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COST-EFFECTIVE EVALUATION AND MANAGEMENT OF THE ACUTE ABDOMEN
COST EFFECTIVENESS IN SURGERY
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COST-EFFECTIVE EVALUATION AND MANAGEMENT OF THE ACUTE ABDOMEN Brian D. Gill, MD, and Jeffrey R. Jenkins, MD
HISTORICAL PERSPECTIVE
“The responsibility lies with the first doctor called in to see the ~atient.”~, l2 Such were the words of Dr. J. B. Murphy over 100 years ago, remarking on the proper and efficient management of patients with acute abdominal pain-more specifically with acute appendicitis. At the 1889 Chicago Medical Society Meeting, Dr. Murphy presented a paper in which he described 100 cases of appendicitis. The critical issue of his day was overcoming the reluctance in the medical community to accept early operation in cases of suspected appendicitis.12The critical issue of our day has become cost containment and cost-effective delivery of health care. The responsibility referred to by Dr. Murphy, over a century ago, rested with the primary physician to provide timely diagnosis and treatment. With increasing financial pressure on today’s medical system and with increasing emphasis placed on “gate-keepers” to access health care specialists, Dr. Murphy’s statement may be reinterpreted: The financial responsibility (and not necessarily the responsibility for timely diagnosis and treatment) . . . lies with the first doctor called in to see
The opinions and assertions contained herein are the private views of the authors and are not to be considered as the official policy or position of the US Government, the Department of Defense, or the Department of the Air Force.
From the Department of Surgery, David Grant Medical Center, Travis Air Force Base, California
SURGICAL CLINICS OF NORTH AMERICA VOLUME 76 * NUMBER 1 * FEBRUARY 1996
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GILL & JENKINS
the patient. The diagnostic and therapeutic responsibility rests with the specialist summoned by the gate-keeper. Managed care mandates that gate-keepers efficiently consult the most economic specialist for the pathology to be treated. This new financial responsibility cannot be separated from proper diagnosis and treatment of the patient with acute abdominal pain-even if the financial responsibility of the gate-keeper is separated by person from the timely diagnosis and treatment of the specialist. To truly realize the most economic approach to quality health care delivery for the patient with an acute abdomen, surgeons must avoid the temptation to widen the gap between managed care gate-keepers and surgical specialists, for only a surgeon’s early intervention by directing the evaluation of the patient with an acute abdomen maximizes both the economic and health benefit.
THE OAK ENTITLED “ACUTE ABDOMEN”
Attempting to meaningfully define the scope of patients with a diagnosis of acute abdomen and correlate their evaluation and treatment into a cost-effective algorithm is an overwhelming task. Even with today’s new data tracking systems and computerized networking of patient outcomes within many health care delivery organizations, detailed data collection is in its infancy with regard to the wide spectrum of diseases that flourish from the common title ”acute abdomen.” Likened to a mighty oak in the care of surgical patients, the title “acute abdomen” is the trunk that branches into many subdivisions (Fig. 1). Four main subdivisions (not all-inclusive) of the acute abdomen have been previously described6 and are illustrated in Figure 1 as pelvic or gynecologic emergencies, upper abdominal pain, lower abdominal pain, and pathologies in the ICU patient. Taking an ax to the trunk of the oak entitled “acute abdomen” is not a cost-effective step in pruning the individual branches of varied abdominal pathology. Starting with analysis of the common procedure of appendectomy may allow surgeons to acquire skills that will be necessary in cost-effective management of patients with all varieties of aGte abdominal pathology. In an attempt to provide clinically useful information on cost-effective management of the patient with an acute abdomen, the authors have taken the liberty of focusing on acute appendicitis as a representative diagnosis of the acute abdomen. Appendectomy is the most common emergency operation performed by a general surgeon.12The diagnosis of acute appendicitis and the procedure of appendectomy are the logical starting points in attempting to prune and manage the mighty oak of the acute abdomen.
COST-EFFECTIVE EVALUATION AND MANAGEMENT OF THE ACUTE ABDOMEN
UPPER ABDOMINAL
73
LOWER ABDOMINAL
- Appendicitis
- Pancreatitis
GYNECOLOGIC EMERGENCIES
ICU PATIENT PATHOLOGY
Dlsease
- Endometriosis
- Pelvic adhesions - Ovarlan cyst
ABDOMEN
Figure 1. The oak entitled acute abdomen.
DATA
The following report is divided into three separate areas of data on appendicitis and appendectomy. First, data (n = 31,005) are presented from the California Office of Statewide Health Planning and Development, which covers statewide data on all nonfederal California hospitals for diagnosis, length of stay, procedures performed, and hospital charges. This source does lack information on actual health care costs, and the most current data available at the time of this printing are from 1993 (Mary McDonald, personal communications, March-June, 1995). Second, limited data (12 months, n = 35) are presented regarding the authors’ own investigation into actual costs for patients admitted through the emergency room with the diagnosis of appendicitis (DRG 164-167) in a military facility in Northern California. These data are also from 1993 but do represent actual costs as opposed to charges. Third, data (n = 887) are presented which are available from critical pathway programs for appendectomy (DRG 164-167) (Virginia Del Togno-Armanasco,RN, MN, personal communication, June, 1995).These data represent 4-year (1991-1994) actual costs of hospitalizations of patients undergoing appendectomy.
