Quantifying the Burden of Interhospital Cost Variation in Pediatric Surgery Implications for the Prioritization of Comparative Effectiveness Research
Quantifying the Burden of Interhospital Cost Variation in Pediatric Surgery Implications for the Prioritization of Comparative Effectiveness Research
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DOI：
10.1001/jamapediatrics.2016.3926
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发表时间：
2017-02-01
期刊：
影响因子：
26.1
通讯作者：
Rangel, Shawn J.
中科院分区：
文献类型：
--
作者：
Cameron, Danielle B.;Graham, Dionne A.;Rangel, Shawn J.
重要性实践的变化被认为是一个驱动程序的过度医疗保健支出，虽然存在一些客观的数据来指导优先级的比较有效性研究（CER）在pediatric surgery.OBJECTIVE确定高优先级的一般儿科手术程序CER的基础上，以下2个补充措施：当考虑所有医院的病例量时，医院间成本变化的幅度作为CER在患者层面的需求和潜在影响的替代，以及这种成本变化的累积财政负担，这是一项队列研究，患者在2014年1月1日至2015年9月30日期间在45家儿童医院接受30种最昂贵的儿科手术之一。从儿科健康信息系统数据库中提取成本数据，并调整在医院一级的单位为基础的成本差异，并在病例组合和疾病的严重程度在patientlevel.Main结果和措施的差异第一，四分位数范围（WIQR）的宽度调整后的程序特定的中位数成本跨医院。第二，程序的具体成本变化负担，这是计算为总的总成本之间的绝对差异的总和调整后的中位数成本来自所有医院治疗的所有患者和调整后的成本在所有hospital. ResultsA共92 535次会议进行了分析。每家医院的中位就诊次数为2011（四分位距[IQR]，1224-2619），每次手术的中位就诊次数为610（IQR，442-2610）。在最终队列中，66.9%（n = 61933）的患者为男性，中位年龄为7岁（IQR，1.9-12.3岁）。腹裂在医院水平的费用变化最大（WIQR，48471美元;中位数，111566美元[IQR，91195 - 139936美元]），先天性腹股沟疝（WIQR，43948美元;中位数，154730美元[IQR，129764 - 173712美元]），气管食管瘘/食管闭锁（WIQR，$39206;中位数，$105259 [IQR，$87335-$126541]）和溃疡性结肠炎的全结肠切除术（WIQR，$24497;中位数，$34910 [IQR，$28815-$53312]）。以下5种诊断占所有30种疾病累积成本变化负担的52.5%：单纯性阑尾炎（18.0%[$66205117]），并发阑尾炎（14.1%[$51702402]），腹裂（9.5%[$34940331]），胃造口术（5.8% [$21227436]），和小肠闭锁新生儿病例占总病例数的3.6%，占总病例数的26.8的累积成本变化负担从所有30 conditions.Conclusions和相关性一小部分的程序占大多数的成本变化负担在儿科手术，与一些医院之间的成本差异很大。腹裂和小肠闭锁可能是多学科CER工作的特别高产目标，而阑尾炎和胃造口术的管理应被视为儿科外科医生的高优先级条件。
IMPORTANCE Practice variation is believed to be a driver of excess health care spending, although few objective data exist to guide the prioritization of comparative effectiveness research (CER) in pediatric surgery.OBJECTIVE To identify high-priority general pediatric surgical procedures for CER on the basis of the following 2 complementary measures: the magnitude of interhospital cost variation as a surrogate for the need for and potential effect of CER at the patient level and the cumulative fiscal burden of this cost variation when considering the case volume from all hospitals as a surrogate for public health relevance.DESIGN, SETTING, AND PARTICIPANTS This was a cohort study of patients undergoing 1 of the 30 most costly pediatric surgical operations at 45 children's hospitals between January 1, 2014, and September 30, 2015. Cost data were extracted from the Pediatric Health Information System database and adjusted for differences in unit-based costing at the hospital level and for differences in case mix and disease severity at the patient level.MAIN OUTCOMES AND MEASURES First, the width of the interquartile range (WIQR) of the adjusted procedure-specific median cost across hospitals. Second, the procedure-specific cost variation burden, which was calculated as the aggregate sum of absolute cost differences between the overall adjusted median cost derived from all patients treated at all hospitals and the adjusted cost of each individual patient treated at all hospitals.RESULTS A total of 92 535 encounters were analyzed. The median number of encounters per hospital was 2011 (interquartile range [IQR], 1224-2619), and the median number of encounters per procedure was 610 (IQR, 442-2610). In the final cohort, 66.9%(n = 61 933) of the patients were male, and the median age was 7 years (IQR, 1.9-12.3 years). Cost variation at the hospital level was greatest for gastroschisis (WIQR, $48471; median, $111566 [IQR, $91195-$ 139 936]), congenital diaphragmatic hernia (WIQR, $43948; median, $154730 [IQR,$129764-$173712]), tracheoesophageal fistula/esophageal atresia (WIQR, $39206; median, $105259 [IQR, $87335-$126541]), and total colectomy for ulcerative colitis (WIQR, $24497; median, $34910 [IQR,$28815-$53312]). The following 5 diagnoses accounted for 52.5% of the cumulative cost variation burden from all 30 conditions: uncomplicated appendicitis (18.0%[$66205117]), complicated appendicitis (14.1%[$51702402]),gastroschisis (9.5%[$34940331]), gastrostomy (5.8% [$21227436]), and small-intestinal atresia (5.1%[$18840546]).Neonatal cases contributed 3.6% of the case volume and accounted for 26.8% of the cumulative cost variation burden from all 30 conditions.CONCLUSIONS AND RELEVANCE A small number of procedures account for most of the cost variation burden in pediatric surgery, with some demonstrating wide cost variation among hospitals. Gastroschisis and small-intestinal atresia may be particularly high-yield targets for multidisciplinary CER efforts, while the management of appendicitis and gastrostomy should be considered high-priority conditions among pediatric surgeons.