Yu Xiru, Wang Xiaodong, Li Ang, Su Jiao, Du Wei, Liu Yu, Zeng Wenqi, Yan Ling, Zhao Ying
Institute for Hospital Management, Tsinghua University, Shenzhen, Guangdong Province, China.
West China Hospital of Sichuan University, Chengdu, Sichuan, China.
BMJ Open. 2024 Aug 31;14(8):e082072. doi: 10.1136/bmjopen-2023-082072.
To explore a precise control pathway based on patient clinical variations for haemostatic clip usage in laparoscopic cholecystectomy (LC) through on-site research data from a teaching hospital. Specifically, the study aimed to: (1) to calculate the optimal haemostatic clip consumption in LC based on diagnostic grouping and surgical combinations, and (2) to provide evidence for cost containment of high-value medical consumables used in LC.
Retrospective observational study.
Hospital in southwest China.
The inclusion criteria were set as inpatients whose medical records included International Classification of Diseases codes 1-3 with code 51.2300 (corresponding to LC surgery) and who were discharged on medical advice. A dataset containing 1001 patients without any haematological diagnoses was collected.
Two ordered multinomial logit models were established to identify factors affecting haemostatic clip use in LC. Two-step clustering was used to form subgroups. The premodel included preoperative variables (acute cholecystitis and scarring/fibrotic atrophy), while the full model added intraoperative variables (anatomical variation and severe adhesions). Both models met application prerequisites.
Key factors influencing haemostatic clip usage were identified, including acute cholecystitis, scarring/fibrotic atrophy, anatomical variation and severe adhesions. Consumption references for haemostatic clips were established for LC patients with good prognoses on discharge. The ordered multinomial logit model revealed that acute cholecystitis decreased the odds of using four or more clips (p<0.001), while anatomical variation, scarring/fibrotic atrophy and severe adhesions increased the odds (p<0.001 for all). The model suggested using no more than three clips in 17.30% of cases, precisely four clips in 81.72% of cases and five or more clips in 0.98% of cases, depending on the co-occurring factors. Model-predicted clip usage was consistent with actual usage (consistency=0.56).
This study provides a framework for evidence-based consumable management in LC, demonstrating the potential for extrapolation to other consumables and surgical combinations. Continuous monitoring and timely adjustment will be imperative as medical products and practices evolve.
通过一家教学医院的现场研究数据，探索基于患者临床差异的腹腔镜胆囊切除术（LC）中止血夹使用的精确控制途径。具体而言，该研究旨在：（1）根据诊断分组和手术组合计算LC中最佳止血夹消耗量，以及（2）为LC中使用的高值医用耗材的成本控制提供证据。
回顾性观察研究。
中国西南部的医院。
纳入标准设定为病历包含国际疾病分类代码1 - 3且代码为51.2300（对应LC手术）并遵医嘱出院的住院患者。收集了包含1001例无血液学诊断患者的数据集。
建立两个有序多项logit模型以识别影响LC中止血夹使用的因素。采用两步聚类法形成亚组。预模型包括术前变量（急性胆囊炎和瘢痕形成/纤维化萎缩），而完整模型增加了术中变量（解剖变异和严重粘连）。两个模型均符合应用前提条件。
确定了影响止血夹使用的关键因素，包括急性胆囊炎、瘢痕形成/纤维化萎缩、解剖变异和严重粘连。为出院时预后良好的LC患者建立了止血夹消耗参考标准。有序多项logit模型显示，急性胆囊炎降低了使用四个或更多夹子的几率（p<0.001），而解剖变异、瘢痕形成/纤维化萎缩和严重粘连则增加了几率（所有p<0.001）。该模型表明，根据共存因素，17.30%的病例使用不超过三个夹子，81.72%的病例恰好使用四个夹子，0.98%的病例使用五个或更多夹子。模型预测的夹子使用情况与实际使用情况一致（一致性=0.56）。
本研究为LC中基于证据的耗材管理提供了一个框架，证明了将其外推至其他耗材和手术组合的潜力。随着医疗产品和实践的发展，持续监测和及时调整将势在必行。