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CALIFORNIA STATEWIDE 1993 DATA
,
The California office of Statewide Health Planning and Development has a mainframe computer data base in Sacramento. All 610 licensed acute care hospitals and facilities in the State of California are required to produce semiannual reports of all hospital admissions and patient encounters to the California Patient Discharge Data Base. Ninetynine percent of the data is gathered via magnetic tape provided either by private abstracting firms or by the hospitals themselves. As more and more hospitals within the State of California obtain mainframe computers, they are able to produce these data directly from their own records departments. A few small facilities report on hard copy forms, but these institutions have total patient encounters numbering less than 200 per year. Personnel in the Sacramento office then read from the report forms and enter the information into the computer data base. Hospitals are given 6 months to report data, and the ensuing 6 months are used by the personnel in the Sacramento office to verify and arrange the data before the data are suitable for release. There is therefore a 12to 18-month lag between the patient's hospitalization and the release date of the data. At the time of this publication the most recent data available were those of a 12-month period from 1 January 1993 to 31 December 1993. Data are entered into this California statewide computer data base according to diagnosis and procedure codes. Acute abdomen is much too broad a topic to provide any meaningful data, even if it were one of the diagnostic codes used. The diagnostic code of appendicitis and the procedure code of appendectomy were therefore selected to represent titles to search the statewide data on these subsets of patients. Table 1 shows the total number of California hospital admissions with an admission diagnosis of appendicitis for the year 1993 to be 31,005 patients. Fifty-eight percent of these patients were male. Charge data are available on 27,214 of these patients, or 87% of the 31,005 cases. From this large denominator, 9,163 appendectomies were performed. Of the patients undergoing appendectomy, 72% were female, which is contrary to the historical preponderance of males.4Charge data were available for 7,884, or 86%, of the total number of appendectomies performed. r There are several reasons why the data base does not have charge data on 100% of the patients. Shriner Hospitals provide 100% charity care and no bill is generated unless no charge data exist. Additionally, one FHP and over 20 Kaiser facilities represent HMO capitated plans Table 1. CALIFORNIA STATEWIDE 1993 DATA ON APPENDICITIWAPPENDECTOMY Hospital admissions Admission diagnosis of appendicitis Admissions with charge data available Appendectomies performed Appendectomies with charge data available
31,005 27,214(87%) 9,163 7,884(86Yo)
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Table 2. CALIFORNIA STATEWIDE 1993 DATA ADMISSION DIAGNOSIS OF APPENDICITIS (N = 31,005) BY SOURCE OF ADMISSION
Source of Admission
N (Patients)
Routine (home) Emergency room Other hospital Intermediate care/other
9,196 21,139 509 161
Average Length of Stay (Days)
Average Charge (Dollars)
4
12,315 12,259 17,368 16,803
4
8 6
with no bill generated for individual hospital stays. Additionally, individual cases from the other reporting hospitals may fall out as charity cases or have no charge data recorded. Federal facilities such as military or Veterans Administration hospitals are not subject to this California statewide reporting policy. From the data presented in Table 1, it is seen that 70% of the patients admitted with the diagnosis of appendicitis were discharged without an appendectomy performed. Thirty percent of the patients admitted with a diagnosis of appendicitis underwent appendectomy. That is, more than two thirds of patients who were initially thought to have appendicitis went on to have other sources of acute abdominal pain. Both groups, the broad group of patients with an admission diagnosis of appendicitis and the more narrow group of patients admitted with diagnosis of appendicitis and subsequently undergoing appendectomy, are presented in the following tables. Tables 2 and 3 show data on the broader group of patients with'an admission diagnosis of appendicitis. Table 2 shows a breakdown of this group by source of admission. Table 3 breaks down this same group by expected payment source at the time of admission to the hospital. Number of patients, average length of stay in days, and average charges in dollars are shown for each subgroup. From Table 2 it is appreciated that most patients hospitalized with a diagnosis of appendicitis enter into Table 3. CALIFORNIA STATEWIDE 1993 DATA ADMISSION DIAGNOSIS OF APPENDICITIS (N = 31,005) BY EXPECTED PAYMENT SOURCE
Expected Payment Source
N (Patients)
Medicare Medical Blue Cross/Blue Shield Insurance (other third party) HMO/PHP Workers' Compensation Other (government) Other (nongovernment)
1,597 6,751 1,479 5,279 10,729 24 2,199 2,947
Average Length of Stay (Days)
Average Charge (Dollars) 25,423 12,925 17,441 11,198 11,090 17,441 12,485 10,902
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Table 4. CALIFORNIA STATEWIDE 1993 DATA PROCEDURE CODE OF APPENDECTOMY (N = 9,163)BY SOURCE OF ADMISSION
Source of Admission
N (Patients)
Average Length of Stay (Days)
Routine (home) Emergency room Other hospital Intermediate care other
6,691 (73%) 2,073 (23%) 263 136
6 9 28 37
Average Charge (Dollars)
19,784 36,310 97,960 155,116
the health care delivery system through the emergency room (68%of all 31,005 patients). The category “intermediate care/other” includes skilled nursing facilities and referral through home health services, prison infirmaries, or other facilities not licensed as acute care hospitals. Newborn infant nurseries also are listed as an ”other” source of admission, but in general this entire category represents a small fraction of the total number of patients. Patients transferred from other hospitals carrying the diagnosis of appendicitis having a longer average length of stay, as could be predicted by either complex medical problems or difficult diagnostic dilemmas requiring transfer to a more specialized center. Table 3 shows that the greatest number of California patients are participants of either HMO (Health Maintenance Organization) or PHP (Prepaid Health Plan) programs. But it should be remembered that these data in Table 3 lack financial charge data on the Kaiser population and from a single FHP institution. National Medicare and its California equivalent, Medical, are represented. Blue Cross/Blue Shield represents a large enough group to be separated from other third-party insurances; and Workers’ Compensation is shown mostly out of interest for data on length of stay (as this does represent a very small fraction of the total number of patients). Tables 4 and 5 are in the same format and show data similar to Tables 2 and 3, but Tables 4 and 5 detail patients admitted to California Table 5. CALIFORNIA STATEWIDE 1993 DATA PROCEDURE CODE OF APPENDECTOMY (N = 9,163)BY EXPECTED PAYMENT SOURCE
Expected Payment Source
N (Patients)
Average Length of Stay (Days)
Medicare Medical Blue CrosdBlue Shield Insurance (Other third party) HMOlPHP Workers’ Compensation Other (government) Other (nongovernment)
1,460 1,272 569 1,922 3,190 20 332 398
11 12 6 6 7 19 8 7
Average Charge (Dollars)
35,936 38,083 20,437 19,163 22,771 27,248 29,400 21,210
