National Clinician Scholars Program at the Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, MI.
Department of Surgery, University of Michigan, Ann Arbor, MI.
Ann Surg. 2019 Mar;269(3):453-458. doi: 10.1097/SLA.0000000000002663.
The aim of this study was to determine the feasibility of "hot spotting" in elective surgical populations.
Prospective identification of high-cost patients, known as "hot spotting," is well developed in medical populations, but has not been performed in surgical populations. Population-based management of surgical expenditures requires identification of high-cost surgical patients to allow for effective implementation of cost-saving strategies.
Using 100% Medicare claims data for 2010 to 2013, we identified patients aged 65 to 99 years undergoing elective surgical procedures. We calculated price-standardized Medicare payments for the surgical episode from the index admission through 30 days after discharge. Patient-level factors associated with payments were analyzed by multivariable linear regression.
Medicare patients in the highest decile of spending accounted for a disproportionate share of aggregate costs: 30% in Colectomy (COL), 22% in coronary artery bypass grafting (CABG), 19% in Total Hip Arthroplasty, and 18% in Total Knee Arthroplasty. Medicare expenditure differences between the highest and lowest deciles were because of a 5-fold difference for COL and 3-fold difference for CABG in index hospitalization cost. In contrast, for orthopedic procedures, there were 47- to 80-fold post-acute care expenditures between highest and lowest deciles. In multivariable analyses, patients with ≥3 comorbidities had significantly higher costs than healthier patients.
We found that a subset of multimorbid patients was responsible for a disproportionate share of total Medicare spending, but the individual components of spending vary by procedure. These findings suggest that targeting high-cost Medicare patients (ie, hot spotting) for cost containment efforts would be a potentially effective strategy to reduce costs in surgical populations.
本研究旨在确定在择期手术人群中进行“热点定位”的可行性。
在医疗人群中，前瞻性识别高成本患者（称为“热点定位”）已经得到很好的发展，但尚未在手术人群中进行。基于人群的手术支出管理需要识别高成本手术患者，以便有效地实施节省成本的策略。
我们使用 2010 年至 2013 年的 100%医疗保险索赔数据，确定了年龄在 65 岁至 99 岁之间接受择期手术的患者。我们计算了从索引入院到出院后 30 天的手术期间的价格标准化医疗保险支付。通过多变量线性回归分析与支付相关的患者个体因素。
在支出最高的十分位数中，医疗保险患者占总费用的不成比例份额：结肠切除术（COL）为 30%，冠状动脉旁路移植术（CABG）为 22%，全髋关节置换术为 19%，全膝关节置换术为 18%。最高和最低十分位数之间的医疗保险支出差异是由于索引住院费用中 COL 的差异为 5 倍，CABG 的差异为 3 倍。相比之下，对于骨科手术，最高和最低十分位数之间的急性后护理支出差异为 47 至 80 倍。在多变量分析中，患有≥3 种合并症的患者的成本明显高于健康患者。
我们发现，一组多合并症患者对医疗保险总支出的不成比例份额负责，但支出的各个组成部分因手术而异。这些发现表明，针对高成本医疗保险患者（即热点定位）进行成本控制努力可能是降低手术人群成本的有效策略。
