Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Center for Surgery and Public Health, Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
J Endourol. 2020 Dec;34(12):1248-1254. doi: 10.1089/end.2019.0684. Epub 2020 Apr 7.
Budgetary constraints and novel minimally invasive surgical approaches have resulted in surgical care being increasingly provided at ambulatory centers rather than traditional inpatient settings. Despite increasing use of ambulatory-based procedure for bladder outlet obstruction (BOO) procedures, little is known about the effect of care setting on perioperative outcomes and costs. We sought to compare 30-day readmissions rates and costs of BOO procedure performed in the ambulatory inpatient setting. Using Florida and New York all-payer data from the 2014 Healthcare Cost and Utilization Project State Databases, we identified patients who underwent transurethral resection, thermotherapy, or laser/photovaporization for BOO. Patient demographics, regional data, 30-day readmissions rates, and costs (from converted charges) associated with the index procedure and revisits were analyzed. Predictors of 30-day revisits were also identified by fitting a multivariate logistic regression model with facility-level clustering. Of the 15,094 patients identified, 1444 (9.6%) had a 30-day revisit at a median cost of $4263.43. The 30-day readmission rate for inpatient cases was significantly higher than that of surgeries performed in the ambulatory setting (12.0% 8.1%, < 0.001). Payer status (private Medicare: odds ratio [OR] = 0.77, 95% confidence interval [CI] = 0.62-0.95; = 0.02) and index care setting (ambulatory inpatient: OR = 0.48, 95% CI = 0.40-0.57; < 0.001) predicted 30-day revisits. We identified that index care setting and payer status are independent predictors of 30-day revisit after BOO procedure, with the inpatient setting and Medicare insurance associated with higher odds of revisit. Ambulatory procedures are significantly less costly than procedures performed in the inpatient setting, even after accounting for ambulatory procedures leading to an admission. There is an obvious cost benefit of offering BOO procedure in the ambulatory setting to the appropriate patient. In the context of value-based health care initiatives, our findings have important implications for policymakers seeking to reduce variation in nonclinical sources of perioperative costs and outcomes.
预算限制和新的微创外科方法导致手术护理越来越多地在门诊中心提供，而不是传统的住院环境。尽管越来越多地将门诊为基础的方法用于膀胱出口梗阻（BOO）手术，但对于护理环境对围手术期结果和成本的影响知之甚少。我们旨在比较门诊和住院环境下进行 BOO 手术的 30 天再入院率和成本。
使用 2014 年医疗保健成本和利用项目州数据库的佛罗里达州和纽约全州付费数据，我们确定了接受经尿道切除术、热疗或激光/光汽化治疗 BOO 的患者。分析了患者人口统计学数据、区域数据、与索引手术和复诊相关的 30 天再入院率和费用（来自转换后的费用）。还通过拟合具有设施级聚类的多变量逻辑回归模型确定了 30 天复诊的预测因素。
在确定的 15094 名患者中，有 1444 名（9.6%）在中位数为 4263.43 美元的费用下 30 天内再次入院。住院病例的 30 天再入院率明显高于门诊手术（12.0% 8.1%， < 0.001）。付款人身份（私人 医疗保险：优势比 [OR] = 0.77，95%置信区间 [CI] = 0.62-0.95； = 0.02）和指数护理环境（门诊 住院：OR = 0.48，95%CI = 0.40-0.57； < 0.001）预测 30 天复诊。
我们发现，指数护理环境和付款人身份是 BOO 手术后 30 天复诊的独立预测因素，住院环境和医疗保险与复诊的可能性更高相关。即使考虑到导致入院的门诊手术，门诊手术的成本也明显低于住院环境下的手术。为合适的患者提供 BOO 门诊手术具有明显的成本效益。在基于价值的医疗保健计划的背景下，我们的研究结果对于寻求减少非临床围手术期成本和结果来源差异的政策制定者具有重要意义。
