outcomes and lower costs? The SHEWHART cluster randomised trial, conducted by Sarah Skinner and colleagues and published in BMJ Quality & Safety, answers precisely this question. This study provides an economic analysis of how monitoring surgical outcomes using “control charts” affects hospital length of stay and hospital costs reimbursed by the insurer.

Purpose and Importance of the Study

Previous research has shown that quality control methods developed in the manufacturing sector to improve product quality and reduce costs have been adapted for healthcare. Control charts are one such tool; they visually track an indicator’s performance over time, allowing for the detection of abnormal variations and providing a basis for corrective actions. Earlier findings from the SHEWHART trial had already demonstrated that this method reduces major adverse events and patient deaths. This new economic analysis goes a step further by aiming to evaluate the potential impact of control charts on hospital resource consumption. The primary objective of the study was to determine if this intervention could reduce the number of hospital bed-days within 30 days following surgery and the insurer-reimbursed costs of care.

How Was the Study Conducted?

The study was designed as a national, parallel, cluster-randomised trial involving 40 surgical departments from different hospitals across France. A total of 155,362 patients over 18 years of age who underwent digestive surgery (such as hernia repair, cholecystectomy, appendectomy, bariatric, and colorectal surgery) were included in the analyses.

The study design included the following steps:

1. Baseline Period (2014–2015): Data from all 40 hospitals were collected for a two-year period before the intervention.
2. Randomisation: Hospitals were randomly allocated to either an “intervention” group (20 hospitals) or a “control” group (20 hospitals).
3. Implementation Period (2017–2018): The 20 hospitals in the intervention group were provided with quarterly control charts to monitor their surgical outcomes (inpatient death, intensive care stay, reoperation, and severe complications).

In the intervention hospitals, teams consisting of a surgeon and a collaborator (another surgeon, an anaesthesiologist, or a nurse) were trained to review the control charts, display posters in operating rooms, and design improvement plans. In these meetings, they investigated the root causes of abnormal fluctuations in outcomes (special cause variations) and planned actions to improve care processes. In contrast, no specific intervention was implemented in the control group hospitals during this period.

Striking Findings: Better Outcomes, Lower Costs

The results of the study demonstrated that the use of control charts provides significant benefits for both patient care and hospital finances:

• Significant Reduction in Length of Stay: In the intervention group hospitals, the number of hospital bed-days per patient within 30 days following surgery decreased by 3.3% compared to the control group. This corresponds to a total of 8,910 hospital bed-days saved in the intervention hospitals.
• Decrease in Hospital Costs: The hospital costs per patient reimbursed by the insurer showed a significant 1.3% decrease in the intervention group compared to the control group. This resulted in total savings of €2,615,524 in the intervention hospitals after implementation.

These findings prove that interventions aimed at improving quality can not only enhance patient safety but also reduce healthcare spending.

Conclusion and Implications for the Future

This study is the first large-scale randomised controlled trial to show that providing surgical teams with regular feedback on their outcomes via control charts significantly reduces both hospital stays and costs. The authors emphasize that the success of this method is not just due to providing the charts, but also to the active discussion of this data by surgical teams, their commitment to making behavioural and organizational changes, and their willingness to implement new solutions.

Control charts are a relatively simple, low-cost tool that can be implemented using routinely collected data. Due to these characteristics, they offer promising potential for improving surgical outcomes and reducing resource pressure on hospital systems worldwide. This study provides strong evidence that quality control interventions targeting patient safety can simultaneously reduce healthcare expenditures.

Reference: Skinner, S., Pascal, L., Polazzi, S., Chollet, F., Lifante, J-C., & Duclos, A. (2024). Economic analysis of surgical outcome monitoring using control charts: the SHEWHART cluster randomised trial. BMJ Quality & Safety, 33(4), 284–292. https://doi.org/10.1136/bmjqs-2022-015390