Heinz T R, Cowper P A, Levin L S
Division of Plastic Surgery, University of Alabama at Birmingham, 35294-3295, USA.
Plast Reconstr Surg. 1999 Jul;104(1):89-96.
Reliable information on cost and value in microsurgery is not readily available in the literature. Driving factors for cost, determinants of complications, and cost-reduction strategies have not been elucidated in this population, despite such progress in other areas of medicine. Clearly, the time-consuming and costly nature of this endeavor demands that appropriate indications and patient management be delineated; to operate proactively in this cost-conscious time, financial and outcome determinations are critical. One hundred seven consecutive free-tissue transfers performed from 1991 to 1994 by a single microsurgeon were studied. Retrospective chart review for clinical parameters was combined with analysis of hospital costs and professional charges. Operating room and anesthesia costs were based on a microcost analysis of actual operating room time, materials, labor, and overhead. Other patient level costs were generated by Transition 1, a hospital cost-accounting system. The following issues were addressed: (1) flap survival; (2) total costs and length of stay for all free flaps; (3) payments received from various insurers; (4) breakdown of operating room costs by labor, supplies, and overhead; (5) breakdown of inpatient costs by category; (6) additional costs of complications and takebacks; (7) factors associated with complications and flap takebacks; and (8) cost-reduction strategies. Mean free flap operating room costs (exclusive of professional fees) ranged among case types from $4439 to $6856 and were primarily a function of operating room times. Elective patient cases lasted a mean 440 minutes. There was a large disparity in reimbursement: private insurers covered hospital costs (not charges) completely, whereas Medicare paid 79 percent and Medicaid only 64 percent. Length of stay, operative procedures, and complications had the greatest influence on inpatient costs in this group of free flap patients. Potential cost savings as a result of possible practice changes (e.g., shortening intensive care unit stays and avoiding staged operations) can be predicted. This analysis has caused a revision in these institutions' practice patterns and lays the foundation for planned outcome studies in this population.
关于显微外科手术成本和价值的可靠信息在文献中并不容易获得。尽管在医学的其他领域取得了进展，但在这一人群中，成本的驱动因素、并发症的决定因素以及成本降低策略尚未得到阐明。显然，这项工作耗时且成本高昂，这就要求明确适当的适应症和患者管理方法；在这个注重成本的时代积极开展手术，财务和结果的判定至关重要。对一位显微外科医生在1991年至1994年间连续进行的107例游离组织移植手术进行了研究。对临床参数进行回顾性图表审查，并结合医院成本和专业收费分析。手术室和麻醉成本基于对实际手术室时间、材料、人工和间接费用的微观成本分析。其他患者层面的成本由医院成本核算系统Transition 1生成。研究了以下问题：（1）皮瓣存活情况；（2）所有游离皮瓣的总成本和住院时间；（3）从各种保险公司获得支付；（4）手术室成本按人工、耗材和间接费用的细分；（5）住院成本按类别细分；（6）并发症和回植的额外成本；（7）与并发症和皮瓣回植相关的因素；（8）成本降低策略。游离皮瓣手术室平均成本（不包括专业费用）在不同病例类型中从4439美元到6856美元不等，主要取决于手术室时间。择期患者病例平均持续440分钟。报销存在很大差异：私人保险公司全额支付医院成本（而非收费），而医疗保险支付79%，医疗补助仅支付64%。住院时间、手术程序和并发症对这组游离皮瓣患者的住院成本影响最大。可以预测，由于可能的实践改变（例如缩短重症监护病房住院时间和避免分期手术）可能节省的成本。该分析导致了这些机构实践模式的修订，并为该人群的预期结果研究奠定了基础。
