Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
Cardiovascular Program, ICES, Toronto, Ontario, Canada.
Can J Cardiol. 2020 Aug;36(8):1244-1251. doi: 10.1016/j.cjca.2019.12.011. Epub 2019 Dec 16.
There is wide variation in hospitalization costs for transcatheter aortic valve replacement (TAVR), suggesting inefficiency in care delivery. Our goal was to identify drivers of health care costs in TAVR.
Demographics, procedural details, in-hospital complications, and costs for all adults undergoing first-time TAVR from 2012 to 2016 in Ontario, Canada, were obtained through linkages of clinical/administrative databases. Total costs included were from initial referral to the first of either death or 1-year post-TAVR. Phase-based costing was performed to empirically estimate the presence, duration, and cost per patient for each phase up to 1 year or death. Multivariable regression was used to identify drivers of cost accumulation per phase.
We identified 2009 first-time TAVR patients (mean age 81.7 ± 7.6, 45.9% female and Society of Thoracic Surgeons (STS) score of 7.2 ± 5.8). Phases of cost were identified with an early high-cost period within 60 days of referral, a second phase from the procedure to 60 days, and a stable phase from 60 to 360 days postprocedure. The referral phase median cost was $4527 (interquartile range [IQR]: 1708-12,594), the procedure to 60 days phase median cost was $29,518 (IQR: 24,842-40,279), and the post 60-day stable phase median cost was $6053 (IQR: 3320-17,048). Predictors of higher cost in the referral phase were in-hospital wait location, dialysis dependence, and heart-failure status. In the second (procedural) phase, predictors were nontransfemoral access, complications of stroke, and pacemaker insertion. Predictors of higher cost in the third (stable) phase were predominantly nonmodifiable, such as frailty.
This analysis shows that there are 3 distinct phases of cost accumulation from referral to post-TAVR with some potentially modifiable cost drivers in each phase.
经导管主动脉瓣置换术（TAVR）的住院费用存在广泛差异，这表明医疗服务提供效率低下。我们的目标是确定 TAVR 医疗成本的驱动因素。
通过临床/行政数据库的链接，获取 2012 年至 2016 年期间加拿大安大略省所有首次接受 TAVR 的成年人的人口统计学、程序详细信息、住院并发症和费用。总成本包括从最初转诊到 TAVR 后 1 年或死亡的第一个时间点。采用基于阶段的成本核算方法，从经验上估计每个阶段的存在、持续时间和每位患者的成本，直至 1 年或死亡。多变量回归用于确定每个阶段成本累积的驱动因素。
我们确定了 2009 名首次接受 TAVR 的患者（平均年龄 81.7±7.6 岁，45.9%为女性，STS 评分 7.2±5.8）。成本阶段的确定与转诊后 60 天内的早期高成本期、手术至 60 天的第二阶段以及术后 60-360 天的稳定阶段有关。转诊阶段的中位费用为 4527 美元（四分位距[IQR]：1708-12594），手术至 60 天阶段的中位费用为 29518 美元（IQR：24842-40279），术后 60 天稳定阶段的中位费用为 6053 美元（IQR：3320-17048）。转诊阶段费用较高的预测因素包括住院等待位置、透析依赖和心力衰竭状态。在第二（手术）阶段，预测因素是非经股入路、中风并发症和起搏器植入。第三（稳定）阶段费用较高的预测因素主要是不可改变的因素，如虚弱。
这项分析表明，从转诊到 TAVR 后，存在 3 个不同的成本累积阶段，每个阶段都有一些潜在的可改变的成本驱动因素。
