Jackson Cabo: Thanks, Dr. Chang. I'm really excited to be here and really appreciate the opportunity. So, I think this study was really born out of need in that at Mayo Arizona, we actually did identify, within our urology population, that we did have a significant number of patients who were using outpatient in-a-bed slots, meaning they were staying after relatively minor urologic procedures and often not necessarily requiring high resources, but because of distance traveled for those patients or need for, say, Foley catheter removal, drain removal the following day, ended up staying in the hospital, which did end up presenting significant cost to the institution. So, that was the initial motivation behind this. And again, this study is looking at implementation of a Care Hotel for urology patients after minimally-invasive urologic surgery. So, certainly the minimally-invasive surgical techniques have been increasingly used for common urologic conditions such as BPH. So we have HoLEP, TURP obviously has been on for a long time.
And then for stone disease, we have ureteroscopy, PCNL being increasingly utilized and allowing patients to recover faster. But even despite these advances, many patients following these procedures, even though they may not require high-acuity care, do have follow-up care needs. So, these may include Foley catheter removal, nephrostomy tube removal or nephrostogram or drain removal. And in addition, many patients travel long distances to seek care at tertiary-care centers and may not be comfortable traveling all the way home if it's multiple hours following an outpatient surgery. And because outpatient and bed usage is really poorly reimbursed or typically not reimbursed at all, keeping these patients overnight does present significant costs, not only to the institution, but also to patients themselves. So this was, again, the motivation behind creation of the Mayo Clinic Arizona Care Hotel. This was a freestanding building that is on campus here at Mayo Clinic that was initially opened in 2022. It includes six beds, and then also includes a virtual monitoring kit that allows for patient vitals to be read and interpreted through a command center, which is actually located at Mayo Clinic, Florida.
Care Hotel stays present no cost to the patient or their insurer. And there is onsite staff during the day to assist with check-in and then teaching about the technology bundle, but overnight there's no staff basically, skilled nursing onsite. All of that is kind of worked through the command center through a virtual monitoring system. Here's the flow chart for use of the Care Hotel. So typically, during the consent process in clinic, the surgeon will approach the patient to discuss Care Hotel candidacy. Again, we do typically try to prioritize patients who have need for follow-up procedures the day after surgery. So, that may be a nephrostogram after a PCNL or a patient who's going to keep a catheter for one night following a HoLEP. And then, also try to prioritize patients who have a long travel distance from home. So those coming from out of state, for example, who don't have other arrangements available. And so, essentially then the surgery is completed and patients then are reassessed for candidacy for the Care Hotel. Again, patients who are essentially deemed stable to go to the Care Hotel are then able to progress there. Of course, if a patient needs, say, continuous bladder irrigation or something overnight, then they can be transferred to typical in-hospital observation.
Below, you can see just an example of just looking at HoLEP procedures, how those patients broke down over the last several years. We can see 43% of them ended up discharging to home. About a third ended up being discharged to the Care Hotel for a single night of observation, and then about 23% ended up being observed overnight for one night following procedure. So, the design of the study that we're talking about here, what we really sought to assess was what was the short-term safety and efficacy, as well as patient satisfaction associated with the Care Hotel. So, we looked at that in patients who stayed at the Care Hotel over a two-year period. Our primary outcome was emergency room encounters and readmissions within 72 hours of surgery. So, again, our key initial outcome we wanted to look at is it safe to send patients to this Care Hotel with a virtual monitoring system as compared to, say, just observing them overnight in the hospital? Secondarily, we sought to assess the cost implications of this, comparing the costs associated with the Care Hotel compared to admitting these patients for observation overnight. And then, we also looked at predictors of ER presentation in the short term.
We had a total of 756 patients included who stayed at the Care Hotel during that two-year study period, and the median age was 69, with 235 patients having an ASA score over three, so more medically complex patients. 46% of patients, so just 6.1% bounced back to the ER within 72 hours of Care Hotel check-in, with only 10 of these patients ultimately requiring readmission out of the entire study cohort of 756. We did perform logistic regression analysis and found that medical complexity by ASA score was not a significant predictor of ER presentation. And perhaps, critically importantly, we did find that 97% of patients who stayed at the Care Hotel would report they would recommend it to others, so patients were very satisfied with the service. This table here just shows the cost breakdown comparing essentially what the per-person cost of a Care Hotel stay was relative to an outpatient and a bed observation. And so, you can see it did vary month by month, especially according to the number of Care Hotel admissions that there were.
