Advanced Practice Providers Improve Efficiency and Decrease Costs in Outpatient Oral Surgery

Pressure on physicians to complete time-consuming administrative tasks and increase patient volume while receiving decreased compensation have led to the rapid incorporation of advanced practice providers (APPs) such as physician assistants (PAs) and nurse practitioners (NPs) into medical practices in recent decades.¹ The use of APPs, however, has not become widespread in oral and maxillofacial surgery. The aim of this study was to determine the effects on time and cost of integrating APPs into the procedural components of an outpatient oral and maxillofacial surgery (OMS) practice.

This is a prospective study of patients undergoing third molar extractions with intravenous sedation in the outpatient setting at Boston Children’s Hospital from August 2014 to March 2016. Subjects were divided into two cohorts: those treated prior to the incorporation of APPs in to the practice (No APP group) and those treated with AAPs (APP group). To be included, patients had to: 1) have an American Society of Anesthesiology Physical Status of Class I or II, 2) be deemed appropriate candidates for outpatient intravenous anesthesia, and 3) had to have four routine third molars removed in a single encounter. All patients were treated by the same 3 board-certified OMSs. A process map detailing the activities that occur from procedure preparation to patient discharge was devised for each cohort. Processes were observed by two of the authors and times for each activity were recorded. Time-Driven Activity-Based Costing²was used to quantify the average personnel cost for each process using cost rates for each staff member that were derived based on national published data. Post-operative complication rates were calculated using departmental records. Two-sample t-tests were used for analysis and p<0.05 was considered statistically significant.

Fifty subjects were included in the study, with 25 subjects in each cohort. The average total times and personnel costs from patient arrival to discharge for the No APP group were 100.5 minutes and $463.20, and for the APP group were 91.4 minutes and $381.95. The primary roles of the APP in these procedures were in the provision of local anesthesia after adequate intravenous sedation had been delivered and in wound closure after the removal of the third molars. During the time that the APP was directly involved in the procedure, the OMS provided indirect supervision and was free to see other patients. The average time the OMS was in the procedure room was 26.1 ± 12.4 minutes in the No APP group and 11.6 ± 5.7 minutes in the APP group (average decreased of 14.5 minutes, p<0.001). There was an average overall savings of $81.25 in the APP group compared to the No APP group (p<0.001). There was no significant difference in the mean complication rate (5.1% in the No APP group, 4.3% in the APP group, p=0.8).

In conclusion, the addition of APPs resulted in decreased costs for routine third molar procedures, even after accounting for the APP’s salary. The OMSs involvement was nearly 15 minutes shorter per procedure after the addition of APPs, allowing the OMS to see more patients in a day. There was no increase in complication rates after APPs were added.

References

1. Druss BG, Marcus SC, Olfson M, Tanielian T, Pincus HA: Trends in care by nonphysician clinicians in the United States. N Engl J Med 348:130, 2003

2. Kaplan RS, Anderson SR: Time-driven activity-based costing. Harv Bus Rev 82:131, 2004