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hospitals in 1993 with a procedure code of appendectomy. In Table 4 it is very interesting to note that the majority of these patients have recorded as their source of admission ”routine”-meaning home or place of residence, as opposed to the emergency room. Seventy-three percent of these patients are admitted directly after outpatient contact with physicians or health care referral personnel, and 23% are admitted after formal emergency room evaluations, including work-ups by an emergency physician. The patients thus evaluated formally by an emergency room team, including an emergency room physician, incurred a higher average charge, $36,000, than those who entered the system with more direct access to specialty care (average charge of nearly $20,000). Longer length of stay may account for part of the $16,000 difference between these two groups, but not all of it. (Formal statistics could not be properly performed as no variance was provided on the 9,163 patients.) Of note in the ”intermediate care” and “other” category of Table 4, 75 newborns having never left the hospital since birth make up the largest portion of this subgroup of 136 patients. Seventy-four newborns had an average length of stay of 52 days and an average charge of $215,682. This greatly skews this subgroup’s data in Table 4. In Table 5, the older population of Medicare and Medical did have longer average length of stays and subsequently higher average charges than the presumed younger populations in either Blue Cross/Blue Shield, other third-party insurance, or HMO/PHP groups. Again for interest sake, a small group of the Workers’ Compensation patients should be noted for their prolonged average length of stay. Tables 6 and 7 show the same data for the two groups, admission diagnosis of appendicitis and procedure code of appendectomy, arranged by distribution of the patients’ places of residence. Fourteen Table 6. CALIFORNIA STATEWIDE 1993 DATA ADMISSION DIAGNOSIS OF APPENDICITIS (N = 31,005) BY PATIENT’S RESIDENCE
Patient’s Residence
N (Patients)
Average Length of Stay (Days)
Northern California Golden Empire North Bay West Bay AlameddContra Costa North San Joaquin Valley Santa Clara County Mid-Coast Central California VenturdSanta Barbara Los Angeles Inland Counties Orange County San Diego/lmperial
936 1,683 758 1,518 1,827 1,282 1,415 878 2,078 1,192 9,196 2,756 2,739 2,287
4 4 4 5 4 4 4 4 4 4 5 4 4 4
Average Charge (Dollars) 10,702 15,451 10,761 12,503 14,973 12,755 11,493 11,450 8,975 9,873 12,635 12,775 13,891 12,569
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Table 7. CALIFORNIA STATEWIDE 1993 DATA PROCEDURE CODE OF APPENDECTOMY (N = 9,163)BY PATIENT'S RESIDENCE
Patient's Residence
N (Patients)
Average Length of Stay (Days)
Northern California Golden Empire North Bay West Bay AlameddContra Costa North San Joaquin Valley Santa Clara County Mid-Coast Central California VenturdSanta Barbara Los Angeles Inland Counties Orange County San Diego/lmperial
349 635 223 314 547 524 265 248 742 371 2,481 846 906 589
7 7 9 9 9 6 10 7 7 7 9 9 8 7
Average Charge (Dollars)
19,315 24,971 26,175 27,413 37,078 18,352 31,709 26,079 19,922 21,904 30,510 28,701 28,364 26,113
areas or subdivisions of the state of California are represented. Patients are not separated in these tables by age or gender, and all races are represented. Comparison of the charge data for the two groups, appendicitis and appendectomy, shows that central California generated the lowest average 1993 charge to patients with diagnosis of appendicitis and one of the lowest average total charges for patients undergoing appendectomies. Patients undergoing appendectomy were also broken down by age, as shown in Table 8. Extremes in life shared extremes for length of stay and average charge. 1993 COST DATA FROM A CALIFORNIA MILITARY MEDICAL CENTER
Frustrated by the empty comparative value of charge data in a cost data world, the authors determined the 1993 actual costs for DRG 164-167 at David Grant US Air Force Medical Center in California. These cost data (Table 9) were tabulated for the single hospitalization during which appendectomy was performed. Additional cost factors related to postoperative infection with need for readmission or frequent wound checks at the surgical clinic were not investigated as other authors have previously reported.13 Historically, the military medical System has been far from cost-conscious; but now, even federal referral centers like David Grant US Air Force Medical Center are of necessity being forced into the cost-issue arena to maintain functioning. The actual cost data can be calculated, but effective data entry and follow-up are required so that cost-saving changes can be implemented into practice
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Table 8. CALIFORNIA STATEWIDE 1993 DATA PROCEDURE CODE OF APPENDECTOMY BY AGE GROUP
Age Group
N (Patients)
Average Length of Stay (Days)
0-5 years 6-1 0 years 11-1 5 years 16-20 years 21-25 years 26-30 years 31-35 years 36-40 years 41- 4 5 years 46-50 years 51-55 years 56-60 years 61-65 years 66-70 years 71-75 years 81-85 years 86-90 years 91 + years
647 107 185 295 380 544 793 1,048 1,174 933 540 447 430 478 457 164 67 351
21 7 6 5 6 6 5 5 5 6 7 8 10 10 11 13 12 12
Average Charge (Dollars) 81,845 22,877 19,780 16,870 17,889 17,776 16,605 16,188 16,555 17,460 19,771 26,112 35,014 30,561 34,663 48,961 38,486 46,466
patterns. Specifically for appendectomy, the authors learned that the single most cost-effective way to evaluate and manage a patient with an acute abdomen is to consult the responsible general surgeon immediately upon hearing the patient's history so that the surgeon can direct the diagnostic work-up.Previously, rule-out appendicitis patients would register in the emergency room, undergo nursing and ER physician evaluation, have an intravenous line placed, have blood drawn for laboratory tests (CBC, differential, electrolytes, liver panel, urinalysis), and have abdominal radiographs taken-all before the surgical residents were even informed that a patient was already waiting (with disease possibly progressing) in the hospital emergency room. Of radiographs in the preoperative evaluation of suspected appendicitis, F. R. Lewis stated after his review of 1000 cases in 10 years: "One may conclude that an abdominal roentgenogram is not often helpful in diagnosing appendicitis and, even Table 9. DAVID GRANT USAF MEDICAL CENTER 1993 COST DATA-APPENDECTOMY (N = 35)
DRG
Group
N (Patients)
Average cost (Dollars)
164 165 166 167
Complicated with co-morbidities Noncornplicatedwithout co-morbidities Noncomplicated with co-morbidities Complicated without co-morbidities
2 26 1 6
7,459 2,700 3,981 4,400
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GILL&JENKINS
when abnormal, the findings are usually nonspecific.”y The current costconscious approach to appendicitis is manifest in the development of several critical pathways-none of which recommends routine preoperative abdominal radiographs.* Yet without being forced to recognize unnecessary excess such as plain abdominal radiographs, the practice of overordering persists. All too often in the authors’ own experience, especially in female patients, abdominal plain films and abdominal ultrasonography will have been completed by the first (emergency room) medical team before a trained surgeon is consulted or enabled to apply “the pressure of one finger on the patient” (as Charles McBurneyl” described in 1889). To a surgeon, appendicitis is a diagnosis best made with an inexpensive touch of a hand. If localized tenderness is not present, observation with repeat examination serially over the course of 6 to 12 hours is usually adequate if the patient is hydrated and close at hand.’, The authors can foresee a future in which patients are checked into an ambulatory observation unit to be serially checked by the same responsible surgeon, instead of undergoing routine laboratory tests and radiographs, in cases of suspected appendicitis. TUCSON MEDICAL CENTER 4-YEAR COST DATA