So, again, the more patients that stayed at the Care Hotel, there was a lot of fixed costs associated with the Care Hotel. So, the more patients you get to stay there, typically see greater cost savings compared to those patients being observed overnight. And so, you can see for the 2024 total, the average per-person cost of a Care Hotel admission was 50% of what it would be for an outpatient and a bed observation. So, significant savings to the institution associated with that. And again, just wanted to highlight that the Care Hotel service is free for patients, so no cost to them or their insurer. And so, for our take-home messages here, implementation of a freestanding patient facility with virtual monitoring and no onsite nursing staff reduced outpatient and out-of-bed use at our institution after minimally-invasive urologic surgery, with significant associated cost savings and very high patient satisfaction.
Certainly, this is already kind of underway at Mayo Clinic Scottsdale here. We are expanding access to the Care Hotel to other specialties. I think we do see orthopedics, some neurosurgery, some cardiology patients using the Care Hotel as well. And so, we look to continue to expand and to identify which patients may be good candidates for it, as obviously increasing the occupancy of the hotel will also help decrease overall institutional costs and help improve access to the service to a broader population of patients.
Sam Chang: Jackson, thank you so much for a really interesting presentation. I think impressions really make a big difference in patient or people's initial evaluation of anything. So, on face, this sounds like a wonderful idea. It sounds like something that really makes sense, not only for the institution, but for the patient. So, I just want to ask a couple kind of quick specific granular questions regarding process. So, these patients are determined by whom that they can go to the urology Care Hotel?
Jackson Cabo: So, I would say the ultimate determination is up to the operating surgeon. So, again, it is, like I mentioned before, we do try to prioritize patients who are, say, traveling a distance from home or are going to require, say, clinic procedures the following day, so they're going to have to come back anyways. But ultimately, it's up to the operating surgeon for a patient they feel is appropriate and safe to do it. So, a patient who they typically say, "Oh, in this, I typically would send this patient home," but maybe there's other extenuating circumstances such as they're coming from out of state for this surgery, that they're going to have to travel four hours home after a HoLEP and then have to come back for the Foley removal the next day. That's obviously not ideal patient care. So, again, some degree of looking at the specific circumstances of the patient, but ultimately up to the operating surgeon.
Sam Chang: I think really important as this becomes, I think, inevitably more popular, codifying who is really eligible versus not, I think makes a lot of sense. Second process question. The emergency happens, patient's pulse ox goes down, blood pressure decreases, etc. Things that we normally, actually once they're home, we hear about a day or two later because they've gone to the ER, etc., etc. What is the process of there's a situation going on, nobody's on site, but the monitors at Mayo Jacksonville have gotten these parameters that are read once every few hours or whenever they're read, what then happens?
Jackson Cabo: Yeah. So basically, the way that would work, so first of all, I would say all of the patients who stay at the Care Hotel, when they check in, and even if say the surgery runs late and the patient's not actually getting there until late, at least their caregiver or spouse would be taught, "Okay, this is how you use the virtual monitoring panel, this is how you get in touch with the command center. If you have any issues, questions, this is how to call them basically." And so, they're taught how to use the technology bundle first of all, very thoroughly. Then basically say, yeah, there was an issue, say blood pressure was low, patient was feeling dizzy, etc. That call essentially is routed through the command center, and then the command center is staffed by typically a paramedic and then in addition to nursing staff. And so, they would basically then triage the situation with the patient through the technology bundle. So there's an iPad, so they can do a video call and such, triage what's going on, be like, "Okay, yeah, so I'm going to need you to adjust the pulse ox because we're not getting good reading there."
Sam Chang: How many times did that happen? 2% of the time, 20%? How often?
Jackson Cabo: Yeah. So I would say the call rate, I don't have an exact percentage off the top of my head, and we didn't measure that directly in the study, but I would say that calls to the command center are not infrequent. We only had, again, about a very low percentage who ended up being readmitted and then only about a low percentage-
Sam Chang: 10% with the ER visits, etc.
