An Institutional Experience in Applying Quality Improvement Measures to Pituitary Surgery: Clinical and Resource Implications

Objective: To report our experience developing the Lean Six Sigma Clinical Care Pathway (CCP) for endoscopic endonasal transsphenoidal operations.

Methods: Using Lean Six Sigma quality improvement principles including the Define, Measure, Analyze, Improve, and Control (DMAIC) framework, we developed a CCP for endoscopic endonasal transsphenoidal operations, incorporating preoperative, intraoperative, inpatient postoperative, and outpatient postoperative phases-of-care. Efficacy and quality metrics were defined as postoperative length-of-stay (LOS), presentation to the emergency department (ED) or readmission within 30 days of discharge, and hospital charges. We included all adult patients who underwent elective endoscopic endonasal resection for pituitary adenoma, Rathke’s cleft cyst, craniopharyngioma, pituicytoma, or arachnoid cyst during the sampling frame 4/1/2018 to 12/31/2022.

Results: A total of 228 patients met criteria and were included; 94 were treated before and 134 were treated after CCP implementation. Differences between groups in age, gender, race, body mass index, American Society of Anesthesiologists classification, geographic distribution, preoperative serum sodium, tumor size, adenoma functional status, or prior surgery were not significant. Mean postoperative LOS decreased from 4.5 days to 1.7 days following CCP implementation (p < 0.0001); LOS variability also decreased, with the standard deviation declining from 3.1 to 1.5 midnights. The proportion of patients discharging on postoperative day (POD) 1 increased from 0 to 61.9% (p < 0.0001). Less than a quarter of patients (23.4%) were discharged by POD 2 prior to CCP, while 88.8% of patients were discharged by POD 2 after CCP implementation (p < 0.0001). Following implementation of the CCP, LOS improved year-over-year. LOS improved from 2.3 days in 2020 to 1.6 in 2021 and 1.3 in 2022. The variability among LOS also decreased. In 2020, 36.8% were discharge on POD 1 and 73.7% by POD 2, whereas in 2022, 74.1% were discharged on POD 1 and 96.3% by POD 2. Rates of 30-day ED presentations or readmissions were not significantly different (2.1 vs. 6.0%, p = 0.20; 7.5 vs. 6.7%, p > 0.99). Mean per-patient hospital costs declined from $38,326 to $26,289 (p < 0.0001), with an associated change in cost variability from a standard deviation of $16,716 to $12,498.

Conclusions: CCP implementation significantly improved LOS and costs of endoscopic endonasal resection, without adversely impacting postoperative ED presentations or readmissions.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
05 February 2024