In 1991, Tucson Medical Center in Arizona began a computerized tracking of patients with appendicitis based on DRG 164-167 in a critical pathway program. Following the program for the past 4 years has led to the acquisition of actual cost data on 887 patients, as shown in Table 10. Costs are listed in dollar amounts, with no attempt to correct for inflation over time. Having a 4-year cost record by DRG is invaluable when evaluating new treatment modalities such as laparoscopic appendectomy. Studies2, 7, l1 investigating cost differences between open and laparoscopic appendectomy lack the solid background that such facility-specific data can assure. The future developments of accurate, cost-effective algorithms hinge on present-day establishment of actual cost data bases such as that of Table 10. Other medical facilities are currently engaged in development of critical pathways which, if tracked with true cost data, will advance our knowledge of the most economic method to treat abdominal pain even as new technology arises. Thirteen facilities with appendectomy pathways are listed in the 1995 Critical Pathways directory.* The author’s personal communication with many of them reveals that although the pathway plan is in place, not many data have been gathered, entered into computer data bases, or reviewed to determine if (1) the pathway decreases expensive hospital length of stay and (2) if actual cost savings are gained through pathway implementation. As alluded to above, however, most of the pathways share the common tenets that (1)the surgical specialist is the responsible physician for diagnostic and therapeutic
COST-EFFECTIVE EVALUATION AND MANAGEMENT OF THE ACUTE ABDOMEN
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Table 10. TUCSON MEDICAL CENTER FOUR-YEAR COST DATAAPPENDECTOMY (N = 887)
Year
Group
N (Patients)
Average Length of Stay (Days)
1991
Complicated with co-morbidities Complicated without co-morbidities Noncomplicated with co-morbidities Noncomplicated without co-morbidities Complicated with co-morbidities Complicated without co-morbidities Noncomplicated with co-morbidities Noncomplicated without co-morbidities Complicated with co-morbidities Complicated without co-morbidities Noncomplicated with co-morbidities Noncomplicated without co-morbidities Complicated with co-morbidities Complicated without co-morbidities Noncomplicated with co-morbidities Noncomplicated without co-morbidities
23 46 19 115 12 74 17 126 15 76 12 123 24 55 12 130
10.1 5.9 3.5 2.6 8.0 5.3 3.2 2.2 8.7 5.3 3.4 2.4 7.3 6.2 3.8 2.3
1992
1993
1994
Average Cost (Dollars) 13,327 3,815 3,235 2,436 6,076 3,942 3,595 2,785 7,361 4,433 2,386 2,582 7,194 5,709 5,195 2,875
interventions from the beginning of the patient’s medical evaluation; (2) few laboratory studies are required (CBC with differential, urinalysis; electrolytes only if patient is on diuretics or if a nasogastric tube is required); and (3) abdominal radiographs are not routine. SUMMARY 1. Managed care gate-keeper financial responsibility must be balanced with specialist diagnostic and therapeutic responsibility to maximize cost effectiveness and quality of medical service. 2. Cost in health care is closely tied to length of stay and operating room time; extremes of patient age are associated with increased costs. 3. Through years of training and subsequent experience, surgeons are best qualified to direct work-up of patients with an acute abdomen, especially when the work-up requires costly imaging (e.g., CT scan, ultrasonography, angiography). 4. Cost is increased when the surgeon is not involved early in cases of acute abdomen. 5. Surgeons must be willing to enter the evaluation phase of the patient with an acute abdomen patient eurZy and follow during the observation period to best reduce unnecessary laboratory work or tests. 6 . Health care teams willing to implement pathways and then document the effect such pathways exert will be most successful in assessing new technologies’ cost effectiveness.
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ACKNOWLEDGMENTS Mary McDonald, Health Policy and Planning Division of the California Office of Statewide Health Planning and Development, Sacramento, CA, obtained and tailored the 1993 data on the 31,005 appendicitis patients. Virginia Del Togno-Armanasco, RN, MN, Coordinator for Case Management at Tucson Medical Center, Tucson, AZ, provided the 1991-1994 actual cost data from the appendectomy critical pathway data base.
References 1. Cacioppo JC, Diettrich NA, Kaplan G, et al: The consequences of current constraints on surgical treatment of appendicitis. Am J Surg 157276-281, 1989 2. Cohen MM, Dangleis K The cost-effectivenessof laparoscopic appendectomy. J Laparendosc Surg 393-97, 1993 3. Davis L, Murphy JB: New York, GP Putnam & Sons, 1938, p 136 4. Fitz RH: Perforating inflammation of the vermiform appendix: With special reference to its early diagnosis and treatment. Trans Assoc Am Physicians I:107-136, 1886 5. Foster GE, Bolwell J, Balfour TW, et al: Clinical and economic consequences of wound sepsis after appendectomy and their modification by metronidazole or povidone iodine. Lancet 4769-771, 1981 6. Gill BD, Traverso LW: The acute abdomen and laparoscopy. Gastroenterol Clin North Am 3:271-282, 1993 7. Kum CK, Ngoi SS, Goh PMY, et al: Randomized controlled trial comparing laparoscopic and open appendectomy. Br J Surg 80:1559-1600,1993 8. Lang M (ed): National Directory of Healthcare: Critical Pathways. Santa Barbara, COR Healthcare Resources, 1995, p 22 9. Lewis FR, Holcroft JW, Boey J, et a1 Appendicitis: A critical review of diagnosis and treatment in 1,000 cases. Arch Surg 110677484, 1975 10. McBumey C: Experience with early operative interference in cases of disease of the vermiform appendix. NY Med J 50:67&684, 1889 11. Mompean JAL, Campos RR, Parico PP, et al: Laparoscopic versus open appendicectomy: A prospective assessment. Br J Surg 81:133-135, 1994 12. Sheldon GF: Editorial comment. Am J Surg 157281, 1989 Acute nonperforating appendicitis: Efficacy of brief 13. Winslow RE, Dean RE, Harley JW: antibiotic prophylaxis. Arch Surg 118:651455, 1983
Address reprint requests to Brian D. Gill, MD Department of Surgery/SGOS 101 Bodin Circle 60th Medical Group David Grant Medical Center Travis Air Force Base, CA 94535
0039-6109/96 $0.00
+
.20
COST-EFFECTIVE EVALUATION AND MANAGEMENT OF THE ACUTE ABDOMEN Brian D. Gill, MD, and Jeffrey R. Jenkins, MD
HISTORICAL PERSPECTIVE
“The responsibility lies with the first doctor called in to see the ~atient.”~, l2 Such were the words of Dr. J. B. Murphy over 100 years ago, remarking on the proper and efficient management of patients with acute abdominal pain-more specifically with acute appendicitis. At the 1889 Chicago Medical Society Meeting, Dr. Murphy presented a paper in which he described 100 cases of appendicitis. The critical issue of his day was overcoming the reluctance in the medical community to accept early operation in cases of suspected appendicitis.12The critical issue of our day has become cost containment and cost-effective delivery of health care. The responsibility referred to by Dr. Murphy, over a century ago, rested with the primary physician to provide timely diagnosis and treatment. With increasing financial pressure on today’s medical system and with increasing emphasis placed on “gate-keepers” to access health care specialists, Dr. Murphy’s statement may be reinterpreted: The financial responsibility (and not necessarily the responsibility for timely diagnosis and treatment) . . . lies with the first doctor called in to see
The opinions and assertions contained herein are the private views of the authors and are not to be considered as the official policy or position of the US Government, the Department of Defense, or the Department of the Air Force.
