Okamura Kikuo, Ozawa Hideo, Kinukawa Tsuneo, Imamura Masaaki, Saito Shiro, Terai Akihito, Takei Mineo, Hasegawa Tomonori
Department of Urology, National Center for Geriatrics and Gerontology.
Nihon Hinyokika Gakkai Zasshi. 2004 Nov;95(7):792-9. doi: 10.5980/jpnjurol1989.95.792.
To investigate the length of hospitalization and medical charges when a common clinical path for TURP (transurethral resection of prostate) was implemented in multiple hospitals.
This study included 310 patients in 2001 and 298 in 2002, who were diagnosed with benign prostatic hyperplasia and who underwent TURP in seven hospitals in Japan. While the patients were treated according to the managing methods of each hospital in 2001, the patients were managed using a common clinical path in 2002, on which we conferred and established in 2001. We investigated the change of various outcome indicators before and after implementation of the common clinical path.
The background of patients and surgical outcome in 2002 were equal to those in 2001, except in incidence of preoperative urinary tract infection, general anesthesia and blood transfusion, and number of surgeons. Implementation of a common clinical path shortened the pre- and postoperative hospital stay, duration of bed rest, administration of antibiotics and Foley catheter indwelling, and reduced the standard deviation of these indicators. The total medical charge decreased from 515,439 to 491,935 yen. However, outcomes were considerably different among the seven hospitals. Multivariate analyses identified the hospitals, cognitive impairment, preoperative indwelling catheter and preoperative variance as the factors affecting preoperative hospital stay, and the hospitals, co-existing disease, blood transfusion, postoperative urinary tract infection and postoperative variance as factors affecting postoperative stay. Based on these analyses, we determined four exclusion criteria against using a common clinical path: 1) patients requiring examination or surgery other than TURP simultaneously, 2) patients whose ADL disturbance, cognitive impairment, past history and/or coexisting disease are expected to affect postoperative convalescence, 3) patients with a preoperative indwelling catheter just before operation, and 4) patients with preoperative urinary tract infection. By excluding 122 (39.4%) and 129 (43.3%) patients fulfilling the above criteria in 2001 and 2002, respectively, there were reduction in the length of pre- and postoperative hospital stay, and the total admission fee. Furthermore, there were decrease in their standard deviations.
A common clinical path was valid for reducing variance of the critical indicators affecting the clinical course of TURP and shortening the pre- and postoperative stay in the multiple hospitals. It is mandatory to establish the standard perioperative management for TURP from the viewpoint of urologists, under the circumstances of the impending introduction of the Diagnosis Procedure Combination (DPC).
探讨在多家医院实施经尿道前列腺切除术（TURP）的常见临床路径时的住院时间和医疗费用。
本研究纳入了2001年的310例患者和2002年的298例患者，这些患者均被诊断为良性前列腺增生，并在日本的7家医院接受了TURP手术。2001年患者按照各医院的管理方法进行治疗，2002年患者则采用2001年共同商讨并制定的常见临床路径进行管理。我们调查了常见临床路径实施前后各项结局指标的变化。
2002年患者的背景和手术结局与2001年相当，但术前尿路感染发生率、全身麻醉和输血情况以及外科医生数量除外。实施常见临床路径缩短了术前和术后住院时间、卧床休息时间、抗生素使用时间和导尿管留置时间，并降低了这些指标的标准差。总医疗费用从515,439日元降至491,935日元。然而，7家医院的结局存在显著差异。多因素分析确定医院、认知障碍、术前留置导尿管和术前差异是影响术前住院时间的因素，医院、合并疾病、输血、术后尿路感染和术后差异是影响术后住院时间的因素。基于这些分析，我们确定了四项不适用常见临床路径的排除标准：1）同时需要进行TURP以外的检查或手术的患者；2）日常生活活动能力障碍、认知障碍、既往史和/或合并疾病预计会影响术后康复的患者；3）术前即将留置导尿管的患者；4）术前尿路感染的患者。通过分别排除2001年和2002年符合上述标准的122例（39.4%）和129例（43.3%）患者，术前和术后住院时间以及总住院费用均有所缩短。此外，它们的标准差也有所降低。
常见临床路径对于减少影响TURP临床过程的关键指标的差异以及缩短多家医院的术前和术后住院时间是有效的。在即将引入诊断程序组合（DPC）的情况下，从泌尿外科医生的角度建立TURP的标准围手术期管理是必要的。
