Development of a Patient-Oriented Organizational Management System for Intravitreal Injection Therapy in a Standardized "Treat-and-Extend" Regime at a University Eye Clinic

[Economics of operating room use at a university eye hospital]

BACKGROUND

In ophthalmologic surgery, there are usually short operation times and thus many changes between the individual operations, which are not subject to remuneration. As in maximum care hospitals consecutive different operations with different durations are often performed, emergency operations have to be inserted and further training of colleagues is practiced, it is particularly important to generate the shortest possible transfer times in order to have both sufficient operation time and to be able to treat as many cases as possible. The aim of this work is to evaluate the efficiency of the surgical performance of a university eye hospital.

MATERIAL AND METHOD

The surgeries performed in 2021 at the MHH Eye Clinic were evaluated with respect to the spectrum, number, surgery duration, transfer times and process times. In terms of personnel, each operating room was staffed with one assistant anesthesiologist, one nurse anesthetist, two operating room nurses, one surgeon, and 20% senior anesthesiologist supervision. Based on a theoretical concept, which provides an increased staffing ratio while maintaining the same infrastructure, it was calculated how many more surgeries could be performed if the transfer time was halved and whether the additional financial expense could be compensated.

RESULTS

With a total of n = 2712 surgeries performed during regular duty hours (244 working days) in 2 operating rooms (average daily n = 11.1; weekly n = 53.6 and monthly n = 237.1), the average surgery duration was 37 min and the transition time 43 min. This means that the operating rooms were used for surgery for 51% of the total operating time. Main procedures were vitrectomy with n = 1350 and cataract surgery with n = 1308. The new personnel concept provided one additional operating room nurse per operating room and one additional anesthesiologist for both operating rooms. The additional costs for this personnel expenditure were calculated at approx. 300,000 € per year. The halving of the transfer time from 43 min to about 21 min through possible overlapping induction and parallel work, which was not possible until now, results in an additional operation time of about 100 min per operating room, so that at least 4 additional operations can be planned and performed. In this way, with stringent implementation and the same spatial structures with stable fixed costs, n = 976 more operations could be performed, which, minus the personnel costs, the additional material costs for surgery and anesthesia of 557,042 € and the inpatient hotel costs of 600,663 €, with an average length of stay of 2.8 days, would result in an additional revenue of about 2.4 times the additional personnel costs at the current flat rate of 3739.40 € and an average case mix index of the MHH Eye Hospital of 0.649 (total revenue: 2,155,449 €; profit margin II: 701,389 €) for the considered surgical patient collective in 2021.

CONCLUSION

An increase of the personnel expenditure in the operating room for surgical subjects such as ophthalmology with shorter interventions and many changes is economically worthwhile also for a large hospital in order to enable and optimize overlapping transfers of anesthesia and surgical care. This should therefore also be considered separately, contrary to standardized staffing of the overall hospital, in order to use existing resources with their fixed costs as optimally as possible.

[Performance and cost calculation for a university ophthalmological outpatient clinic]

BACKGROUND

Outpatient procedures at a university hospital are generally considered to be unprofitable. In the present publication we evaluate the turnover and costs of the university eye outpatient department of the Hannover Medical School (MHH) in terms of a cost unit accounting as well as providing a summary of the workload.

MATERIAL AND METHOD

Given the data of the hospital information system (IS-H/i.s.h.med from SAP) and a proprietary software (TimeElement), all patient contacts in the year 2019 were evaluated. The latter software is applied in a standardized manner to record the patient flow of our outpatient service in real time electronically. The total costs consist of personnel, material and room costs including infrastructure of the MHH and are compared to the flat-rate revenues according to the university outpatient contract (HSA) as well as further revenues from internal referral services, self-pay patients, outpatient surgery and cooperation contracts for intravitreal injections (IVOM).

RESULTS

With an average full-time equivalent (FTE) headcount of 10.63 assistant physicians, 3.6 specialist physicians, and 21 nonphysicians (plus 4 Federal Volunteer Service, BUFDI) in our policlinic, we have determined € 2,927,022 in personnel costs, including overheads, for the entire year. Including infrastructure (€ 524,942), material and equipment costs with overheads and internal cost allocation of € 258.657, the total costs in 2019 resulted in € 3,710,621. In contrast, the total income in 2019 was € 3,524,737 generated through the abovementioned patient segments, resulting in a deficit of € -185,884 (5%). Our data provide evidence that regular outpatient revenues are insufficient and are mainly balanced by outpatient surgery, IVOMs and self-pay patients. In total, there were 19,453 patient contacts during regular office hours (with 17,305 billable cases). At n = 9943, the majority of the contacts were HSA visits; however, only 82% of the cases could effectively be charged due to multiple visits per quarter. The median total patient attendance was 3.21 h (mean 3.38 h). On average, 78 patient contacts were counted per working day. The analysis with TimeElement unveiled a median of n = 2 physician contacts per patient (mean n = 1.91). The median duration per interaction with a physician was 17.98 min (mean 23.23 min). For diagnostics, we counted a median of n = 2 interactions per patient (mean n = 2.31), with an entire interaction lasting a median of 18.30 min (mean 22.60 min). In total n = 37,363 individual diagnostic procedures were recorded in 2019, with SD-OCT being the primary procedure at n = 10,888.

CONCLUSION

The cost/turnover calculation showed a marginal financial loss through our ophthalmological outpatient department. Thus, the costs of a university eye outpatient department in Lower Saxony do not seem to be sufficiently covered by direct outpatient revenues. Maintaining quarterly flat rates for all cases of the outpatient department would require a fee of about € 214 in our setting to remain cost neutral. Currently, the lower flat rates in the HSA area are compensated by other areas. Obviously, the high content-related workload in our setting requires a high personnel expenditure with a considerable personnel cost contribution of nearly 80%.