From the Department of Surgery, David Grant Medical Center, Travis Air Force Base, California
SURGICAL CLINICS OF NORTH AMERICA VOLUME 76 * NUMBER 1 * FEBRUARY 1996
71
72
GILL & JENKINS
the patient. The diagnostic and therapeutic responsibility rests with the specialist summoned by the gate-keeper. Managed care mandates that gate-keepers efficiently consult the most economic specialist for the pathology to be treated. This new financial responsibility cannot be separated from proper diagnosis and treatment of the patient with acute abdominal pain-even if the financial responsibility of the gate-keeper is separated by person from the timely diagnosis and treatment of the specialist. To truly realize the most economic approach to quality health care delivery for the patient with an acute abdomen, surgeons must avoid the temptation to widen the gap between managed care gate-keepers and surgical specialists, for only a surgeon’s early intervention by directing the evaluation of the patient with an acute abdomen maximizes both the economic and health benefit.
THE OAK ENTITLED “ACUTE ABDOMEN”
Attempting to meaningfully define the scope of patients with a diagnosis of acute abdomen and correlate their evaluation and treatment into a cost-effective algorithm is an overwhelming task. Even with today’s new data tracking systems and computerized networking of patient outcomes within many health care delivery organizations, detailed data collection is in its infancy with regard to the wide spectrum of diseases that flourish from the common title ”acute abdomen.” Likened to a mighty oak in the care of surgical patients, the title “acute abdomen” is the trunk that branches into many subdivisions (Fig. 1). Four main subdivisions (not all-inclusive) of the acute abdomen have been previously described6 and are illustrated in Figure 1 as pelvic or gynecologic emergencies, upper abdominal pain, lower abdominal pain, and pathologies in the ICU patient. Taking an ax to the trunk of the oak entitled “acute abdomen” is not a cost-effective step in pruning the individual branches of varied abdominal pathology. Starting with analysis of the common procedure of appendectomy may allow surgeons to acquire skills that will be necessary in cost-effective management of patients with all varieties of aGte abdominal pathology. In an attempt to provide clinically useful information on cost-effective management of the patient with an acute abdomen, the authors have taken the liberty of focusing on acute appendicitis as a representative diagnosis of the acute abdomen. Appendectomy is the most common emergency operation performed by a general surgeon.12The diagnosis of acute appendicitis and the procedure of appendectomy are the logical starting points in attempting to prune and manage the mighty oak of the acute abdomen.
COST-EFFECTIVE EVALUATION AND MANAGEMENT OF THE ACUTE ABDOMEN
UPPER ABDOMINAL
73
LOWER ABDOMINAL
- Appendicitis
- Pancreatitis
GYNECOLOGIC EMERGENCIES
ICU PATIENT PATHOLOGY
Dlsease
- Endometriosis
- Pelvic adhesions - Ovarlan cyst
ABDOMEN
Figure 1. The oak entitled acute abdomen.
DATA
The following report is divided into three separate areas of data on appendicitis and appendectomy. First, data (n = 31,005) are presented from the California Office of Statewide Health Planning and Development, which covers statewide data on all nonfederal California hospitals for diagnosis, length of stay, procedures performed, and hospital charges. This source does lack information on actual health care costs, and the most current data available at the time of this printing are from 1993 (Mary McDonald, personal communications, March-June, 1995). Second, limited data (12 months, n = 35) are presented regarding the authors’ own investigation into actual costs for patients admitted through the emergency room with the diagnosis of appendicitis (DRG 164-167) in a military facility in Northern California. These data are also from 1993 but do represent actual costs as opposed to charges. Third, data (n = 887) are presented which are available from critical pathway programs for appendectomy (DRG 164-167) (Virginia Del Togno-Armanasco,RN, MN, personal communication, June, 1995).These data represent 4-year (1991-1994) actual costs of hospitalizations of patients undergoing appendectomy.
