a Health Finance & Access Initiative , Bryn Mawr , PA , USA.
b Stony Brook University Medical Center, Stony Brook University (New York) , Stony Brook , NY , USA.
J Med Econ. 2019 Jul;22(7):645-651. doi: 10.1080/13696998.2019.1591147. Epub 2019 Mar 25.
Recent studies indicate intraoperative hypotension, common in non-cardiac surgical patients, is associated with myocardial injury, acute kidney injury, and mortality. This study extends on these findings by quantifying the association between intraoperative hypotension and hospital expenditures in the US. Monte Carlo simulations (10,000 trial per simulation) based on current epidemiological and cost outcomes literature were developed for both acute kidney injury (AKI) and myocardial injury in non-cardiac surgery (MINS). For AKI, three models with different epidemiological assumptions (two models based on observational studies and one model based on a randomized control trial [RCT]) estimate the marginal probability of AKI conditional on intraoperative hypotension status. Similar models are also developed for MINS (except for the RCT case). Marginal probabilities of AKI and MINS sequelae (myocardial infarction, congestive heart failure, stroke, cardiac catheterization, and percutaneous coronary intervention) are multiplied by marginal cost estimates for each outcome to evaluate costs associated with intraoperative hypotension. The unadjusted (adjusted) model found hypotension control lowers the absolute probability of AKI by 2.2% (0.7%). Multiplying these probabilities by the marginal cost of AKI, the unadjusted (adjusted) AKI model estimated a cost reduction of $272 [95% CI = $223-$321] ($86 [95% CI = $47-$127]) per patient. The AKI model based on relative risks from the RCT had a mean cost reduction estimate of $281 (95% CI = -$346-$750). The unadjusted (adjusted) MINS model yielded a cost reduction of $186 [95% CI = $73-$393] ($33 [95% CI = $10-$77]) per patient. The model results suggest improved intraoperative hypotension control in a hospital with an annual volume of 10,000 non-cardiac surgical patients is associated with mean cost reductions ranging from $1.2-$4.6 million per year. Since the magnitude of the RCT mean estimate is similar to the unadjusted observational model, the institutional costs are likely at the upper end of this range.
最近的研究表明，非心脏手术患者中常见的术中低血压与心肌损伤、急性肾损伤和死亡率有关。本研究通过量化术中低血压与美国医院支出之间的关系，进一步扩展了这些发现。基于当前的流行病学和成本结果文献，为非心脏手术中的急性肾损伤 (AKI) 和心肌损伤 (MINS) 开发了蒙特卡罗模拟 (每次模拟 10,000 次试验)。对于 AKI，有三个具有不同流行病学假设的模型 (两个基于观察性研究的模型和一个基于随机对照试验 [RCT] 的模型) 用于估计术中低血压状态下 AKI 的边际概率。也为 MINS 开发了类似的模型 (除了 RCT 情况)。AKI 和 MINS 后遗症 (心肌梗死、充血性心力衰竭、中风、心脏导管插入术和经皮冠状动脉介入治疗) 的边际概率乘以每个结果的边际成本估计值，以评估与术中低血压相关的成本。未调整 (调整) 模型发现，低血压控制可使 AKI 的绝对概率降低 2.2%(0.7%)。将这些概率乘以 AKI 的边际成本，未调整 (调整) AKI 模型估计每位患者的成本降低 272 美元[95%置信区间 = 223 美元-321 美元] (86 美元[95%置信区间 = 47 美元-127 美元])。基于 RCT 相对风险的 AKI 模型估计的平均成本降低估计值为 281 美元 (95%置信区间 = -346 美元-750 美元)。未调整 (调整) MINS 模型产生的成本降低为每位患者 186 美元[95%置信区间 = 73 美元-393 美元] (33 美元[95%置信区间 = 10 美元-77 美元])。模型结果表明，在每年进行 10,000 例非心脏手术的医院中，改善术中低血压控制与每年约 120 万至 460 万美元的平均成本降低相关。由于 RCT 平均估计值的幅度与未调整的观察模型相似，因此机构成本可能处于该范围的上限。
