Addressing the High Costs of Pancreaticoduodenectomy at Safety-Net Hospitals
Addressing the High Costs of Pancreaticoduodenectomy at Safety-Net Hospitals
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DOI：
10.1001/jamasurg.2016.1776
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发表时间：
2016-10-01
期刊：
影响因子：
16.9
通讯作者：
Hoehn, Richard S.
中科院分区：
文献类型：
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作者：
Go, Derek E.;Abbott, Daniel E.;Hoehn, Richard S.
重要性安全-网络医院照顾脆弱的患者，以更高的成本提供复杂的手术。目的建立安全网医院降低复杂手术成本的不同技术模型。从大学卫生系统联盟数据库(2009年1月1日至2013年12月31日)查询实施胰腺十二指肠切除术(PD)的医院的设计、设置和参与者，并根据安全网负担进行分组。构建了一个决策分析模型，并用临床和成本数据进行填充。然后进行敏感性分析，以确定患者在医院组之间管理或重新分配的变化如何影响成本。主要结果和衡量PD后每个患者的总成本。结果在研究的5年中，15090名患者接受了PD。安全网医院中，低负担医院4220例(28.0%)，中等负担医院9505例(63.0%)，高负担医院1365例(9.0%)。高负担医院的并发症或合并症的发生率更高，病情严重的患者也更多。围手术期死亡率，高压组(3.7%)是低温组(1.6%)和高压组(1.7%)的两倍(P<；.001)。在基本情况下，当考虑所有临床和费用数据时，HBH的PD费用为每个患者35303美元，分别比MBH(27130美元)和LBH(25916美元)高30.1%和36.2%。减少50%的围手术期并发症或合并症导致HBH患者的成本降低高达4607美元，而降低死亡率的效果可以忽略不计。然而，将HBH患者重新分配到LBH和MBH导致了显著更多的成本节约，每个HBH患者节省了9155美元，或每个患者总共节省了699美元。结论和相关安全网医院实施PD的结果较差，成本较高，改善围手术期结果可能对降低这些成本有名义上的作用。将患者从安全网医院重新引导到复杂的手术可能是降低成本的最佳选择，但这样的政策的实施无疑将面临重大挑战。
IMPORTANCE Safety-net hospitals care for vulnerable patients, providing complex surgery at increased costs. These hospitals are at risk due to changing health care reimbursement policies and demand for better value in surgical care.OBJECTIVE To model different techniques for reducing the cost of complex surgery performed at safety-net hospitals.DESIGN, SETTING, AND PARTICIPANTS Hospitals performing pancreaticoduodenectomy (PD) were queried from the University HealthSystem Consortium database (January 1, 2009, to December 31, 2013) and grouped according to safety-net burden. A decision analytic model was constructed and populated with clinical and cost data. Sensitivity analyses were then conducted to determine how changes in the management or redistribution of patients between hospital groups affected cost.MAIN OUTCOMES AND MEASURES Overall cost per patient after PD.RESULTS During the 5 years of the study, 15 090 patients underwent PD. Among safety-net hospitals, low-burden hospitals (LBHs), medium-burden hospitals (MBHs), and high-burden hospitals (HBHs) treated 4220 (28.0%), 9505 (63.0%), and 1365 (9.0%) patients, respectively. High-burden hospitals had higher rates of complications or comorbidities and more patients with increased severity of illness. Perioperative mortality was twice as high at HBHs (3.7%) than at LBHs (1.6%) and MBHs (1.7%) (P < .001). In the base case, when all clinical and cost data were considered, PD at HBHs cost $ 35 303 per patient, 30.1% and 36.2% higher than at MBHs ($ 27 130) and LBHs ($ 25 916), respectively. Reducing perioperative complications or comorbidities by 50% resulted in a cost reduction of up to $ 4607 for HBH patients, while reducing mortality rates had a negligible effect. However, redistribution of HBH patients to LBHs and MBHs resulted in significantly more cost savings of $ 9155 per HBH patient, or $ 699 per patient overall.CONCLUSIONS AND RELEVANCE Safety-net hospitals performing PD have inferior outcomes and higher costs, and improving perioperative outcomesmay have a nominal effect on reducing these costs. Redirecting patients away from safety-net hospitals for complex surgery may represent the best option for reducing costs, but the implementation of such a policy will undoubtedly meet significant challenges.