74
GILL &JENKINS
CALIFORNIA STATEWIDE 1993 DATA
,
The California office of Statewide Health Planning and Development has a mainframe computer data base in Sacramento. All 610 licensed acute care hospitals and facilities in the State of California are required to produce semiannual reports of all hospital admissions and patient encounters to the California Patient Discharge Data Base. Ninetynine percent of the data is gathered via magnetic tape provided either by private abstracting firms or by the hospitals themselves. As more and more hospitals within the State of California obtain mainframe computers, they are able to produce these data directly from their own records departments. A few small facilities report on hard copy forms, but these institutions have total patient encounters numbering less than 200 per year. Personnel in the Sacramento office then read from the report forms and enter the information into the computer data base. Hospitals are given 6 months to report data, and the ensuing 6 months are used by the personnel in the Sacramento office to verify and arrange the data before the data are suitable for release. There is therefore a 12to 18-month lag between the patient's hospitalization and the release date of the data. At the time of this publication the most recent data available were those of a 12-month period from 1 January 1993 to 31 December 1993. Data are entered into this California statewide computer data base according to diagnosis and procedure codes. Acute abdomen is much too broad a topic to provide any meaningful data, even if it were one of the diagnostic codes used. The diagnostic code of appendicitis and the procedure code of appendectomy were therefore selected to represent titles to search the statewide data on these subsets of patients. Table 1 shows the total number of California hospital admissions with an admission diagnosis of appendicitis for the year 1993 to be 31,005 patients. Fifty-eight percent of these patients were male. Charge data are available on 27,214 of these patients, or 87% of the 31,005 cases. From this large denominator, 9,163 appendectomies were performed. Of the patients undergoing appendectomy, 72% were female, which is contrary to the historical preponderance of males.4Charge data were available for 7,884, or 86%, of the total number of appendectomies performed. r There are several reasons why the data base does not have charge data on 100% of the patients. Shriner Hospitals provide 100% charity care and no bill is generated unless no charge data exist. Additionally, one FHP and over 20 Kaiser facilities represent HMO capitated plans Table 1. CALIFORNIA STATEWIDE 1993 DATA ON APPENDICITIWAPPENDECTOMY Hospital admissions Admission diagnosis of appendicitis Admissions with charge data available Appendectomies performed Appendectomies with charge data available
31,005 27,214(87%) 9,163 7,884(86Yo)
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Table 2. CALIFORNIA STATEWIDE 1993 DATA ADMISSION DIAGNOSIS OF APPENDICITIS (N = 31,005) BY SOURCE OF ADMISSION
Source of Admission
N (Patients)
Routine (home) Emergency room Other hospital Intermediate care/other
9,196 21,139 509 161
Average Length of Stay (Days)
Average Charge (Dollars)
4
12,315 12,259 17,368 16,803
4
8 6
with no bill generated for individual hospital stays. Additionally, individual cases from the other reporting hospitals may fall out as charity cases or have no charge data recorded. Federal facilities such as military or Veterans Administration hospitals are not subject to this California statewide reporting policy. From the data presented in Table 1, it is seen that 70% of the patients admitted with the diagnosis of appendicitis were discharged without an appendectomy performed. Thirty percent of the patients admitted with a diagnosis of appendicitis underwent appendectomy. That is, more than two thirds of patients who were initially thought to have appendicitis went on to have other sources of acute abdominal pain. Both groups, the broad group of patients with an admission diagnosis of appendicitis and the more narrow group of patients admitted with diagnosis of appendicitis and subsequently undergoing appendectomy, are presented in the following tables. Tables 2 and 3 show data on the broader group of patients with'an admission diagnosis of appendicitis. Table 2 shows a breakdown of this group by source of admission. Table 3 breaks down this same group by expected payment source at the time of admission to the hospital. Number of patients, average length of stay in days, and average charges in dollars are shown for each subgroup. From Table 2 it is appreciated that most patients hospitalized with a diagnosis of appendicitis enter into Table 3. CALIFORNIA STATEWIDE 1993 DATA ADMISSION DIAGNOSIS OF APPENDICITIS (N = 31,005) BY EXPECTED PAYMENT SOURCE
Expected Payment Source
N (Patients)
Medicare Medical Blue Cross/Blue Shield Insurance (other third party) HMO/PHP Workers' Compensation Other (government) Other (nongovernment)
1,597 6,751 1,479 5,279 10,729 24 2,199 2,947
Average Length of Stay (Days)
Average Charge (Dollars) 25,423 12,925 17,441 11,198 11,090 17,441 12,485 10,902
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Table 4. CALIFORNIA STATEWIDE 1993 DATA PROCEDURE CODE OF APPENDECTOMY (N = 9,163)BY SOURCE OF ADMISSION
Source of Admission
N (Patients)
Average Length of Stay (Days)
Routine (home) Emergency room Other hospital Intermediate care other
6,691 (73%) 2,073 (23%) 263 136
6 9 28 37
Average Charge (Dollars)
19,784 36,310 97,960 155,116
the health care delivery system through the emergency room (68%of all 31,005 patients). The category “intermediate care/other” includes skilled nursing facilities and referral through home health services, prison infirmaries, or other facilities not licensed as acute care hospitals. Newborn infant nurseries also are listed as an ”other” source of admission, but in general this entire category represents a small fraction of the total number of patients. Patients transferred from other hospitals carrying the diagnosis of appendicitis having a longer average length of stay, as could be predicted by either complex medical problems or difficult diagnostic dilemmas requiring transfer to a more specialized center. Table 3 shows that the greatest number of California patients are participants of either HMO (Health Maintenance Organization) or PHP (Prepaid Health Plan) programs. But it should be remembered that these data in Table 3 lack financial charge data on the Kaiser population and from a single FHP institution. National Medicare and its California equivalent, Medical, are represented. Blue Cross/Blue Shield represents a large enough group to be separated from other third-party insurances; and Workers’ Compensation is shown mostly out of interest for data on length of stay (as this does represent a very small fraction of the total number of patients). Tables 4 and 5 are in the same format and show data similar to Tables 2 and 3, but Tables 4 and 5 detail patients admitted to California Table 5. CALIFORNIA STATEWIDE 1993 DATA PROCEDURE CODE OF APPENDECTOMY (N = 9,163)BY EXPECTED PAYMENT SOURCE
Expected Payment Source
N (Patients)
Average Length of Stay (Days)
