From the Department of Surgery (C.K.Z., K.A.D.), Yale School of Medicine, New Haven, Connecticut; Center for Surgery and Public Health, Department of Surgery (C.K.Z., S.A.H.), Brigham & Women's Hospital, Harvard Medical School; Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Surgery (A.C.B.), College of Medicine, University of Kentucky, Lexington, Kentucky; Department of Surgery (J.P.M.), University of Texas Southwestern Medical Center, Dallas, Texas; and Department of Surgery (K.L.S.), Stanford School of Medicine, Stanford, California.
J Trauma Acute Care Surg. 2020 May;88(5):619-628. doi: 10.1097/TA.0000000000002611.
Efforts to improve health care value (quality/cost) have become a priority in the United States. Although many seek to increase quality by reducing variability in adverse outcomes, less is known about variability in costs. In conjunction with the American Association for the Surgery of Trauma Healthcare Economics Committee, the objective of this study was to examine the extent of variability in total hospital costs for two common procedures: laparoscopic appendectomy (LA) and laparoscopic cholecystectomy (LC).
Nationally weighted data for adults 18 years and older was obtained for patients undergoing each operation in the 2014 and 2016 National Inpatient Sample. Data were aggregated at the hospital-level to attain hospital-specific median index hospital costs in 2019 US dollars and corresponding annual procedure volumes. Cost variation was assessed using caterpillar plots and risk-standardized observed/expected cost ratios. Correlation analysis, variance decomposition, and regression analysis explored costs' association with volume.
In 2016, 1,563 hospitals representing 86,170 LA and 2,276 hospitals representing 230,120 LC met the inclusion criteria. In 2014, the numbers were similar (1,602 and 2,259 hospitals). Compared with a mean of US $10,202, LA median costs ranged from US $2,850 to US $33,381. Laparoscopic cholecystectomy median costs ranged from US $4,406 to US $40,585 with a mean of US $12,567. Differences in cost strongly associated with procedure volume. Volume accounted for 9.9% (LA) and 12.4% (LC) of variation between hospitals, after controlling for the influence of other hospital (8.2% and 5.0%) and patient (6.3% and 3.7%) characteristics and in-hospital complications (0.8% and 0.4%). Counterfactual modeling suggests that were all hospitals to have performed at or below their expected median cost, one would see a national cost savings of greater than US $301.9 million per year (95% confidence interval, US $280.6-325.5 million).
Marked variability of median hospital costs for common operations exists. Differences remained consistent across changing coding structures and database years and were strongly associated with volume. Taken together, the findings suggest room for improvement in emergency general surgery and a need to address large discrepancies in an often-overlooked aspect of value.
Epidemiological, level III.
提高医疗保健价值（质量/成本）在美国已成为当务之急。尽管许多人试图通过减少不良结果的变异性来提高质量，但对于成本的变异性知之甚少。本研究与美国创伤外科学会医疗保健经济委员会合作，旨在检查两种常见手术：腹腔镜阑尾切除术（LA）和腹腔镜胆囊切除术（LC）的总住院费用的变异性程度。
从 2014 年和 2016 年国家住院患者样本中获得 18 岁及以上成人接受每种手术的数据。将数据汇总到医院层面，以获得 2019 年以美元计价的医院特定中位数指数住院费用和相应的年度手术量。使用毛毛虫图和风险标准化观察/预期成本比评估成本变化。相关性分析、方差分解和回归分析探讨了成本与数量的关系。
2016 年，有 1563 家医院代表 86170 例 LA 和 2276 家医院代表 230120 例 LC 符合纳入标准。2014 年，数字相似（1602 家和 2259 家医院）。与平均 10202 美元相比，LA 的中位数费用范围为 2850 美元至 33381 美元。LC 的中位数费用范围为 4406 美元至 40585 美元，平均为 12567 美元。成本差异与手术量密切相关。在控制其他医院（8.2%和 5.0%）和患者（6.3%和 3.7%）特征和住院并发症（0.8%和 0.4%）的影响后，医院之间的差异占 9.9%（LA）和 12.4%（LC），占 9.9%（LA）和 12.4%（LC）。假设所有医院的执行费用都低于或等于其预期中位数成本，那么每年全国的节省费用将超过 3.019 亿美元（95%置信区间为 2.806 亿美元至 3.255 亿美元）。
常见手术的中位数医院费用存在显著差异。差异在不断变化的编码结构和数据库年份中保持一致，并且与数量密切相关。总的来说，这些发现表明，急诊普通外科仍有改进的空间，需要解决价值中一个经常被忽视的方面的巨大差异。
流行病学，三级。
