Barzi Afsaneh, Klein Eric A, Daneshmand Siamak, Gill Inderbir, Quinn David I, Sadeghi Sarmad
Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA.
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
Urol Oncol. 2017 Jul;35(7):459.e15-459.e24. doi: 10.1016/j.urolonc.2017.01.021. Epub 2017 Mar 9.
Evidence suggests that redirecting surgeries to high-volume providers may be associated with better outcomes and significant societal savings. Whether such referrals are feasible remains unanswered.
Medicare Provider Utilization and Payment Data, SEER 18, and US Incidence data were used to determine the geographic distribution and radical prostatectomy volume for providers. Access was defined as availability of a high-volume provider within driving distance of 100 miles. The opportunity cost was defined as the value of benefits achievable by performing the surgery by a high-volume provider that was forgone by not making a referral. The savings per referral were derived from a published Markov model for radical prostatectomy.
A total of 14% of providers performed>27% of the radical prostatectomies with>30 cases per year and were designated high-volume providers. Providers with below-median volume (≤16 prostatectomies per year) performed>32% of radical prostatectomies. At least 47% of these were within a 100-mile driving distance (median = 22 miles), and therefore had access to a high-volume provider (>30 prostatectomies per year). This translated into a discounted savings of more than $24 million per year, representing the opportunity cost of not making a referral. The average volume for high- and low-volume providers was 55 and 13, respectively, resulting in an annual experience gap of 43 and a cumulative gap of 125 surgeries over 3 years. In 2014, the number of surgeons performing radical prostatectomy decreased by 5% while the number of high- and low-volume providers decreased by 25% and 11% showing a faster decline in the number of high-volume providers compared with low-volume surgeons.
About half of prostatectomies performed by surgeons with below-median annual volume were within a 100-mile driving distance (median of 22 miles) of a high-volume surgeon. Such a referral may result in minimal additional costs and substantially improved outcomes.
有证据表明，将手术转诊至手术量大的医疗机构可能会带来更好的治疗效果，并为社会节省大量费用。但这种转诊是否可行仍未得到解答。
利用医疗保险提供者利用情况和支付数据、监测、流行病学和最终结果（SEER）18数据库以及美国发病率数据，确定各医疗机构的地理分布和前列腺癌根治术手术量。可及性定义为在100英里车程内有手术量大的医疗机构。机会成本定义为因未转诊而放弃由手术量大的医疗机构进行手术所能获得的收益价值。每次转诊节省的费用来自已发表的前列腺癌根治术马尔可夫模型。
共有14%的医疗机构实施了超过27%的前列腺癌根治术，每年手术量超过30例，被指定为手术量大的医疗机构。手术量低于中位数（每年≤16例前列腺切除术）的医疗机构实施了超过32%的前列腺癌根治术。其中至少47%的患者距离手术量大的医疗机构在100英里车程内（中位数为22英里），因此能够转诊至手术量大的医疗机构（每年>30例前列腺切除术）。这意味着每年可节省超过2400万美元的贴现费用，这代表了未转诊的机会成本。手术量大和手术量小的医疗机构的平均手术量分别为55例和13例，导致每年的经验差距为43例，3年内累计差距为125例手术。2014年，实施前列腺癌根治术的外科医生数量减少了5%，而手术量大和手术量小的医疗机构数量分别减少了25%和11%，与手术量小的外科医生相比，手术量大的医疗机构数量下降更快。
每年手术量低于中位数的外科医生所实施的前列腺切除术，约有一半距离手术量大的外科医生在100英里车程内（中位数为22英里）。这样的转诊可能只会带来极少的额外费用，并显著改善治疗效果。