Medicare Medical Blue CrosdBlue Shield Insurance (Other third party) HMOlPHP Workers’ Compensation Other (government) Other (nongovernment)
1,460 1,272 569 1,922 3,190 20 332 398
11 12 6 6 7 19 8 7
Average Charge (Dollars)
35,936 38,083 20,437 19,163 22,771 27,248 29,400 21,210
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hospitals in 1993 with a procedure code of appendectomy. In Table 4 it is very interesting to note that the majority of these patients have recorded as their source of admission ”routine”-meaning home or place of residence, as opposed to the emergency room. Seventy-three percent of these patients are admitted directly after outpatient contact with physicians or health care referral personnel, and 23% are admitted after formal emergency room evaluations, including work-ups by an emergency physician. The patients thus evaluated formally by an emergency room team, including an emergency room physician, incurred a higher average charge, $36,000, than those who entered the system with more direct access to specialty care (average charge of nearly $20,000). Longer length of stay may account for part of the $16,000 difference between these two groups, but not all of it. (Formal statistics could not be properly performed as no variance was provided on the 9,163 patients.) Of note in the ”intermediate care” and “other” category of Table 4, 75 newborns having never left the hospital since birth make up the largest portion of this subgroup of 136 patients. Seventy-four newborns had an average length of stay of 52 days and an average charge of $215,682. This greatly skews this subgroup’s data in Table 4. In Table 5, the older population of Medicare and Medical did have longer average length of stays and subsequently higher average charges than the presumed younger populations in either Blue Cross/Blue Shield, other third-party insurance, or HMO/PHP groups. Again for interest sake, a small group of the Workers’ Compensation patients should be noted for their prolonged average length of stay. Tables 6 and 7 show the same data for the two groups, admission diagnosis of appendicitis and procedure code of appendectomy, arranged by distribution of the patients’ places of residence. Fourteen Table 6. CALIFORNIA STATEWIDE 1993 DATA ADMISSION DIAGNOSIS OF APPENDICITIS (N = 31,005) BY PATIENT’S RESIDENCE
Patient’s Residence
N (Patients)
Average Length of Stay (Days)
Northern California Golden Empire North Bay West Bay AlameddContra Costa North San Joaquin Valley Santa Clara County Mid-Coast Central California VenturdSanta Barbara Los Angeles Inland Counties Orange County San Diego/lmperial
936 1,683 758 1,518 1,827 1,282 1,415 878 2,078 1,192 9,196 2,756 2,739 2,287
4 4 4 5 4 4 4 4 4 4 5 4 4 4
Average Charge (Dollars) 10,702 15,451 10,761 12,503 14,973 12,755 11,493 11,450 8,975 9,873 12,635 12,775 13,891 12,569
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Table 7. CALIFORNIA STATEWIDE 1993 DATA PROCEDURE CODE OF APPENDECTOMY (N = 9,163)BY PATIENT'S RESIDENCE
Patient's Residence
N (Patients)
Average Length of Stay (Days)
Northern California Golden Empire North Bay West Bay AlameddContra Costa North San Joaquin Valley Santa Clara County Mid-Coast Central California VenturdSanta Barbara Los Angeles Inland Counties Orange County San Diego/lmperial
349 635 223 314 547 524 265 248 742 371 2,481 846 906 589
7 7 9 9 9 6 10 7 7 7 9 9 8 7
Average Charge (Dollars)
19,315 24,971 26,175 27,413 37,078 18,352 31,709 26,079 19,922 21,904 30,510 28,701 28,364 26,113
areas or subdivisions of the state of California are represented. Patients are not separated in these tables by age or gender, and all races are represented. Comparison of the charge data for the two groups, appendicitis and appendectomy, shows that central California generated the lowest average 1993 charge to patients with diagnosis of appendicitis and one of the lowest average total charges for patients undergoing appendectomies. Patients undergoing appendectomy were also broken down by age, as shown in Table 8. Extremes in life shared extremes for length of stay and average charge. 1993 COST DATA FROM A CALIFORNIA MILITARY MEDICAL CENTER
Frustrated by the empty comparative value of charge data in a cost data world, the authors determined the 1993 actual costs for DRG 164-167 at David Grant US Air Force Medical Center in California. These cost data (Table 9) were tabulated for the single hospitalization during which appendectomy was performed. Additional cost factors related to postoperative infection with need for readmission or frequent wound checks at the surgical clinic were not investigated as other authors have previously reported.13 Historically, the military medical System has been far from cost-conscious; but now, even federal referral centers like David Grant US Air Force Medical Center are of necessity being forced into the cost-issue arena to maintain functioning. The actual cost data can be calculated, but effective data entry and follow-up are required so that cost-saving changes can be implemented into practice
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Table 8. CALIFORNIA STATEWIDE 1993 DATA PROCEDURE CODE OF APPENDECTOMY BY AGE GROUP
Age Group
N (Patients)
Average Length of Stay (Days)
0-5 years 6-1 0 years 11-1 5 years 16-20 years 21-25 years 26-30 years 31-35 years 36-40 years 41- 4 5 years 46-50 years 51-55 years 56-60 years 61-65 years 66-70 years 71-75 years 81-85 years 86-90 years 91 + years
647 107 185 295 380 544 793 1,048 1,174 933 540 447 430 478 457 164 67 351
21 7 6 5 6 6 5 5 5 6 7 8 10 10 11 13 12 12
Average Charge (Dollars) 81,845 22,877 19,780 16,870 17,889 17,776 16,605 16,188 16,555 17,460 19,771 26,112 35,014 30,561 34,663 48,961 38,486 46,466
patterns. Specifically for appendectomy, the authors learned that the single most cost-effective way to evaluate and manage a patient with an acute abdomen is to consult the responsible general surgeon immediately upon hearing the patient's history so that the surgeon can direct the diagnostic work-up.Previously, rule-out appendicitis patients would register in the emergency room, undergo nursing and ER physician evaluation, have an intravenous line placed, have blood drawn for laboratory tests (CBC, differential, electrolytes, liver panel, urinalysis), and have abdominal radiographs taken-all before the surgical residents were even informed that a patient was already waiting (with disease possibly progressing) in the hospital emergency room. Of radiographs in the preoperative evaluation of suspected appendicitis, F. R. Lewis stated after his review of 1000 cases in 10 years: "One may conclude that an abdominal roentgenogram is not often helpful in diagnosing appendicitis and, even Table 9. DAVID GRANT USAF MEDICAL CENTER 1993 COST DATA-APPENDECTOMY (N = 35)
DRG
Group
N (Patients)
Average cost (Dollars)
164 165 166 167
Complicated with co-morbidities Noncornplicatedwithout co-morbidities Noncomplicated with co-morbidities Complicated without co-morbidities
2 26 1 6
7,459 2,700 3,981 4,400
