Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan.
Department of Cardiothoracic Surgery, Stanford University, Palo Alto, California.
Ann Thorac Surg. 2021 Feb;111(2):479-486. doi: 10.1016/j.athoracsur.2020.05.114. Epub 2020 Jul 18.
Despite the superiority of mitral valve repair (MVr) over replacement for degenerative disease, repair rates vary widely across centers. Traveling to a mitral reference center (MRC) is 1 way to increase the odds of MVr. This study assessed the economic value (quality/cost) and long-term outcomes of distant referral to an MRC.
Among 746 mitral surgery patients between January 2011 and June 2013, low-risk patients with an ejection fraction greater than 40% undergoing isolated degenerative MVr were identified and included 26 out-of-state (DISTANT) and 104 in-state patients (LOCAL). Short- and long-term outcomes and institutional financial data (including travel expenses) were used to compare groups. National average and MRC-specific MVr rates, clinical outcomes, and marginal value of quality-adjusted life-years collected from The Society of Thoracic Surgeons database and Medicare estimates were used to perform a nationally representative cost-benefit analysis for distant referral.
Age, ejection fraction, operative time, blood transfusions, and annuloplasty ring size did not differ between groups. Median charges were $76,022 for LOCAL and $74,171 for DISTANT (P = .35), whereas median payments (including travel expenses) were $57,795 for LOCAL and $58,477 for DISTANT (P = .70). Short- and long-term outcomes were similar between groups and median follow-up was 7.1 years. Estimated 5-year survival was 97% (96% for LOCAL and 100% for DISTANT; P = .24). Cost-benefit analysis showed a net benefit through distant referral to an MRC ranging from $436 to $6078 to the payer and $22,163 to $30,067 to the patient, combining for an estimated $22,599 to $32,528 societal benefit.
These data suggest that distant referral to an MRC is achievable and reasonable.
尽管二尖瓣修复术（MVr）在退行性疾病方面优于置换术，但各中心的修复率差异很大。前往二尖瓣参考中心（MRC）是增加 MVr 机会的一种方法。本研究评估了到 MRC 进行远程转诊的经济价值（质量/成本）和长期结果。
在 2011 年 1 月至 2013 年 6 月期间进行的 746 例二尖瓣手术患者中，确定了 EF 大于 40%的低危退行性 MVr 患者，并包括 26 例州外（偏远地区）和 104 例州内患者（当地）。使用短期和长期结果以及机构财务数据（包括差旅费）比较两组。使用来自胸外科医师学会数据库和医疗保险估算的全国平均和 MRC 特定的 MVr 率、临床结果和质量调整生命年的边际价值进行全国代表性的成本效益分析，以进行远程转诊。
年龄、EF、手术时间、输血和瓣环尺寸在两组之间无差异。当地的中位数费用为 76022 美元，偏远地区为 74171 美元（P=0.35），而当地的中位数支付额（包括差旅费）为 57795 美元，偏远地区为 58477 美元（P=0.70）。两组的短期和长期结果相似，中位随访时间为 7.1 年。估计 5 年生存率为 97%（当地为 96%，偏远地区为 100%；P=0.24）。成本效益分析表明，通过远程转诊到 MRC，支付方的净收益范围为 436 美元至 6078 美元，患者的净收益为 22163 美元至 30067 美元，估计社会收益为 22599 美元至 32528 美元。
这些数据表明，到 MRC 的远程转诊是可行且合理的。