Jackson Cabo: ... With the ER visit, yes. So, 10% with the ER visit. So I would say probably the call rate would be higher than that, maybe as much as 25, 30%. Again, most of that ends up being able to be triaged either by the command center or through the provider team who's taking care of the patient. So, obviously the urology on-call resident. So, say the question that will get routed to the command centers, "Oh, the catheter's not draining," something like that. That could then be triaged by the command center, routed to the urology resident on-call who could then say, "Okay, catheter's not draining at all. We'll have you come to the ER, we can work with the catheter, etc."
Sam Chang: I think it would be important to know that because it would be great to know a correlation between those who called and hence, oh higher, there's some issues going on and oh, they're the ones who had a higher admission rate or higher ER visit rate because then you could actually focus on those versus, oh, actually they never called and a few days later something happened. Being an inpatient would've made no difference at all. So, it would only strengthen going to the urology Care Hotel really may not have prevented something, but you wouldn't have prevented it if they were inpatient either. Along those lines, in the morning, after my procedure, who determines when I can leave? Is there a certain checkout time? Is there, you can get an extra hour for free for a checkout? I mean, who determines that?
Jackson Cabo: Yeah, good question. So, in terms of when you're able to leave the Care Hotel, you basically are free to leave whenever you need to go to your morning appointment. There's not necessarily formal discharge process like there would be from the hospital itself. Again, when you leave the hospital and go across the parking lot to the Care Hotel, you still get the normal kind of discharge teaching from the PACU nurses about, "These are what things to watch out for. Here are your medications," all of that. That's all done as it usually would be for an outpatient surgery, but you just have the added level of security if you get that virtual monitoring overnight, you're nearby and you're able to come to your appointment the next morning. But no, you don't have to have any sort of formal checkout or repeat discharge once you're in the Care Hotel.
Sam Chang: Great. Thanks, Jackson. This is the last question. This is the overall regarding it seems to be safe and you can see the patients benefit from it. At least the vast majority, almost 100% would want to do this again and recommend it. The third point that you emphasize in the study is the cost. So, when you say that the institution saves money, 50% of the cost, what do you mean by that? Because if a patient does have an outpatient, say there's a reimbursement to that, you're saying because that they're actually, you're bundled for the same amount as an outpatient/short stay, that because they're actually not taking a room, you're decreasing the cost. Tell me about the cost savings for the institution and the cost savings for the patient.
Jackson Cabo: Yeah. Yeah. So, I think exactly to your point, so a lot of these procedures, I would say most of these patients' procedures that people end up staying in the Care Hotel for are procedures that typically are not approved as, say, inpatient stays. And so, you have certainly variable costs associated with those patients if they actually end up staying in the hospital for say social reasons or just, oh, they need a void trial tomorrow or they need a drain removal tomorrow or something like that. If they're truly ending up staying for that, you're not reimbursed as much. And as say, it would be as safe as you're using that bed for an inpatient stay, or a higher-acuity patient who, probably a better use of the bed for a patient who needs that higher level of care as compared to a patient who likely would be fine with and perfectly safe. And again, we demonstrated that in the study, these patients are safe to go to the Care Hotel. They don't need the higher acuity or expense associated with staying in, say, a hospital bed after these procedures. So, certainly some of the cost saving is from freeing up that bed for a higher-acuity indication. And then, some of the cost savings is just also related to reimbursement of particular procedures and patients who are typically not, cases that are not reimbursed as an inpatient procedure, having those patients, if they're safe to go, to go to a less intensive level of care.
Sam Chang: Yeah. So, Jackson, this work I think is really important as we attempt to personalize our care in a sense of taking into account distance traveled, perhaps the overall, although not predictive, the overall risks associated with that patient's overall physical and functional wellbeing. So I think you will get many, many questions, many, many queries, and we look forward to the integration of this further through Mayo, and to help other institutions integrate something along these lines. You have hospital-to-home programs that are occurring and working with various infusions, various treatments. You can see how this goes hand in hand. And so, setting up that process and that workflow I think is really important. Kudos to you and all the folks at Mayo having this set up. And we look forward to touching base with you in a year or two and telling us how this program has progressed and moved on from there. So, thank you so much for spending some time with us and we look forward to those updates.
Jackson Cabo: Thanks, Dr. Chang. Really appreciate it.