Effect of repair strategy on hospital cost for infants with tetralogy of fallot
Effect of repair strategy on hospital cost for infants with tetralogy of fallot
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DOI：
10.1097/00000658-199706000-00015
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发表时间：
1997-06-01
影响因子：
9
通讯作者：
Greeley, WJ
中科院分区：
文献类型：
--
作者：
Ungerleider, RM;Kanter, RJ;Greeley, WJ
目的比较1岁以下婴幼儿法乐四联症(TOF)一期与二期修复术的住院总费用(HC)。摘要背景资料目前婴儿期TOF完全(一期)矫正术取得了良好的效果。或者，可以采用两个阶段的方法，在生命的第一年对婴儿进行姑息治疗，然后在以后的时间进行完全修复。在一些机构，两阶段法是1岁以下婴儿的标准做法，或选择性地用于右室流出道(RVOT)上有冠状动脉异常、“小肺动脉”、多发性先天性异常、危重疾病(CI)的患者，这些疾病会增加旁路(例如败血症或糖尿病)的风险，或在出现时出现严重的紫癜性痉挛(HS)。这两种方法的成本影响尚不清楚。方法作者回顾了1993-1995年间在他们的机构接受TOF修复的22名1岁以下的患者。18例患者一期修复(1°)，平均年龄3.4+/-3.1个月，范围3天~9个月；4例患者采用分期治疗，初步缓解(1.6+/-0.4个月；范围1.5-2个月)，随后修复(14.75+/-1.5个月；范围13-16个月)。缓解的原因是发病时严重的HS(2例)、冠状动脉畸形(1例)和CI(1例)。在18例1度修补术中，3例(16.6%)合并HS，6例(33.3%)行经房环修补术，6例(33.3%)完全经房室入路修补(最年轻，1.5个月)。对所有患者的HC(1996美元)和住院天数(LOS；天)进行评估。我们的医疗中心自1992年7月开始使用一种成本核算系统--TRANSION I来计算HCS。过渡I提供了所有直接和间接的基于医院的、非专业的费用的完整数据。接受1度修复的组平均LOS为14.5+/-11.2天，而姑息组平均LOS为14+/-6.4天。当姑息组返回进行完全修复时，平均LOS为28.8+/-25天，两阶段策略的总LOS为43+/-30.8天(p=0.003比1度修复)。1度修复的HC为32,541+/-15,968美元，而姑息性修复的HC为25,737+/-1900美元(p=与1度修复相比不显著)，后续完全修复的HC为54,058+/-39,395美元(p=与1度修复相比不显著)(总的两阶段修复HC=79,795+/-40,625美元；P=0.001，与1度修复相比)，两阶段组的LOS和HC结合了总的缓解和后来的修复，因此，反映了两个独立的住院和恢复期，为了消除成本异常值，执行了最佳病例分析，从每组中剔除50%的患者。使用这一分析，两阶段方法导致平均(总)LOS为16.5+/-2.1天，而1度组为8.5+/-1.4天。在最佳病例组中，两阶段策略的总成本为44,660+/-3,645美元，而1度修复的总成本为22,360+/-3,331美元(p=0.00001)。结论本综述的数据显示，单纯姑息手术产生的HC与婴儿1度修复TOF相似，而姑息+最终修复TOF(两阶段法)的HC和LOS合计显著高于1度修复。此外，这些数据不包括在缓解和修复之间提供护理的额外费用(例如，门诊就诊、心导管插入术、连续超声心动图)。尽管有时使用先缓解后修复的策略似乎是谨慎的，但成本显然更高，卫生保健资源的使用也更多。
ObjectiveThis study compares the total hospital cost (HC) for one-stage versus ''two-stage'' repair of tetralogy of Fallot (TOF) in infants younger than 1 year of age.Summary Background DataTotal (one-stage) correction of TOF is now being performed with excellent results in infancy. Alternatively, a two-stage approach, with palliation of infants in the first year of life, followed by complete repair at a later time can be used. In some institutions, the two-stage approach is standard practice for infants younger than 1 year of age or is used selectively in patients with an anomalous coronary artery across the right ventricular outflow tract (RVOT), ''small pulmonary arteries,'' multiple congenital anomalies, critical illnesses (CI), which increase the risk of bypass (e.g., sepsis or DIG), or severe hypercyanotic spells (HS) at the time of presentation. The cost implications of these two approaches are unknown.MethodsThe authors reviewed 22 patients younger than 1 year of age who underwent repair of TOF at their institution between 1993 and 1995. Eighteen patients had one-stage (1 degrees) repair (mean age, 3.4 +/- 3.1 months; range, 3 days-9 months) and 4 patients were treated by a staged approach with initial palliation (1.6 +/- 0.4 month; range, 1.5-2 months) followed by later repair (14.75 +/- 1.5 months; range, 13-16 months). The reasons for palliation were severe HS at time of presentation (two patients), anomalous coronary artery (one patient) and CI (one patient). In the 18 patients undergoing 1 degrees repair, 3 (16.6%) presented with HS, 6 (33.3%) had a transanular repair, and 6 (33.3%) were able to be repaired through an entirely transatrial approach (youngest patient, 1.5 months). The HC (1996 dollars) and hospital length of stay (LOS; days) were evaluated for all patients. The HCs were calculated using transition I, which is a cost accounting system used by our medical center since July 1992. Transition I provides complete data on all direct and indirect hospital-based, nonprofessional costs.ResultsThere was no mortality in either group. The group undergoing 1 degrees repair had an average LOS of 14.5 +/- 11.2 days compared to an average LOS for palliation of 14 +/- 6.4 days, When the palliated group returned for complete repair, the average LOS was 28.8 +/- 25 days, yielding a total LOS for the two-stage strategy of 43 +/- 30.8 days (p = 0.003 compared to 1 degrees repair). The HC for 1 degrees repair was $32,541 +/- $15,968 compared to $25,737 +/- $1900 for palliation (p = not significant compared to 1 degrees repair) and $54,058 +/- $39,395 for subsequent complete repair (p = not significant compared to 1 degrees repair) (total two-stage repair HC = $79,795 +/- $40,625; p = 0.001 compared to 1 degrees repair), The LOS and HC for the two-stage group combine a total of palliation plus later repair and, as such, reflect two separate hospitalizations and convalescent periods, To eliminate cost outliers, a best-case analysis was performed by eliminating 50% of patients from each group. Using this analysis, the two-stage approach resulted in an average (total) LOS of 16.5 +/- 2.1 days compared to 8.5 +/- 1.4 days for the 1 degrees group. Total cost for the two-stage strategy in this best-case group was $44,660 +/- $3645 compared to $22,360 +/- $3331 for 1 degrees repair (p = 0.00001).ConclusionsThe data from this review show that palliation alone generates HC similar to that from 1 degrees infant repair of TOF, and total combined HC and LOS for palliation plus eventual repair of TOF (two-stage approach) are significantly higher than from 1 degrees repair. Furthermore, these data do not include additional costs for care delivered between palliation and repair (e.g., outpatient visits, cardiac catheterization, serial echocardiography). Although there may be occasions when a strategy using initial palliation followed by later repair may seem prudent, the cost is clearly higher and use of health care resources greater.