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when abnormal, the findings are usually nonspecific.”y The current costconscious approach to appendicitis is manifest in the development of several critical pathways-none of which recommends routine preoperative abdominal radiographs.* Yet without being forced to recognize unnecessary excess such as plain abdominal radiographs, the practice of overordering persists. All too often in the authors’ own experience, especially in female patients, abdominal plain films and abdominal ultrasonography will have been completed by the first (emergency room) medical team before a trained surgeon is consulted or enabled to apply “the pressure of one finger on the patient” (as Charles McBurneyl” described in 1889). To a surgeon, appendicitis is a diagnosis best made with an inexpensive touch of a hand. If localized tenderness is not present, observation with repeat examination serially over the course of 6 to 12 hours is usually adequate if the patient is hydrated and close at hand.’, The authors can foresee a future in which patients are checked into an ambulatory observation unit to be serially checked by the same responsible surgeon, instead of undergoing routine laboratory tests and radiographs, in cases of suspected appendicitis. TUCSON MEDICAL CENTER 4-YEAR COST DATA
In 1991, Tucson Medical Center in Arizona began a computerized tracking of patients with appendicitis based on DRG 164-167 in a critical pathway program. Following the program for the past 4 years has led to the acquisition of actual cost data on 887 patients, as shown in Table 10. Costs are listed in dollar amounts, with no attempt to correct for inflation over time. Having a 4-year cost record by DRG is invaluable when evaluating new treatment modalities such as laparoscopic appendectomy. Studies2, 7, l1 investigating cost differences between open and laparoscopic appendectomy lack the solid background that such facility-specific data can assure. The future developments of accurate, cost-effective algorithms hinge on present-day establishment of actual cost data bases such as that of Table 10. Other medical facilities are currently engaged in development of critical pathways which, if tracked with true cost data, will advance our knowledge of the most economic method to treat abdominal pain even as new technology arises. Thirteen facilities with appendectomy pathways are listed in the 1995 Critical Pathways directory.* The author’s personal communication with many of them reveals that although the pathway plan is in place, not many data have been gathered, entered into computer data bases, or reviewed to determine if (1) the pathway decreases expensive hospital length of stay and (2) if actual cost savings are gained through pathway implementation. As alluded to above, however, most of the pathways share the common tenets that (1)the surgical specialist is the responsible physician for diagnostic and therapeutic
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Table 10. TUCSON MEDICAL CENTER FOUR-YEAR COST DATAAPPENDECTOMY (N = 887)
Year
Group
N (Patients)
Average Length of Stay (Days)
1991
Complicated with co-morbidities Complicated without co-morbidities Noncomplicated with co-morbidities Noncomplicated without co-morbidities Complicated with co-morbidities Complicated without co-morbidities Noncomplicated with co-morbidities Noncomplicated without co-morbidities Complicated with co-morbidities Complicated without co-morbidities Noncomplicated with co-morbidities Noncomplicated without co-morbidities Complicated with co-morbidities Complicated without co-morbidities Noncomplicated with co-morbidities Noncomplicated without co-morbidities
23 46 19 115 12 74 17 126 15 76 12 123 24 55 12 130
10.1 5.9 3.5 2.6 8.0 5.3 3.2 2.2 8.7 5.3 3.4 2.4 7.3 6.2 3.8 2.3
1992
1993
1994
Average Cost (Dollars) 13,327 3,815 3,235 2,436 6,076 3,942 3,595 2,785 7,361 4,433 2,386 2,582 7,194 5,709 5,195 2,875
interventions from the beginning of the patient’s medical evaluation; (2) few laboratory studies are required (CBC with differential, urinalysis; electrolytes only if patient is on diuretics or if a nasogastric tube is required); and (3) abdominal radiographs are not routine. SUMMARY 1. Managed care gate-keeper financial responsibility must be balanced with specialist diagnostic and therapeutic responsibility to maximize cost effectiveness and quality of medical service. 2. Cost in health care is closely tied to length of stay and operating room time; extremes of patient age are associated with increased costs. 3. Through years of training and subsequent experience, surgeons are best qualified to direct work-up of patients with an acute abdomen, especially when the work-up requires costly imaging (e.g., CT scan, ultrasonography, angiography). 4. Cost is increased when the surgeon is not involved early in cases of acute abdomen. 5. Surgeons must be willing to enter the evaluation phase of the patient with an acute abdomen patient eurZy and follow during the observation period to best reduce unnecessary laboratory work or tests. 6 . Health care teams willing to implement pathways and then document the effect such pathways exert will be most successful in assessing new technologies’ cost effectiveness.
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ACKNOWLEDGMENTS Mary McDonald, Health Policy and Planning Division of the California Office of Statewide Health Planning and Development, Sacramento, CA, obtained and tailored the 1993 data on the 31,005 appendicitis patients. Virginia Del Togno-Armanasco, RN, MN, Coordinator for Case Management at Tucson Medical Center, Tucson, AZ, provided the 1991-1994 actual cost data from the appendectomy critical pathway data base.
References 1. Cacioppo JC, Diettrich NA, Kaplan G, et al: The consequences of current constraints on surgical treatment of appendicitis. Am J Surg 157276-281, 1989 2. Cohen MM, Dangleis K The cost-effectivenessof laparoscopic appendectomy. J Laparendosc Surg 393-97, 1993 3. Davis L, Murphy JB: New York, GP Putnam & Sons, 1938, p 136 4. Fitz RH: Perforating inflammation of the vermiform appendix: With special reference to its early diagnosis and treatment. Trans Assoc Am Physicians I:107-136, 1886 5. Foster GE, Bolwell J, Balfour TW, et al: Clinical and economic consequences of wound sepsis after appendectomy and their modification by metronidazole or povidone iodine. Lancet 4769-771, 1981 6. Gill BD, Traverso LW: The acute abdomen and laparoscopy. Gastroenterol Clin North Am 3:271-282, 1993 7. Kum CK, Ngoi SS, Goh PMY, et al: Randomized controlled trial comparing laparoscopic and open appendectomy. Br J Surg 80:1559-1600,1993 8. Lang M (ed): National Directory of Healthcare: Critical Pathways. Santa Barbara, COR Healthcare Resources, 1995, p 22 9. Lewis FR, Holcroft JW, Boey J, et a1 Appendicitis: A critical review of diagnosis and treatment in 1,000 cases. Arch Surg 110677484, 1975 10. McBumey C: Experience with early operative interference in cases of disease of the vermiform appendix. NY Med J 50:67&684, 1889 11. Mompean JAL, Campos RR, Parico PP, et al: Laparoscopic versus open appendicectomy: A prospective assessment. Br J Surg 81:133-135, 1994 12. Sheldon GF: Editorial comment. Am J Surg 157281, 1989 Acute nonperforating appendicitis: Efficacy of brief 13. Winslow RE, Dean RE, Harley JW: antibiotic prophylaxis. Arch Surg 118:651455, 1983
Address reprint requests to Brian D. Gill, MD Department of Surgery/SGOS 101 Bodin Circle 60th Medical Group David Grant Medical Center Travis Air Force Base, CA 94535