Morey R C, Fine D J, Loree S W, Retzlaff-Roberts D L, Tsubakitani S
Department of Health Systems Management, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112.
Med Care. 1992 Aug;30(8):677-98. doi: 10.1097/00005650-199208000-00002.
The debate concerning quality of care in hospitals, its "value" and affordability, is increasingly of concern to providers, consumers, and purchasers in the United States and elsewhere. We undertook an exploratory study to estimate the impact on hospital-wide costs if quality-of-care levels were varied. To do so, we obtained costs and service output data regarding 300 U.S. hospitals, representing approximately a 5% cross section of all hospitals operating in 1983; both inpatient and outpatient services were included. The quality-of-care measure used for the exploratory analysis was the ratio of actual deaths in the hospital for the year in question to the forecasted number of deaths for the hospital; the hospital mortality forecaster had earlier (and elsewhere) been built from analyses of 6 million discharge abstracts, and took into account each hospital's actual individual admissions, including key patient descriptors for each admission. Such adjusted death rates have increasingly been used as potential indicators of quality, with recent research lending support for the viability of that linkage. The authors then utilized the economic construct of allocative efficiency relying on "best practices" concepts and peer groupings, built using the "envelopment" philosophy of Data Envelopment Analysis and Pareto efficiency. These analytical techniques estimated the efficiently delivered costs required to meet prespecified levels of quality of care. The marginal additional cost per each death deferred in 1983 was estimated to be approximately $29,000 (in 1990 dollars) for the average efficient hospital. Also, over a feasible range, a 1% increase in the level of quality of care delivered was estimated to increase hospital cost by an average of 1.34%. This estimated elasticity of quality on cost also increased with the number of beds in the hospital.
在美国及其他地区，医院护理质量、其“价值”及可负担性方面的争论日益受到提供者、消费者及购买者的关注。我们开展了一项探索性研究，以估算护理质量水平变化时对全院成本的影响。为此，我们获取了300家美国医院的成本及服务产出数据，这些医院约占1983年运营的所有医院的5%；涵盖了住院和门诊服务。探索性分析所使用的护理质量衡量指标是该年度医院实际死亡人数与预测死亡人数的比率；医院死亡率预测模型此前（在其他地方）是根据对600万份出院摘要的分析构建的，并考虑了每家医院的实际个体入院情况，包括每次入院的关键患者描述信息。这种调整后的死亡率越来越多地被用作质量的潜在指标，近期研究为这种联系的可行性提供了支持。作者随后利用了基于“最佳实践”概念和同业分组的配置效率经济结构，采用数据包络分析的“包络”理念和帕累托效率构建而成。这些分析技术估算了达到预先设定的护理质量水平所需的有效交付成本。对于平均效率较高的医院，1983年每推迟一例死亡的边际额外成本估计约为29,000美元（按1990年美元计算）。此外，在可行范围内，所提供的护理质量水平每提高1%，估计医院成本平均增加1.34%。这种质量对成本的估计弹性也随着医院病床数量的增加而增大。
