McCashland T, Brand R, Lyden E, de Garmo P
Department of Medicine, University of Nebraska Medical Center, Omaha, USA.
Am J Gastroenterol. 2000 Nov;95(11):3129-32. doi: 10.1111/j.1572-0241.2000.03280.x.
To use a national endoscopy database (Clinical Outcomes Research Initiative, CORI) to determine 1) if fellow involvement increases procedure time; and 2) the financial impact of fellow participation for academic centers compared to private practice.
CORI database from 4/1/97 to 4/1/99 was used to compare endoscopists from private practices, academic medical centers, and Veterans Administration hospitals, with or without fellows-in-training. Data were captured in a computer-generated endoscopy report and transmitted to a central database for analysis. Duration of procedure (minutes) was recorded for diagnostic esophagogastroduodenoscopy (EGD), EGD with biopsy, diagnostic colonoscopy, and colonoscopy with biopsy, in ASA 1 patients. Financial outcomes used 1999 Medicare reimbursement rates for respective procedures and were calculated as procedures per hour on a theoretical practice of 4000 procedures.
Teaching fellows endoscopy added 2-5 min for EGD, with or without biopsy, and 3-16 min for colonoscopy, with or without biopsy. Calculating the number of procedures/h of endoscopy, the reimbursement loss resulting from using fellows-in-training in a university setting would be half a procedure/h. In Veterans Administration hospitals, training of fellows would lose a full procedure/h. In a model of 1000 procedures each of EGD, EGD with biopsy, colonoscopy, and colonoscopy with biopsy, the reimbursement difference between private practice physicians or academic attending physicians and procedures involving fellows-in-training would be $500,000 to $1,000,000/yr.
Fellow involvement prolonged procedure time by 10-37%. Thus, per-hour reimbursement is reduced at teaching institutions, causing financial strain related to these time commitments.
利用一个全国性的内镜检查数据库（临床结果研究倡议组织，CORI）来确定：1）住院医师参与是否会增加手术时间；2）与私人诊所相比，住院医师参与对学术中心的财务影响。
使用1997年4月1日至1999年4月1日的CORI数据库，比较来自私人诊所、学术医疗中心和退伍军人管理局医院的内镜医师，无论有无住院医师参与培训。数据通过计算机生成的内镜检查报告获取，并传输到中央数据库进行分析。记录了美国麻醉医师协会（ASA）1级患者进行诊断性食管胃十二指肠镜检查（EGD）、活检的EGD、诊断性结肠镜检查以及活检的结肠镜检查的手术时长（分钟）。财务结果采用1999年各手术的医疗保险报销率，并按照每小时4000例手术的理论实践计算每小时的手术例数。
无论有无活检，住院医师参与EGD检查会增加2 - 5分钟，无论有无活检，住院医师参与结肠镜检查会增加3 - 16分钟。计算每小时的内镜检查手术例数，在大学环境中使用住院医师参与培训导致的报销损失为每小时0.5例手术。在退伍军人管理局医院，培训住院医师会导致每小时损失1例完整手术。在一个包含1000例EGD、活检的EGD、结肠镜检查以及活检的结肠镜检查的模型中，私人执业医师或学术主治医师与涉及住院医师参与培训的手术之间的报销差异每年将达到50万至100万美元。
住院医师参与使手术时间延长了10% - 37%。因此，教学机构每小时的报销额减少，导致与这些时间投入相关的财务压力。
