Ruhumuriza J, Odhiambo J, Riviello R, Lin Y, Nkurunziza T, Shrime M, Maine R, Omondi J M, Mpirimbanyi C, de la Paix Sebakarane J, Hagugimana P, Rusangwa C, Hedt-Gauthier B
Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda.
Partners In Health, Harvard Medical School Boston Massachusetts USA.
BJS Open. 2018 Feb 7;2(1):25-33. doi: 10.1002/bjs5.35. eCollection 2018 Feb.
In low- and middle-income countries, the majority of patients lack access to surgical care due to limited personnel and infrastructure. The Lancet Commission on Global Surgery recommended laparotomy for district hospitals. However, little is known about the cost of laparotomy and associated clinical care in these settings.
This costing study included patients with acute abdominal conditions at three rural district hospitals in 2015 in Rwanda, and used a time-driven activity-based costing methodology. Capacity cost rates were calculated for personnel, location and hospital indirect costs, and multiplied by time estimates to obtain allocated costs. Costs of medications and supplies were based on purchase prices.
Of 51 patients with an acute abdominal condition, 19 (37 per cent) had a laparotomy; full costing data were available for 17 of these patients, who were included in the costing analysis. The total cost of an entire care cycle for laparotomy was US$1023·40, which included intraoperative costs of US$427·15 (41·7 per cent) and preoperative and postoperative costs of US$596·25 (58·3 per cent). The cost of medicines was US$358·78 (35·1 per cent), supplies US$342·15 (33·4 per cent), personnel US$150·39 (14·7 per cent), location US$89·20 (8·7 per cent) and hospital indirect cost US$82·88 (8·1 per cent).
The intraoperative cost of laparotomy was similar to previous estimates, but any plan to scale-up laparotomy capacity at district hospitals should consider the sizeable preoperative and postoperative costs. Although lack of personnel and limited infrastructure are commonly cited surgical barriers at district hospitals, personnel and location costs were among the lowest cost contributors; similar location-related expenses at tertiary hospitals might be higher than at district hospitals, providing further support for decentralization of these services.
在低收入和中等收入国家，由于人员和基础设施有限，大多数患者无法获得外科治疗。《柳叶刀》全球外科委员会建议在地区医院开展剖腹手术。然而，对于这些地区剖腹手术及相关临床护理的成本知之甚少。
这项成本核算研究纳入了2015年卢旺达三家农村地区医院患有急腹症的患者，并采用了基于时间驱动作业成本法。计算了人员、场地和医院间接成本的产能成本率，并乘以时间估算值以获得分摊成本。药品和耗材成本基于采购价格。
在51例患有急腹症的患者中，19例（37%）接受了剖腹手术；其中17例患者有完整的成本核算数据，被纳入成本分析。剖腹手术整个护理周期的总成本为1023.40美元，其中术中成本为427.15美元（41.7%），术前和术后成本为596.25美元（58.3%）。药品成本为358.78美元（35.1%），耗材成本为342.15美元（33.4%），人员成本为150.39美元（14.7%），场地成本为89.20美元（8.7%），医院间接成本为82.88美元（8.1%）。
剖腹手术的术中成本与先前的估计相似，但任何扩大地区医院剖腹手术能力的计划都应考虑到可观的术前和术后成本。虽然人员短缺和基础设施有限通常被认为是地区医院的手术障碍，但人员和场地成本是成本贡献最低的因素之一；三级医院类似的场地相关费用可能高于地区医院，这为这些服务的分散化提供了进一步支持。
